Yeshua Healthcare Application Form

Appraisal

It is required by the NHS, that you be annually appraised by a senior clinician and this must be recorded in a database register. Please call our office and arrange with one of our senior midwives should in case you require to be appraised.
Name of Appraiser
Date of Last Appraisal

MonthDayYear
Date of Next Appraisal

MonthDayYear

Training Details

Kindly input your training provider's name and the date of the training. Certificates of all your training will be required and verified
Moving and Handling
Date

MonthDayYear
Health and Safety
Date

MonthDayYear
Safeguarding
Date

MonthDayYear
Basic Life Support
Date

MonthDayYear
Food and Hygiene
Date

MonthDayYear
Date
Medication
Date

MonthDayYear
Fire and Safety
Date

MonthDayYear
COSHH
Date

MonthDayYear
RIDDOR
Date

MonthDayYear
Infection Control
Date

MonthDayYear
Complaint Handling
Date

MonthDayYear
Risk Incident Reporting
Date

MonthDayYear

References

Please provide details from your last or most recent employer. References must be relevant to the position you are applying for
Reference 1
Name of Organisation
Name

SurnameFirst name
Professional Title
Telephone No

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Email Address
example@example.com
Relationship
Can we contact immediately ?

YesNo
References

Please provide details from your last or most recent employer. References must be relevant to the position you are applying for
Reference 2
Name of Organisation
Name

SurnameFirst name
Professional Titile
Telephone No

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Email Address
example@example.com
Relationship
Can we contact immediately ?

YesNo

Declarations

Criminal Convictions - Rehabilitation of Offenders Act 1974 - The Rehabilitation of Offenders Act 1974 (as amended) helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions after the rehabilitation period set by the Court has elapsed and the convictions become 'spent'. During the rehabilitation period, convictions are referred to as 'unspent' convictions and must be declared.Yeshua Healthcare aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. The organisation undertakes not to discriminate unfairly against applicants since a criminal conviction or other information declared.
Do you have any convictions, cautions or reprimands that are not “protected” as defined by the rehabilitations of Offenders Act (Amended 2013)?*

YesNo
Are you aware of any Police enquiries undertaken following allegations made?against you, which may have a bearing on your sustainability for this post?*

YesNo
Have you ever had a police check in another country? If so, please providedetails below and enclose a copy.*

YesNo
If you have answered Yes to any of the above, please give details below.

Yeshua Healthcare Ltd Non-Substantive Payroll New Starter Form
Name of Next Kin

First NameLast Name
Relationship
Next of Kin Contact No

Area CodePhone Number
Expiry Date

MonthDayYear
BANK DETAILS BANK / BUILDING SOCIETY
Name
Bank
Post Code
Account Number
Roll Number (If applicable)
Sort code
National Insurance No
Signature

Clear
I confirm that the above information is correct and that I will not exceed 48 hours per week as a combination of contracted and bank hours.I also confirm that should I leave my permanent employment; I will inform Yeshua Healthcare immediately.

YesNo

MEDICAL QUESTIONNAIRE
Confidential

Due to the nature of the role you have applied for we need to carry out a complete a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.Before health clearance is given for employment you may be contacted and asked to contact your GP to arrange 3 doses of Hepatitis B Vaccination over a period of months. With your consent, these results would have to be seen and recorded on our database. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice.Yeshua Healthcare Agency aim to promote and maintain the health of all individuals in the workplace: staff, service users and third parties.
GP Details
GP Name
GP Address

Street Address

Street Address Line 2

CityState / Province

Post Code

Immunisation History

Have you had any of the following immunisations
Polio

YesNo
If yes; Date

MonthDayYear
Tetanus*

YesNo
If yes; Date

MonthDayYear
Hepatitis B (If Yes is ticked please give dates below)

YesNo
Course 1

MonthDayYear
Course 2

MonthDayYear
Course 3

MonthDayYear
Boosters 1

MonthDayYear
Boosters 2

MonthDayYear
Boosters 3

MonthDayYear
Proof of Immunity (Please upload the following)
Varicelle (You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showingvaricella immunity)

Browse Files

Cancelof
Tubercolosis (We require an occupational health/GP certificate of a positive scar or a record of apositive skin test result (Do not Self Declare))

