BRANCH DETAILS:
QUARTZ HEALTHCARE LTD
SUITE 309A WELLINGTON HOUSE
90-92 BUTT ROAD
COLCHESTER
ESSEX
CO3 3DA
ATTACH STAFF
PHOTO
POSITION APPLIED FOR:
TITLE (Mr / Mrs / Miss etc):
FORENAMES:
SURNAME:
PREVIOUS SURNAME:
NATIONALITY:
DATE OF BIRTH:
FULL ADDRESS:
HOME TELEPHONE NUMBER:
POSTCODE:
MOBILE NUMBER:
EMAIL ADDRESS:
NATIONAL INSURANCE NUMBER:
DO YOU HOLD A CURRENT FULL DRIVING LICENSE?
DO YOU HAVE ACCESS TO A CAR?
(mark as applicable)
(mark as applicable)
YES
NO
YES
NO
NEXT OF KIN (TO BE CONTACTED IN CASE OF EMERGENCY):
FULL NAME:
RELATIONSHIP TO YOU:
FULL ADDRESS:
POSTCODE:
MOBILE NUMBER:
HOME TELEPHONE NUMBER:
TYPE OF WORK DESIRED:
(mark as applicable)
FULL TIME
NHS
PART TIME
NURSING HOMES
DAYS
RESIDENTIAL HOMES
GEOGRAPHICAL AREAS YOU CAN WORK:
NIGHTS
WEEKENDS
LEARNING DISABILITIES
ANY
MENTAL HEALTH
DATE YOU CAN COMMENCE WORK:
EXPLAIN HOW YOU HEARD ABOUT QUARTZ HEALTHCARE (Web / advert / referral etc):
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Property of Quartz Healthcare Ltd
EMPLOYMENT HISTORY:
PLEASE LIST ALL POSITIONS HELD SINCE LEAVING SCHOOL. START WITH YOUR CURRENT / MOST RECENT WORKPLACE. IF THERE HAVE
BEEN ANY TIMES THAT YOU HAVE NOT BEEN IN EMPLOYMENT, PLEASE LIST THE DATES AND EXPLAIN WHY YOU WERE NOT IN WORK
(bringing up family / extra studies etc). PLEASE USE A CONTINUATION PIECE OF PAPER IF NECESSARY, AND INCLUDE YOUR CV.
NAME & ADDRESS OF
POSITION HELD
DATE FROM
DATE TO
REASON FOR LEAVING
EMPLOYER
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Property of Quartz Healthcare Ltd
EXPERIENCE QUESTIONNAIRE:
TO ENABLE QUARTZ HEALTHCARE TO ASSESS YOUR SKILL SET LEVELS, PLEASE PLACE AN “X” IN THE BOXES THAT YOU HAVE
HAD EXPERIENCE IN.
Experience working in Hospitals
Shaving
Nursing / Residential Homes
Care of hair
E.M.I. Units
Care of bladder and bowels
Experience working in Learning Disabilities services
Use of bed pan / commode
Experience working in Mental Health services
Emptying Catheter Bag
Experience working in Childrens Residential services
Moving & Handling Service Users
Experience working with children with Learning Disabilities
Use of walking aids
Experience working in Youth Offending services
Use of hoists
Experience caring for the terminally ill
Obtaining specimens
Experience caring for those with Physical Disabilities
Feeding Service Users
Experience of Spinal Injury care
Pressure Area care
Experience of Acquired Brain Injury care
Recording / Care of Medications
Experience of Stroke Patient care
Observing / Recording / Reporting changes in Service Users
Experience of caring for those with a degenerative conditions
Simple dressings
Experience of taking and recording General Observations
Occupational Therapy (including sports and play)
Experience working with Drug / Alcohol dependency
Bed making
Experience working in a Clinic or community based Practice
Changing a bed with Service User upon it
Bath / Shower / Strip wash
Light housework & washing of Service Users laundry
Use of Bath Aids
Shopping / Collection of Service Users Pension
Mouth Care (including Denture Care)
Peg Feeding
Care of feet (excluding toe nails)
Stoma Care
Care of feet (including toe nails
Experience in Milk Kitchens / Bottle feeding
Dressing / Undressing Service Users
Assisting in Last Offices
Bed bath
Please list any other fields you have working experience in that is not noted in the above table:
TRAINING:
PLEASE LIST THE DATES THAT YOU MOST RECENTLY UNDERTOOK TRAINING IN THE COURSES LISTED BELOW, AND PROVIDE
THE ASSOCIATED CERTIFICATE AT INTERVIEW STAGE.
