testAbout YouTitle *Surname *First Name (s) *Date of Birth *Gender *SelectMaleFemaleMarital Status *National Insurance No. *Address *ZIP/Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweMobile Phone *Home PhoneEmail Address *Do You Drive? *SelectYesNoHow do you usually travel to work? *Next of KinName of Next of KinRelationshipPhone NumberYour SignatureChoose FileNo file chosenDelete uploaded fileDateAbout Your WorkJob TitleSpecialty 1Specialty 2Specialty 3Current Place Of WorkFull TimePart TimeDaysNightsYour Payment DetailsName of Bank/Building SocietyAccount NameSelectPersonalLTDBranch AddressZIP / Postal CodeAccount NumberSort CodeYour Training, Qualifications, Appraisals and ReferencesPlease enclose, with your application a copy of your registration and membership card.NursesNMC NumberRCN NumberBandODPSHPC NumberMandatory TrainingPlease tick if you have completed the following training within the last 12 months. Please enclose copies of your training certificates.Moving and HandlingComplaints HandlingRIDDORLone Worker TrainingResuscitation of the Newborn (Midwifery)Basic Life SupportHandling Violence and AggressionCaldicott ProtocolsEquality & InclusionInterpretation of Cardiotocograph Traces (Midwifery)Intermediate Life SupportFire SafetyData ProtectionFood Hygiene (where required to handle food)PracticalAdvanced Life SupportCOSHHInfection ControlPersonal Safety (Mental Health & Learning Disability’)Upload fileDrag and Drop (or) Choose FilesAppraisals (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.Name of AppraiserPosition and Grade of AppraiserPhone NumberEmail AddressBranch AddressZIP/Postal CodeReferencesPlease 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.Reference 1: NamePositionWork AddressZIP/Postal CodeWork EmailPhone NumberFaxReference 2: NamePositionWork AddressZIP/Postal CodeWork EmailPhone NumberFaxYour DBS status and UniformPlease send a copy of your most recent DBS Disclosure (formally known as CRB)Current DBS Disclosure (formally known as CRB)YesNoIs this certificate registered with the update serviceYesNoIssue DateDisclosure NumberUpload fileChoose FileNo file chosenDelete uploaded fileAll applications who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost. Divine Healthcare Solutions Limited will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate.Uniform Size & QuantityCandidates 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.For FemaleNurseHCA/CHMidwifeSelect Size810121416182022242628Enter QuantityFor MaleNurseHCA/CHMidwifeSelect Size38404244464850Enter QuantityYour Work HistoryPlease 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.Title of Post 1 *Employer GradeFrom *To *Title of Post 2Employer GradeFromToTitle of Post 3Employer GradeFromToTitle of Post 4Employer GradeFromToYour Declarations1. Working Time RegulationsFor 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.Signed (Upload Signature) *Choose FileNo file chosenDelete uploaded filePrint Name *Date *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.Signed (Upload Signature) *Choose FileNo file chosenDelete uploaded filePrint Name *Date *2. Health DeclarationAll 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.I (name) *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 DeclarationI 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. ConfidentialityI 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 QuestionsBecause 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.Do you have any convictions, cautions, or bind overs? *Please select an optionYesNoIf yes, please give details...Have you ever had disciplinary action taken against you? *Please select an optionYesNoIf yes, please give details...Do you agree for Divine Healthcare Solutions Limited to check the status of your DBS by performing an online check at any time during your employment? (For candidate registered on the update service only) *Please select an optionYesNoDo you consent to Divine Healthcare Solutions Limited requesting a (DBS) or any appropriate references on your behalf? *Please select an optionYesNoAre you at present the subject of criminal charges or disciplinary action? *Please select an optionYesNoIf yes, please give details...6. Right to Work in the UKPlease 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.Your entitlement for working in the UK is based upon what status:British CitizenEU or EEA CitizenSpouse of an EU CitizenRight of Abode in the UKWork PermitAdmitted to UK as Doctor Prior to 1985Upload fileChoose FileNo file chosenDelete uploaded file7. Health and SafetyEach 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.8. I.D. And Indemnity Verification *ConfirmNB Nurses & ODP’s only: Please tick this box to confirm you hold your own indemnity insurance.