Athena Surgical Centre: 005 Nurse Job Application Form

Nurse Job Application Form
Welcome to Our Company!

Thank you for expressing interest in joining our team. Are we right for you?

We are private healthcare company with a difference.

We aim to be number one in private healthcare

This will be achieved by:
 Exceeding our customers’ expectations
 Complying with all National Regulations for patient safety
 Having premier facilities
 Only employing skilled and knowledgeable people who CARE about what they do and who are valued
 Ensuring we offer health care that is unique and sets us apart from other hospitals and clinics
 Always getting better at what we do
 Offering ‘value for money’ by competitive pricing whilst not compromising on quality
 Managing resources efficiently to enable us to invest in the business

We believe that getting the best out of people by encouraging and helping them to get the best out of themselves will ultimately result in our company being a unique and satisfying place to work.

All staff have opportunities for training and development, are guided by personal development plans and have the freedom of action to help take the hospital forward. We are a team in every sense of the word.

Healthcare can be both rewarding and difficult, but if you want to have a positive impact and feel you have got what it takes,then The company could be the place for you.

Contact us to find out what opportunities await you……

E. Employment History

Please provide details of ALL employment and any periods of unemployment since leaving school, beginning with your present or most recent job first. Please use continuation sheet if necessary.Please explain any gaps in your employment history.
Employment Details:*
F. Voluntary and Community work experience.
40. Employment Details:*
G. Supporting Information

Please detail below your main achievements to date and the strengths you would bring to this post:
41. Please use this space to detail anything else that may be relevant to this role:*
H. Convictions, Cautions, Rehabilitation and Criminal records

The company aim to provide workers to enable customers to live within their community as independently as possible, including provision of care to vulnerable people. It is therefore essential that you declare whether you have been convicted of any criminal offences.The post to which you are applying is exempt from the provisions of section 4 (2) of the Rehabilitation of Offenders Act, 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exemption) order of and the Rehabilitation of Offenders (Exceptions) Order Northern Ireland, 1979. It is therefore a necessity for you to supply all information regarding convictions which for other purposes would be spent under the provisions of the act. If you are accepted for the post, failure to declare such convictions could result in disciplinary action including dismissal, however the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are ‘protected’ and are not subject to disclosure to employers, and cannot be taken into account.If information has been recorded against you, this does not necessarily prevent you for consideration for the post, but it does depend upon what those convictions are for.
42. Do you have any convictions, cautions, reprimands, final warnings or any pending charges that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)?*

YesNo
43. State when, the court, the offence and disposal.*
44. Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) or Disclosure Scotland from working with children or vulnerable adults?***

YesNo
Please complete if you have subscribed to the DBS Update Service (England and Wales) or PVG Scheme Membership (Scotland)
Certificate / Membership Number:
45. (PVG scheme only) Does your membership cover*

AdultsChildrenBoth
46. (England and Wales) Do you consent to the company accessing your DBS record?*

YesNo

I. References

We require references covering at least the past three years of your employment. At least one of the references must be your current or last employer. Please detail: contact name, contact number, full address and email address for each of your employers. If you have had less than two employers you should give a character reference who must have known you for at least three years and is not a relative.
47.

If you do not wish your current employer to be contacted before interview please tick here
48. Referee 1 :
Name:   First Name*   Last Name*
Mobile:0447712345678*
Email ID:   Email*
Address:   Street Address*   Address Line 2*   City*
County*   Post Code*
Job Title:   *
49. Country Of Referee 1:*
50. Referee 2 :
Name:   First Name*   Last Name*
Mobile:0447712345678*
Email ID:   Email*
Address:   Street Address*   Address Line 2*   City*   County*   Post Code*
Job Title:   *
51. Country Of Referee 2:*
52. Referee 3 :
Name:   First Name*   Last Name*
Mobile: 0447712345678*
Email ID:     Email*
Address:   Street Address*   Address Line 2*   City*
County*   Post Code*
Job Title:   *
53. Country Of Referee 3:*
Character Reference
54. Referee :
Name:   First Name*   Last Name*
Mobile:  0447712345678*
Email ID:   Email*
Address:   Street Address*   Address Line 2*   City*
County*   Post Code*
Relationship :   *
Number of Years Known :   *
55. Country Of Referee :*

J. Declaration (Please read carefully before signing this application)
1. I confirm that all the information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.

2. Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with the Data Protection
Act 1998 and GDPR 2018.

3. I understand that the personal data on this application form is collected by the company for the purpose of recruitment processes, and I
consent for this data to be processed and stored by The company.
56. Signature*

Powered by Jotform SignClear
57. Date*

MonthDayYear
Date
PLEASE COMPLETE THE ENCLOSED EQUAL OPPORTUNITIES FORM AND BRING IT ALONG TO YOUR INTERVIEW.
K. Emergency Contacts
58. Name:*

First NameLast Name
59. Post:*
I confirm that in the unlikely event of an emergency whilst working for the company, the following people may be contacted:-
60. Contact 1 :
Name:   First Name*   Last Name*
Mobile: 0447712345678*
Email ID:   Email*
Address:   Street Address*   Address Line 2*   City*
  County*   Post Code*
Relationship :   *
61. Contact 2 :
Name:   First Name*   Last Name*
Mobile:      0447712345678*
Email ID:   Email*
Address:   Street Address*   Address Line 2*   City*
County*   Post Code*
Relationship :   *

L. Confidentiality Agreement
I agree not to disclose my proposed salary, or any patient details with any other member of staff, either employed directly or indirectly associated with The company.

