ESCS Form A01-AGENCY-Temp ESCS Staff Booking Form (8)

ESCS Form A01-AGENCY-Temp ESCS Staff Booking Form (8)

Booking Form to book ESCS staff for agency work/Bedwatch
Client Detail
Name of person completing this form*

First NameLast Name
Organisation*
Email of person completing this form*
example@example.com
Telephone of person completing*

Area CodePhone Number
Booking Detail
From*

DayMonthYear
DateHourMinutes
To*

DayMonthYear
DateHourMinutes
SU Name/Initials if relevant*
SU DOB*

DayMonthYear
Date
Gender*

MaleFemaleNon-binaryOther
Staffing Requirement*

Days & NightsDays OnlyNights OnlyOther
Booking Location POC*

First NameLast Name
Location of Support/Hospital Name*
ONLY ADD THE HOSPITAL, PLACEMENT, LOCATION OF THE SUPPORT
Address of location Support Worker required/Hospital*

Street Address

Street Address Line 2

CityCounty

Post Code
Ward details*
Ward, Room No etc
Booking location/Ward Location Phone No*
No of Staff Required*
Dress Code*
Footwear*
Specialist or bespoke requirements
Risk and Observation
Current Risks
Legal Act*
Expand in Other risks
Supporting Documentation

Browse Files
Include legal, Support Plans, Care Plans, PBS, Risk Assessment etc Cancelof
Current Risks (Multi)*

Assaulting StaffPhysical AggressionVerbally AggressiveSelf HarmAbsconsion RiskSexually Inappropriate BehaviourCovid positive
Current Risks (Text)
Other Risks and Triggers
Level of Observation*

Line of Sight Inside RoomLine of Sight Outside RoomAs directed by Nursing StaffAs directed by Family (Community Support Only)
Reports
Shift and Incident Reports are to be sent to following emails*
Invoicing
PO Number*
Invoice Contact Name*
Invoice Email*
example@example.com
Invoice Address*

Street Address

Street Address Line 2

CityCounty

Post Code
By ticking the box below, I confirm that I have the authority to make this booking on behalf of my organisation and agree to be bound by the Exclusive Secure Care Services Terms & Conditions.I understand that once this booking is accepted by ESCS (via email confirmation), it forms a binding agreement and will be invoiced in full.I acknowledge that cancellations made with fewer than 12 hours’ notice will be subject to full payment, and staff will be supplied as scheduled unless otherwise agreed in writing with ESCS.In the event of a late cancellation, ESCS reserves the right to reassign staff to an alternative role or patient within their designated scope of practice.For full details of cancellation terms, transfer fees, and service conditions, please review the full Terms & Conditions, or contact the Duty Team on 0843‑523‑6264 / duty.team@securecareservices.co.uk before submitting this request.*

Confirmed
Terms and Conditions

By ticking the box below, I confirm that I have the authority to make this booking on behalf of my organisation and agree to be bound by the Exclusive Secure Care Services Terms & Conditions.

I understand that once this booking is accepted by ESCS (via email confirmation), it forms a binding agreement and will be invoiced in full.

I acknowledge that cancellations made with fewer than 12 hours’ notice will be subject to full payment, and staff will be supplied as scheduled unless otherwise agreed in writing with ESCS.

In the event of a late cancellation, ESCS reserves the right to reassign staff to an alternative role or patient within their designated scope of practice.

For full details of cancellation terms, transfer fees, and service conditions, please review the full Terms & Conditions, or contact the Duty Team on 0843‑523‑6264 / duty.team@securecareservices.co.uk before submitting this request.
Terms and Conditions*

Agree
Should be Empty:

ESCS Form A01-AGENCY-Temp ESCS Staff Booking Form (8)

Client Detail

Booking Detail

Risk and Observation

Reports

Invoicing