TRAINING COURSE
DATE OF LAST TRAINING
TRAINING COURSE
DATE OF LAST TRAINING
MOVING & HANDLING OF CLIENTS
ADMINISTRATION AND CARE OF
MEDICATION
FIRE SAFETY
SAFEGUARDING OF VULNERANBLE
ADULTS
HEALTH & SAFETY (1974/1999 ACTS
CHILD PROTECTION
INCLUDING COSHH/ RIDDOR)
INFECTION CONTROL
PHYSICAL INTERVENTION AND
BREAKAWAY TECHNIQUES
VENEPUNCTURE
UNDERSTANDING AUTISM
EMERGENCIES IN FIRST AID AND
CPR
UNDERSTANDING MENTAL HEALTH
FOOD HYGIENE
RESUCITATION OF THE NEWBORN
PLEASE LIST, AND PROVIDE DATES, OF ANY OTHER TRAINING YOU HAVE RECEIVED THAT IS NOT NOTED IN THE ABOVE TABLE:
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Property of Quartz Healthcare Ltd
RECORD OF IMMUNISATIONS:
PLEASE SUPPLY QUARTZ HEALTHCARE WITH A LAB REPORT FROM YOUR GP / MEDICAL CENTRE CONFIRMING YOUR CURRENT
STATE OF IMMUNISATIONS.
IMMUNISATION
YES
NO
DATE / RESULT
MEASLES DISCLAIMER: I have / have not had measles
SIGNED:
DATED:
VARICELLA DISCLAIMER (Chicken Pox / Shingles):
I confirm that I have suffered from this virus / disease
HEPATITIS B (including Titre Levels)
SIGNED:
DATED:
1/
2/
3/
ANTIBODIES
IMMUNO-DEFICIENCY DISORDERS (including HIV)
HEPATITIS C - ANTIBODIES
TUBERCULOSIS BCG / SCAR
TETANUS
POLIOMYLITIS
RUBELLA (German Measles)
PLEASE NOTE: I am aware that I take full responsibility for accepting work with Quartz Healthcare before completing my full course of
inoculations against Hepatitis B. I have been advised, and am aware, that these inoculations should be completed. However, I understand that
not all work assignments offered by Quartz Healthcare depend on this.
SIGNED:
DATED:
PLEASE NOTE: I agree to be “Health Screened”, or to obtain a “Certificate Of Fitness”, from my GP or an Occupational Health Service if
required.
SIGNED:
DATED:
NAME OF YOUR G.P.:
ADDRESS OF YOUR G.P.:
TELEPHONE NUMBER OF YOUR G.P.:
SIGNED:
DATED:
HAVE YOU BEEN OUTSIDE THE UK IN THE PAST 2 YEARS? IF SO, PLEASE SUPPLY DETAILS BELOW:
COUNTRY VISITED
DATE OF TRAVEL & LENGTH OF STAY
INOCULATIONS REQUIRED
QUALIFICATIONS & REGISTRATION (QUALIFIED NURSES ONLY):
UNION MEMBERSHIP (RCN, Unison, etc):
MEMBERSHIP NUMBER & EXPIRY DATE:
NMC PIN NUMBER:
RENEWAL DATE:
PLEASE PROVIDE DETAILS OF YOUR FURTHER EDUCATION / TRAINING:
NAME OF ESTABLISHMENT:
DATE OF ATTENDANCE:
FROM:
TO:
QUALIFICATIONS GAINED (Please provide Certificates to evidence):
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Property of Quartz Healthcare Ltd
REFERENCES:
PLEASE PROVIDE DETAILS OF 2 PROFESSIONAL REFEREE’S, ONE OF WHICH MUST BE YOUR CURRENT/MOST RECENT
EMPLOYER. THESE REFEREE’S MUST HOLD A MORE SENIOR POSITION TO YOURSELF, AND BE ABLE TO PROVIDE A CREDIBLE
COMMENT ON YOUR ABILITIES TO UNDERTAKE THE DUTIES OF THE POST FOR WHICH YOU ARE APPLYING TO.