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.Signed (Upload Signature) *Choose FileNo file chosenDelete uploaded filePrint Name *Date *New Employee Medical QuestionnaireCONFIDENTIALThe 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 InformationTitleSurnameFirst Name(s)Date of BirthHome TelWork TelMobileHome AddressGP AddressMedical HistoryAll staff groups complete this sectionDo you have any illness/impairment/disability (physical or psychological) which may affect your work?YesNoHave you ever had any illness/impairment/disability which may have been caused or made worse by your work?YesNoDo you think you may need any adjustments or assistance to help you to do the job? Answer Yes/NoYesNoAre you having, or waiting for treatment (including medication) or investigations at present?YesNoIf your answer is yes, please provide further details of the condition, treatment, and datesAdditional Information(If you have answered yes to any questions above, please provide additional information below)TuberculosisClinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006)YesNoHave you lived continuously in the UK for the last 5 years?YesNoIf no, list all of the countries that you have lived in the last 5 yearsHave you had a BCG vaccination in relation to Tuberculosis?YesNoIf you answered yes, please state whenDo you have any of the following:A cough which has lasted for more than 3 weeksUnexplained weight lossUnexplained feverHave you had tuberculosis (TB) or been in recent contact with open TB?YesNoAdditional Information(If you have answered yes to any questions above, please provide additional information below)Chicken Pox or ShinglesHave you ever had chickenpox or shingles?YesNoIf Yes,Immunization HistoryHave you had any of the following immunizations?Triple vaccination as a child (Diphtheria / Tetanus / Whooping cough)YesNoDatePolioYesNoDateTetanusYesNoDateHepatitis BYesNoIf yes, please give datesCourse 1Course 2Course 3Proof of immunityPlease send the followingVaricellaDrag and Drop (or) Choose FilesYou must provide a written statement to confirm that you have had chickenpox or shingles however we strongly advise that you provide serology test result showing varicella immunityTuberculosisDrag and Drop (or) Choose FilesWe require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)Rubella, Measles & MumpsDrag and Drop (or) Choose FilesCertificate of “two” MMR vaccinations or proof of a positive antibody for Rubella Measles & MumpsHepatitis BDrag and Drop (or) Choose FilesYou must provide a copy of the most recent pathology report showing titre levels of 100lu/l or aboveProof of immunity (EPP Candidates Only)Please send the followingHepatitis B Surface AntigenDrag and Drop (or) Choose FilesEvidence of a negative Surface Antigen Test Report must be an identified validated sample. (IVS)Hepatitis CDrag and Drop (or) Choose FilesEvidence of a negative antibody test Report must be an identified validated sample. (IVS)HIVDrag and Drop (or) Choose FilesEvidence of a negative antibody test Report must be an identified validated sample. (IVS)Exposure Prone ProceduresWill your role involve Exposure Prone ProceduresYesNoDeclarationI 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.Signed (Upload Signature)Choose FileNo file chosenDelete uploaded filePrint NameDateYour Registration ChecklistTo complete your registration you will be required to provide the following documentation.Completed Registration Form – signed in all requested areas *Completed Health Questionnaire – signed *CV – E-mailed in word format – Your CV must cover full work history from education *Your Right to Work in the UK as well as your passport and forms of I.D - We require to see the originals of these documents. (Posted originals will be returned the same day received by recorded delivery). *Birth Certificate and Driving License *HPC or NMC Entry Certificate and up to date renewal card *Copy of your most recent DBS – less than 1-year-old *Training Qualifications – Diploma/Degree/NVQ – Any other training Certificates *Mandatory Training Certificates > 1 Year *Manual HandlingBasic Life Support, Paediatrics need Paeds Life support and Midwives new-born Life SupportData Protection, Complaints Handling, COSHH, Fire, Infection Control, Lone worker, RIDDOR, Violence and Aggression, Health & Safety, ‘Quality, Diversion & Inclusion’, Safeguarding Children & Young People Level 2 minimum (if you need to update these please let us know and we will arrange this for you)Mental Health Nurses will need Restraint TrainingImmunizations *• Hep B• Varicella• Evidence of BCG – OR completed TB form, or confirmation on Letter Head paper, including your details and the GMC NMC number of the practitioner confirming the scar.• Measles• RubellaEPP Candidates (IVS = identification was shown at time of blood test) *Hep B Surface Antigen (IVS)Hep C (IVS)HIV (IVS)2x Passport Size Photos *Proof of National Insurance Number *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.To be paid through a Limited Company please ensure you send: *Certificate of IncorporationEvidence of limited bank details and company name, i.e. bank statement, or blank chequeVAT CertificateSigned Self-Billing Form (enclosed)Upload fileDrag and Drop (or) Choose FilesThank 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 travelGet 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?”Reference 1 NameTelephone NumberReference 2 NameTelephone NumberReference 3 NameTelephone NumberReference 4 NameTelephone NumberReference 5 NameTelephone NumberWe 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 3JDPhone: 03335770655 Email: info@divinehealthcaresolutions.co.uk | Website: www.divinehealthcaresolutions.co.uk.Submit & Download