Healthcare Application Form

Healthcare Application
Please attach a copy of the below documents, these are all required to complete your application. If you do not have these to hand immediately, we can process them after submission but this may delay your application.
- A copy of your CV
- 2 x Proof of Address (utility bills, bank statement, council tax etc) dated within the last 3 months
- Passport or Birth Certificate
- Proof of NI (National Insurance card, P45, P60, letter from HMRC)
- Any current training certificates and proof of professional qualifications
- Current DBS Certificate
Other things you will need to complete this form:
- Work Permit/Visa/Share code if applicable
- Driving Licence if applicable
- Marriage Certificate if applicable
- Change of Name Deed if applicable
- Any immunisation records held
- Contact details for previous employers for referencing purposes
- Passport/headshot photo
If you need any assistance please contact us on 01322 474655 Monday to Friday 8:30-17:30
Where did you hear about us*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

TownCounty

Postcode
National Insurance Number*
Do you have a valid driving licence?

YesNo
Do you have your own transport?

YesNo
Please tick the shifts for which you are available?*

NightsDaysRotation shiftsAny hours

Next of Kin details
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to you*

Entitlement to work
Do you need immigration permission to work in the UK?*

YesNo
If permission is restricted, note any restrictions
Expiry date

DayMonthYear
Date
Are you an EEA Citizen?*

YesNo
EEA Citizen Share Code

Bank details
Sort Code*
Account Number*
Name on Account*
Roll Number
Bank/Building Society Name*
Bank/Building Society Address
Starter Declaration - please select one of the following statements which best applies to you*
I confirm that the information provided above is true and correct to the best of my knowledge. I understand that I am liable for any errors resulting from any incorrect information provided by me.*

Clear
Date*

DayMonthYear
Date

Education and Professional Qualifications
Education*
Qualifications*
From*

DayMonthYear
Date
To*

DayMonthYear
Date
Education
Qualifications
From

DayMonthYear
Date
To

DayMonthYear
Date
Education
Qualifications
From

DayMonthYear
Date
To

DayMonthYear
Date

	Double vaccinated	Date of 1st vaccination	Date of 2nd vaccination	NHS proof of vaccination
COVID 19

GDPR - Data Protection Statement
Swanstaff Recruitment Ltd are committed to ensuring the security and protection of the personal information that we process and to provide a compliant and consistent approach to data protection.

Swanstaff controls and processes personal data on the ground that we have a legitimate interest in doing so. The information that you provide along with your CV will be used by Swanstaff for the purpose of providing you with work finding services. This includes for example, contacting you and assessing your suitability for job opportunities, updating our databases, putting you forward for job opportunities, arranging payments to you and developing and managing our services and relationship with you and our clients.

In some cases , we may be required to use your data for the purpose of investigating, reporting and detecting crime and also to comply with laws that apply to us. We may also use your information during the course of internal and external audits to demonstrate our compliance with certain industry standards.

You can find out how to access your data in our privacy policy, this will be sent to you via email. You have the right to withdraw from being contacted or Swanstaff holding your data at any time by informing Swanstaff via GDPR@swanstaff.co.uk, however if you have worked for us, Swanstaff have a legal obligation to hold some elements of your data for auditing and legal compliance reasons.

Reference Authorisation
To Whom It May Concern

I have applied for a position through Swanstaff Ltd. I hereby give consent and authorisation for you to complete a reference form for Swanstaff Recruitment Ltd
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date

Previous Employment and Reference Details

Your full employment history, with no gaps and full reference details must be supplied covering the last 5 years of employment
Current / Last Employer
Company Name*
Company Address

Street Address

Street Address Line 2

TownCounty

Post Code
Reference Contact

NameJob Title
Email
*
phone number.
Dates of employment - From*

DayMonthYear
Dates of employment - To*

DayMonthYear
Job Title*
Job Description
Reason for Leaving*
Will you continue to work for this employer?*

YesNo
Can we contact this company for a reference?*

YesNo

Previous Employer 1
Company Name*
Company Address

Street Address

Street Address Line 2

TownCounty

Post Code
Reference Contact

NameJob Title
Email
*
phone number.
Dates of employment - From*

DayMonthYear
Dates of employment - To*

DayMonthYear
Job Title*
Job Description
Reason for Leaving*

Previous Employer 2
Company Name
Company Address

Street Address

Street Address Line 2

TownCounty

Post Code
Reference Contact

NameJob Title
Email
phone number.
Dates of employment - From

DayMonthYear
Dates of employment - To

DayMonthYear
Job Title
Job Description
Reason for Leaving

Previous Employer 3
Company Name
Company Address

Street Address

Street Address Line 2

TownCounty

Post Code
Reference Contact

NameJob Title
Email
phone number.
Dates of employment - From

DayMonthYear
Dates of employment - To

DayMonthYear
Job Title
Job Description
Reason for Leaving

Previous Employer 4
Company Name
Company Address

Street Address

Street Address Line 2

TownCounty

Post Code
Reference Contact

NameJob Title
Email
phone number.
Dates of employment - From

DayMonthYear
Dates of employment - To

DayMonthYear
Job Title
Job Description
Reason for Leaving

Previous Employer 5
Company Name
Company Address

Street Address

Street Address Line 2

TownCounty

Post Code
Reference Contact

NameJob Title
Email
phone number.
Dates of employment - From

DayMonthYear
Dates of employment - To

DayMonthYear
Job Title
Job Description
Reason for Leaving

Previous Employer 6
Company Name
Company Address

Street Address

Street Address Line 2

TownCounty

Post Code
Reference Contact

NameJob Title
Email
phone number.
Dates of employment - From

DayMonthYear
Dates of employment - To

DayMonthYear
Job Title
Job Description
Reason for Leaving

Character Reference Details

Please supply details of two people who would be willing to act as a character reference for you. They must not be a relative and must have known you for more than 5 years.
Character Reference 1*