Browse Files

Cancelof
Rubella, Measles & Mumps (Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubellaand Measles)

Browse Files

Cancelof
Hepattitis B (You must provide a copy of the most recent pathology report showing titre levels of100lu/l or above)

Browse Files

Cancelof
Proof of Immunity (Please send the following) EPP Candidates Only
Hepatitis B Surface Antigen (Evidence of Hepatitis B Surface Antigen Test (Inc. ‘e’ antigen and DNA viral loads if applicable Report must be an identified validated sample. (IVS))

Browse Files

Cancelof
Hepatitis C (Evidence of a Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR if applicable)Reports must be an identified validated sample. (IVS))

Browse Files

Cancelof
HIV (Evidence of a HIV I and II antibody test (Inc. DNA viral loads if applicable)Reports must be an identified validated sample. (IVS))

Browse Files

Cancelof
Exposure Prone Procedures
Will your role involve Exposure Prone Procedures*

YesNo

Recommendations

I understand that following this assessment, recommendations may be provided to assist my health at work
I give consent for Yeshua Healthcare to make recommendations and for my employer/agencyto provide these recommendations to my placement*

YesNo
I would like to see a written copy of any recommendations Yeshua Healthcare may make beforepresenting it to my placement*

Yes

Declaration

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return.I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.
Name*

SurnameFirst name
Signature*

Clear
Date*

MonthDayYear
Documents

Upload the following documents.
Most up to date Passport and 2 additional identity documents *

Browse Files

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2 most recent proof of addresses

Browse Files

Cancelof
Current DBS or DBS on the update service

Browse Files

Cancelof
Overseas police check if applicable

Browse Files

Cancelof
Most recent CV with no gaps which includes full employment history from date of qualification

Browse Files

Cancelof
Professional qualification certificates

Browse Files

Cancelof
Right to work documents – if applicable

Browse Files

Cancelof
Please confirm availability so we can book you in for a face to face interview via Skype or Microsoft team with our clinical interviewers.

Yes

Consents

I hereby give my consent to Yeshua Healthcare Limited to process some or all the following information
Sensitive personal data
⦁ Gender
⦁ Date of birth
⦁ Race or ethnicity
⦁ Religious beliefs
⦁ Sexual orientation
⦁ Social – economic background
⦁ Disability/Health
I give consent to Yeshua Healthcare Limited to process my sensitive personal data for the reasons stated below:
⦁ Yeshua Healthcare Ltd provides me with temporary/ permanent employment
⦁ Yeshua Healthcare Agency process or transfer my personal data to their client(s) to provide me with job-seeking services.
⦁ Yeshua Healthcare Ltd process my data on a computerised database to provide me with k-seeking job services.
⦁ The recording of diversity information as requested by the clients supplied by Yeshua Healthcare Ltd.
⦁ The completion of occupational health Screening Questionnaire in line with the current Department of
Health Guidelines.
I also consent to Yeshua Healthcare to process my personal data with third parties including, any clients that I provide services to via Yeshua Healthcare Ltd, for the purposes of internal audits and investigations carried out on Yeshua Healthcare Ltd to ensure that the Agency is complying with all relevant laws and obligations.
The consent I give to Yeshua Healthcare Ltd will last for 5 years.
I am aware that I have the right to withdraw my consent at any time by informing Yeshua Healthcare Ltd that I wish to do so.
Name*

SurnameFirst name
Signature*

Clear
Date*

MonthDayYear

	AM	PM	Night
Monday
Tuesday
Wednessday
Thursday
Friday
Saturday
Sunday

YESHUA HEALTHCARE RECRUITMENT AGENCY

Personal Details

Education

Ethnicity

Employment

Appraisal

Training Details

References

References

Declarations

Yeshua Healthcare Ltd Non-Substantive Payroll New Starter Form

BANK DETAILS BANK / BUILDING SOCIETY

MEDICAL QUESTIONNAIRE

Confidential

GP Details

Medical History

Have you suffered from any of the following?

Chicken Pox or Shingles

BBV (Blood Borne Virus)

Tubercolosis

Do you have any of the following ?

Immunisation History

Proof of Immunity (Please upload the following)

Proof of Immunity (Please send the following) EPP Candidates Only

Exposure Prone Procedures

Recommendations

Declaration

Documents

Consents

Timesheet

Preferences