REFERENCE 1 - HOME ADDRESS OF REFEREE IS NOT ACCEPTABLE
NAME:
POSITION:
NAME OF ESTABLISHMENT:
ADDRESS:
POSTCODE:
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL ADDRESS:
HOW LONG HAS THIS PERSON BEEN KNOWN TO YOU IN A PROFESSIONAL/WORKING CONTEXT?
REFERENCE 2 – HOME ADDRESS OF REFEREE IS NOT ACCEPTABLE
NAME:
POSITION:
NAME OF ESTABLISHMENT:
ADDRESS:
POSTCODE:
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL ADDRESS:
HOW LONG HAS THIS PERSON BEEN KNOWN TO YOU IN A PROFESSIONAL/WORKING CONTEXT?
REHABILITATION OF OFFENDERS ACT 1974 AND CRIMINAL RECORDS:
By virtue of the Rehabilitation Of Offenders Act 1974 (exemptions/amendments) order 1986, the provisions of section 4.2 of the Rehabilitation Of
Offenders Act 1974 DO NOT APPLY to any employment which is concerned with the provision of Health Services and which, is such, a kind to
enable the holder to have access to persons in receipt of such services in the course of his/her duties. You are required, therefore, to list all
offences on a separate sheet, even if you believe them to be “spent” or “out of date” for any other reason.
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE? (please mark as applicable)
YES
NO
HAVE YOU EVER BEEN CAUTIONED OR ISSUED WITH A FORMAL WARNING FOR ANY CRIMINAL OFFENCE?
YES
NO
PLEASE NOTE: If you answered “YES” to either of the above, please attach details, including dates, on a separate sheet.
You understand that CRB is responsible for checking Criminal Records. Clients within the Healthcare Sector insist on Agencies making informed
recruitment decisions, which include Criminal Record checks to be carried out on staff annually. It is a condition of this application that a CRB is
applied for.
SIGNATURE:
PRINT NAME:
DATE:
WORKING TIME DIRECTIVE:
The European Union has guidelines for all workers, governing the length of the maximum working week that it is safe to work. The current limit is
48 hours per week. As you under no obligation to accept any work being offered, you will never be compelled to do more than 48 hours a week,
but you may choose to do so. Please sign here to confirm that you have read and understood this information.
SIGNATURE:
PRINT NAME:
DATE:
DATA PROTECTION ACT 1988 & INSPECTION:
You understand that Quartz Healthcare will hold personal information on staff. From time to time we may be required to release elements of this
information about you when placing you in work. Please be assured that we shall only declare details that are necessary. If you have any
concerns about this, please contact your Branch Manager.
SIGNATURE:
PRINT NAME:
DATE:
DECLARATION REGARDING INVESTIGATION / SUSPENSION:
I agree to inform Quartz Healthcare if, at any time whilst registered with them, I am suspended of duties by another organisation.
SIGNATURE:
PRINT NAME:
DATE:
DECLARATION:
The information provided in this application form is true and correct, to the best of my knowledge, in all aspects. I understand that if I knowingly
give false information, I will be disqualified from registration with Quartz Healthcare. I also agree to keep Quartz healthcare informed of any
changes in my circumstances, and information provided herein.
SIGNATURE:
PRINT NAME:
DATE:
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Property of Quartz Healthcare