I acknowledge that a breach of this confidentiality will result in formal disciplinary action and potential dismissal.
Regulation 28

Notification to the Healthcare Commission
As stated in regulation 28:-
“ 28 – (1) the registered person shall give notice to the commission of
(a) the death of a patient-
(i) in an establishment;
(ii) during treatment provided by an establishment or agency; or
(iii) as a consequence of treatment provided by an establishment or agency within the period
of seven days ending on the date of the death and the circumstances of his death.

(b) any serious injury to a patient;
(c) he outbreak in an establishment of any infectious disease, which in the opinion of any medical practitioner
employed in the establishment is sufficiently serious to be so notified;
(d) any allegation of misconduct resulting in actual or potential harm to a patient by the registered person,
any person employed in or for the purpose of the establishment or for the purposes of the agency.
Or any medical practitioner with practicing privileges.
(2) Notice under paragraph(1) shall be given within the period of 24hours beginning with the event in question and, if
given orally shall be confirmed in writing as soon as practicable.”
I understand that I am responsible under regulation 28 to inform the Hospital Manager of any incident that may be the subject
to notification to the CQC.
I also understand that should an incident occur outside of The company, which results in disciplinary action being taken against
me, I will undertake to inform the Hospital Manager immediately.
At the date shown below, I would confirm that I am not the subject of any disciplinary procedure either in the UK or Overseas.
62. Signature*

Powered by Jotform SignClear
63. Name*

First NameLast Name
64. Date*

MonthDayYear
Date
Note: Once this document has been signed it should be returned marked Private and Confidential.

65. Personal Information for accounts:
Title :   *
Name :   First Name*   Last Name*
Job Title :   *
Start Date:   Date*
Address :   Street Address*   Address Line 2*   City*   County*   Post Code*
National Insurance No:   *
Date of Birth :   Date*
66. Have you submitted your P45 or completed a P46?*

YesNo
67. Attach a copy. *

Cancelof
68. Signature*

Powered by Jotform SignClear
69. Will this be your only paid employment :*

YesNo
70. Bank Details:
Account in the Name of:   Type a label*
Name of Bank or Building Society :   Type a label*
Address of Bank or Building Society:   Street Address*   Address Line 2*   City*   County*   Post Code*
Sort Code :
Account Number :

I confirm that all the information given is correct, and that my salary is to be paid into the above account.

Signature*   Date*

	Tick
Work with biological hazards – human
Work using display screens
Work with biological hazards – animal
Carry out Exposure Prone Procedures
Work with cytotoxics/genetic modification
Work involving driving
Work using skin irritants
Shift work/Night work with Details
Work using lung irritants
Work involving food handling
Work with Natural Latex products
Work in isolation
Work involving heavy lifting
Radiation
Other

6 . Vaccinations:

Please provide any official documentation of your vaccinations and blood tests relevant to your employment. Attach copies here.
1. Vaccination Attachment:*

Cancelof
2. Any relevant additional information:
I declare that the foregoing statements are true and complete to the best of my knowledge and belief.

I am aware that any false statements may affect my application and future employment.
3. Signature*

Powered by Jotform SignClear
4. Date*

MonthDayYear
Date

Statement relating to the employment of people with criminal records
Introduction:

The company, by its nature has many posts which are exempt from the provisions of the Rehabilitation of Offenders Act 1974(ROA), by virtue of the ROA Exceptions Order 1975.

To help ensure that we make safe appointments to these posts, the company will use the services of the Disclosure and Barring Service to obtain information about a candidate’s criminal record.

Purpose:

Undertaking checks will help to identify prospective candidates who may be unsuitable for certain work and positions, especially those involving vulnerable adults.

The disclosure information will not be used to unfairly discriminate against candidates who have a criminal record.

Considerations:
In reviewing information about a criminal record the Hospital will consider factors such as:
 Whether the conviction or other matter is relevant to the post applied for
 The seriousness of any offence or other matter revealed
 The length of time since the offence occurred
 Whether there is a pattern of offending behaviour
 Whether the candidate’s circumstances have changed since the offence
 The circumstances surrounding the offence and any explanations offered

Withholding information:
The Disclosure service will provide details of any conviction, even those which may be considered spent for other purposes.Therefore you should not withhold such information from your application of employment.

For posts which are not subject to a criminal record check, any withholding of information about a criminal record could result in disciplinary action or dismissal in the event of employment. The Hospital will only withdraw an offer of employment whereit is concluded that a candidate is genuinely unsuitable for the post.

Further information about the Criminal Records Bureau can be found at www.disclosure.gov.uk.

Declaration:

I acknowledge that I have received, read and understood the Employee Policies, and agree to abide by its provisions, and understand that violation of any of the terms and conditions of my employment may result in disciplinary action. I understand that it is my responsibility to raise any queries with regard to the Policies with my Manager/Director in the first instance.

I understand that under the Data Protection Act. 1998 and GDPR 2018, information relating to me, will be held both on computer and paper form. Such information will include:

Name, address, date of birth, health, pension, ethnic origin, performance records, salary, benefits, absence, amongst others, some of which is considered ‘Sensitive Data’ under the Act.

I therefore, give my permission for such to be held and agree to comply with the policies and procedures contained therein.
Signature*

Powered by Jotform SignClear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Nurse Job Application Form

A. Personal Details:

B. Driving Record:

C. Job Flexibilty:

D. Education and Professional Training

E. Employment History

F. Voluntary and Community work experience.

G. Supporting Information

H. Convictions, Cautions, Rehabilitation and Criminal records

I. References

Character Reference

J. Declaration (Please read carefully before signing this application)

K. Emergency Contacts

L. Confidentiality Agreement

Regulation 28

M. Occupational Health Department

4. Sickness:

5.Medical History:

A .Please answer the following questions fully, using details if necessary.

B. Have you ever suffered with:

6 . Vaccinations:

Statement relating to the employment of people with criminal records