Application Form

Position applied for*

Qualified applicants please complete section 2a. Non-qualified please complete section 2b.

1Personal Details

Next of kin (to be notified in case of emergency)

2aProfessional experience TO BE COMPLETED BY QUALIFIED APPLICANTS ONLY

Professional Indemnity Insurance

All qualified staff members are required to hold individual professional indemnity insurance to the value of £3 Million. Please provide evidence of this:

Failure to provide this information may affect assignment of work within the NHS

2aProfessional Experience CONTINUED

Please tick all the nursing specialities of which you have significant experience


2bExperience TO BE COMPLETED BY NON-QUALIFIED APPLICANTS

To enable us to assess your experience, please tick the appropriate boxes


Are you a

 

3Work experience and education

Mandatory requirements

Please provide the dates(dd/mm/yyy) that you last undertook the following training courses and when you need to update

Employment

Please give details of your complete employment history. Please include reasons for any gaps.





Education

Please give details of your secondary education

Please give details of your further education and training

4Work preference

Please state the specialised areas in which you feel competent and confident to work

5General information

Language

Written

Spoken

Add Language

6Declaration of Health

Please answer all the questions

Have you ever suffered from any of the following:

Yes

No

If yes, additional information

6Declaration of Health CONTINUED

Please answer all the questions

Have you ever suffered from any of the following:

Yes

No

If yes, additional information

6Declaration of Health CONTINUED

Please answer all the questions

Have you ever suffered from any of the following:

Yes

No

If yes, additional information

6Record of immunisations

Lab report from Occupational Health Department or letter from GP confirming status is required

Types of immunisation:

Yes

No

Date

Results

Night shift workers ONLY

7References

Please give the names of two professional people of a senior grade/position to you, including your present or most recent employer or Agency, whom we may approach for a nursing reference. Referees must not be relatives or friends. They ust be able to provide a credible comment on your ability to undertake the duties of the post applied for. Home address of referees are not acceptable.

Reference 1

Reference 2

8Rehabilitation of Offenders Act 1974 and criminal records

By virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986, the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of a kind to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. You should therefore list all offences on a seperate sheet even if you believe them to be 'spent' or 'out of date' for some other reason.

The DBS (Disclosure and Barring Service) is the executive agency for the Home Office responsible for conducting checks on criminal records. We are a registered body for receipt of DBS disclosure information. NHS Trusts and private sector hospitals and nursing homes insist on agencies making informed recruitment decisions which require criminal record checks to be made of all staff. It is a condition of proceeding with your application that you apply for a DBS disclosure (or that you produce an acceptable original disclosure which you have already obtained). The disclosure will be compared with the information given above and any inconsistencies could invalidate your application or lead to cancellation of your registration with us. Insignia Healthcare Group reserve the right to refuse acceptance of a DBS Disclosure obtained via a third party.

9Passport and work permits

People with automatic right to work are citizens of the UK, EU, EEA and certain Commonwealth countries

If yes, please answer the following:

10Working time directives

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that it is dafe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will never be compelled to work more than 48 hours per week, but you may choose to do so.

Please sign below to confirm you have read and understood this information and indicate your preference by circling as appropriate.

11Data Protection Act 1998 and inspection

We are required to hold personal information on staff eg. National Insurance number, address, qualifications, a mechanism for checking health and fitness including records of immunisation, record of training, annual leave and sickness, two written references and Rehabilitation of Offenders information. Form time to time we may be required to release elements of this information in placing you in assignments: please be assured that we would only disclose information that is necessary.

Please complete and sign the declaration below. If you have any concerns, please contact us.


If you are placed on assignments in NHS Trusts under Framework Agreements, part of the inspection process involves checking that we maintain certain information as described above. Inspectors will need to know that the Company is maintaining the information as we should

Please complete and sign the declaration below. If you have any concerns, please contact us.


Please note: Regulatory bodies such as Social Services, Home Office, Immigration, Care Quality Commission have the right to access personal files for inspection in order to verify compliance with legislation and NCSC regulations.

12Declaration

The information that I have given in this form is, to the best of my knowledge, complete and accurate in all respects. I understand that knowingly giving false information will disqualify me from registration with this agency I also agree to keep Insignia Healthcare Solutions advised of any changes to any of the ingormation supplied.

Submit