Application Form - Nurse

Next of Kin

About Your Work

Your Payment Details

Your Training, Qualifications, Appraisals and References

Please enclose, with your application a copy of your registration and membership card.

Nurses

ODPS

Mandatory Training

Please tick if you have completed the following training within the last 12 months. Please enclose copies of your training certificates.

Appraisals (Please give the date of your last appraisal)

In order to work in the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser” Please give details below of the Senior Practitioner who you have made arrangements with to act as your appraiser.

References

Please supply us with two professional referees. One must be from your present or most recent employer and must be a senior grade to yourself and you must have worked for that person for a period of not less than three months duration.

Your DBS status and Uniform

Please send a copy of your most recent DBS Disclosure (formally known as CRB)

Uniform Size & Quantity

Candidates will be required to purchase uniform if required at the cost of £20 this will be deducted from your timesheet once you have started working through us. Please fill in the box below stating your uniform size and quantity.

Your Work History

Please ensure you complete this section even if you have a CV. The NHS states that “Employment history should be recorded on an Application Form which is signed” Please ensure that you leave no gaps unaccounted for and it covers full work history including your education. Please use extra paper if required.

When providing your work history, it is important to include your educational background as well. Make sure to include the dates of your employment, using the mm/yy format, and ensure that there are no gaps in the timeline. In cases where there are gaps in your work history, be sure to mention the reasons for those gaps. Additionally, list any relevant training you have undertaken to showcase your professional development. By including these details, you can present a comprehensive overview of your work experience and qualifications.

Your Declarations

1. Working Time Regulations

For the purposes of the Working Time Regulations 1998 (as amended) I, consent to work more than an average of 48 hours per week, averaged over 17 weeks. I understand that I may withdraw this consent by giving Divine Healthcare Solutions Limited not less than three months’ notice at any time.

In addition, I also consent to work more than the maximum number of hours permitted to work at night under the directive. Please note you are under no obligation to sign either declaration.

2. Health Declaration

All applicants must complete the enclosed health questionnaire to enable us to establish your fitness for work. We would ask all OVERSEAS candidates to provide a medical statement from their GP or medical department confirming your state of health. Your details will be passed to our Occupational Health Doctors to establish your fitness for work. Please sign the declaration below to allow Divine Healthcare Solutions Limited to release your information for inspection.

consent to Divine Healthcare Solutions Limited. Recruitment releasing my health and immunisation records for review to Divine Healthcare Solutions Limited Qualified Occupational Health Advisor. I understand that based on this review I may be required to undergo a medical examination to establish my fitness for work. I confirm that I will immediately inform Divine Healthcare Solutions Limited. Recruitment in confidence if I am HIV Positive, HepB positive or if I have AIDS in accordance with the Department of Health guidelines. I am aware of my obligations regarding MRSA contact and the need for screening. I agree to immediately inform Divine Healthcare Solutions Limited. Recruitment should my general condition of health change. I will inform Day Divine Healthcare Solutions Limited. Recruitment immediately if I discover that I am pregnant. I understand that withholding information or giving false answers may lead to dismissal. I also hereby consent to Divine Healthcare Solutions Limited. obtaining further information regarding my health from my GP or Occupational Health Department.

3. Personal Declaration

I hereby confirm that the information provided on my application is correct and true to the best of my knowledge and that I have not withheld any information that should be taken into account when offering me work. I understand that providing false or inaccurate information may result in the termination of any placement. I agree that I will make best endeavours to make myself aware of the Health & Safety procedures for each client I am assigned to. I confirm that I have read and understood the Terms of Engagement and the terms of the declaration and agree to be bound by them.

4. Confidentiality

I hereby declare that at no time will I divulge to any person, nor use for my own or any other person’s benefit, any confidential information in relation to the Client or the Company Divine Healthcare Solutions Limited) or in relation to any of their employees, business affairs, transactions or finances which I may acquire during the term of my agreement with the Company (Divine Healthcare Solutions Limited) under the Terms of Engagement.

5. Rehabilitation of Offenders Act 1974 – Please Answer All Five Questions

Because of the nature of the work for which you are applying, Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies.

6. Right to Work in the UK

Please complete this form, regardless of your nationality, as it is a legal requirement. If you are an overseas national or require a work permit to work in the UK, please include copies of supporting documentation.

7. Health and Safety

Each agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Crash Call Procedures, the Hot Spot Mechanism for alerting security that an individual is in trouble, Fire Policy, and the Violent Episode Policy.

All Nurses need to have in place an indemnity arrangement as a mandatory requirement of the NMC Code. It is the professional responsibility of each nurse and midwife to ensure that they have cover which is appropriate to their role and scope of practice and its risks. It is your sole responsibility to ensure that indemnity insurance does not expire. The cover that they have in place should be relevant to the risks involved in their practice so that it is reasonably sufficient in the event that a claim is successfully made against them. I give consent for Divine Healthcare Solutions Limited to use an identification document scanner required for NHS frameworks.

Registration Form Declaration (Please Read Carefully)

I declare that by signing this form I am agreeing to declarations 2-8. I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without the relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities. I agree that Divine Healthcare Solutions Limited retains the right to hold this registration form and any other data required to process it and pass onto any authorised third party and the details held within. I also agree to use all reasonable efforts to assist to comply with the Data Protection Act 2018. In addition, I confirm that all the information provided is true and accurate and that I have received and agree to Divine Healthcare Solutions Limited Recruitment terms of engagement and Sta Handbook. You will be requested to update your details annually.

New Employee Medical Questionnaire

CONFIDENTIAL

The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by the Healthier Business UK Ltd and may need to be seen by an occupational health advisor or physician.

Personal Information

Medical History

All staff groups complete this section

Additional Information

(If you have answered yes to any questions above, please provide additional information below)

Tuberculosis

Additional Information

(If you have answered yes to any questions above, please provide additional information below)

Chicken Pox or Shingles

Immunization History

Have you had any of the following immunizations?

Proof of immunity

Please send the following

Proof of immunity (EPP Candidates Only)

Please send the following

Exposure Prone Procedures

Declaration

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for the Healthier Business UK Ltd to make recommendations to my employer.

Your Registration Checklist

To complete your registration you will be required to provide the following documentation.

2x Reference forms. Please ask 2 senior members of staff to complete the reference forms and return them to us. This is to speed up your application. If we apply for them ourselves we often struggle to get them returned and it delays the process. We are happy to apply for them if it is not possible for you to get them. Please ensure they include verification. We will contact the referee to verify once they have been received. All references will be verified by a member of the compliance team, via phone or e-mail.

Thank you for completing your registration form.

Book an appointment to register in the office, as long as you bring all your documents, we will pay your travel

Get yourself complaint within two weeks and we will give you a FREE uniform  We run a daily payroll service.

Do you know if you refer your friends, we will pay you £100 per person? Many of our candidates are earning 100’s through referrals every month, why not start today?”

We agree to refund your travel costs to the office, you must provide a receipt, this is on the condition that you bring all the requested documentation with you on the day. You must be fully compliant within two weeks of receiving your registration pack. We will pay you £100 for every nurse you refer; they must complete 100 hours to receive payment and must be new referrals that are not already held in our database.

Divine Healthcare Solutions Limited, 47 Field Road, Bloxwich, Walsall, West Midlands, United Kingdom, WS3 3JD

Phone: 03335770655 Email: info@divinehealthcaresolutions.co.uk | Website: www.divinehealthcaresolutions.co.uk.