First NameLast Name
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email*
example@example.com
Heading
Heading
Phone Number*
Please enter a valid phone number.
How many years has this person known you?*
How do you know this person*
Character Reference 2*

First NameLast Name
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How many years has this person known you?*
How do you know this person*

Have you worked for an Agency before?

YesNo
Name of Agency
Pay Rates
From

DayMonthYear
To

DayMonthYear
Where did you work? Name of sites / Companies

Application Declaration
1. I declare that the information I have provided in this application form is true and complete. I understand that if I have given any misleading information on this form or made any omissions, this will result in removal from Swanstaff Recruitment Limited’s Register.
2. I give permission for the referees mentioned to be contacted by Swanstaff Recruitment Ltd.
3. Confidentiality Agreement:
  1. During the course of my assignment, I will have access and knowledge of confidential information and trade secrets.
  2. Under the terms of this confidentiality agreement, I agree to keep secret and shall not at any time, either during my assignment or post assignment, use, communicate or reveal to any person, any trade secret or confidential information relating to Swanstaff or any of its clients, service users, members of their families, local authority departments, and fellow professionals.
  3. This Agreement shall not apply to confidential Information which is or comes into the public domain other than through a breach of the terms of this agreement or which is required to be disclosed by law, or a competent authority.
4. I declare that I am not engaged/nor intend to engage in any work and/or business that is prejudicial to the work and/or business that I will be undertaking for and on behalf of Swanstaff Recruitment Limited or any of its clients.
5. I have read, understood and agree to the GDPR Data Protection Statement.
6. I give consent for Swanstaff Recruitment to share my personal data with third parties, for the purpose of audits and investigations. I understand that this is to ensure that Swanstaff Recruitment is compliant with all relevant laws and obligations.
7. I understand that no medical details will be disclosed without my permission to any person, but an opinion about my fitness for night work will be issued to management if applicable.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date

Documents
CV

Cancelof
Passport / Birth Certificate*

Cancelof
Proof of Address (utility bills, bank statement, council tax etc) dated within the last 3 months.*

Cancelof
Proof of Address (2)*

Cancelof
Proof of NI (National Insurance card, P45, P60, letter form HMRC)*

Cancelof
Current DBS Certificate*

Cancelof
Training Certificate / Qualifications*

Cancelof
Training Certificate / Qualifications*

Cancelof
Work permit / visa (if applicable)

Cancelof
Driving Licence (if applicable)

Cancelof
Marriage Certificate (if applicable)

Cancelof
Change of Name Deed (if applicable)

Cancelof
Passport / Headshot

Cancelof
COVID 19 vaccination proof

Cancelof
Should be Empty:

	Can perform unsupervised	Require some supervision	Unable to perform
Bath / Shower / Strip Wash
Bed Bath
Use of Bath Aids
Shaving
Care of Eyes
Mouth Care
Care of Fingernails
Care of Feet
Care of Hair
Dressing / Undressing

	Can perform unsupervised	Require some supervision	Unable to perform
Continence Care
Use of Commodes, Bedpans
Catheter Care
Attaching a Night Bag
Applying a Urinary Sheath
Stoma Care

	Can perform unsupervised	Require some supervision	Unable to perform
Moving & Handling Cert
Use of Wheelchairs
Use of Hoists
Use of Moving Aids

	Can perform unsupervised	Require some supervision	Unable to perform
Preparation of Meals
Feeding Dependant Service Users
Care of PEG's
Special Diet Requirements

	Can perform unsupervised	Require some supervision	Unable to perform
Pressure Area Care
Assisting with Medication
Simple Dressing Procedures
Basic Obs, Temp, BP, Pulse

Healthcare Application

Next of Kin details

Entitlement to work

Bank details

Work Preference

Education and Professional Qualifications

Professional Experience Check List

Health

Night Time Worker Questionnaire

Imunisations

Rehabilitation of Offenders Act 1974

GDPR - Data Protection Statement

Reference Authorisation

Previous Employment and Reference Details

Current / Last Employer

Previous Employer 1

Previous Employer 2

Previous Employer 3

Previous Employer 4

Previous Employer 5

Previous Employer 6

Character Reference Details

Heading

Heading

Application Declaration

Documents

	Can perform unsupervised	Require some supervision	Unable to perform
Bed Making
Light Housework
Washing Personal Laumdry
Cooking
Shopping
Collecting Benifits

	Can perform unsupervised	Require some supervision	Unable to perform
Hospital
Hospice
Residential Home
Nursing Home
Learning Disabilities
Mental Health

	Immunisation	Date of Immunisation	Do you have a Serology Report showing blood levels	Date of Blood Test
Rubella
Mumps
Measles
Tuberculosis
Varicella (Chickenpox)
Hepatitis B