Personal Employment Health & Fitness References & Experience Confirm Personal Details Title Mr.Mrs.Miss/Ms First Name Last Name Job Applied for NurseCare AssistantSenior Carermental health care Preferred Name NMC Nurse PIN No. Expiry Date Home Address Telephone No. Mobile Number Email Address. Date of Birth National Insurance Number Work permit required YesNo Next of Kin, Name Next of Kin, Relationship Next of Kin, Address Next of Kin, Mobile Number Next of Kin, E-mail Nationality/Ethnic Origin AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-bissauGuyanaHaitiHeard Island and Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTimor-lesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Would you require permission to work in the UK? YesNo Do you smoke? YesNo Are you aware of NYS Nursing Agency is no smoking policy? YesNo Do you have a disability? YesNo If Yes please give details Are you currently employed? YesNo If yes where Availability & Access You are available on Full TimePart Time Desired Hrs per Week Desired start date Weekdays YesNo Weekends YesNo Evenings YesNo Night Shift YesNo Do you have a valid UK driving licence? YesNo How did you find us? Passing byNews paper advt.Other Next Employment History Date From Date To Employer's Name Position Held Employer’s Address Main Duties Reason for leaving Date From Date To Employer's Name Position Held Employer’s Address Main Duties Reason for leaving Date From Date To Employer's Name Position Held Employer’s Address Main Duties Reason for leaving Educational Qualification Dates From Dates To School/College/University Qualifications Dates From Dates To School/College/University Qualifications Dates From Dates To School/College/University Qualifications Dates From Dates To School/College/University Qualifications FirstPrevious Next Health and Fitness to Work At NYS nursing we strongly advice Vaccination Have you been vaccinated for the following? Please give details TB YesNo Polio YesNo Tetanus YesNo Typhoid YesNo Rubella YesNo Hepatitis B YesNo Are you physically in good health and have you suffered from/ Do you suffer from any of the following conditions? Any Joint Pain YesNo If yes, give details Varicose Veins YesNo If yes, give details Diabetes YesNo If yes, give details Arthritis YesNo If yes, give details Epilepsy or Fits YesNo If yes, give details Heart disease/Problems YesNo If yes, give details Hernia/ Back Problems/Injuries YesNo If yes, give details Vertigo or Dizziness YesNo If yes, give details Mental Illness YesNo If yes, give details Nervous Breakdown YesNo If yes, give details Asthma YesNo If yes, give details Any Drug or Alcohol Dependency YesNo If yes, give details Any Defect of Hearing YesNo If yes, give details Eczema YesNo If yes, give details Skin Problems/Dermatitis YesNo If yes, give details Surgery /Operations YesNo If yes, give details Serious Accident YesNo If yes, give details Tropical Disease YesNo If yes, give details Cancer or Tuberculosis YesNo If yes, give details Have you had a period of two weeks or more absence in the past 12 months YesNo If yes, give details Receive Treatment by A and E of a hospital in the past 12 month period YesNo If yes, give details Do you smoke cigarettes/tobacco? YesNo If so how much per day Do you drink alcohol? YesNo If so how much per day Have you had more than three spells of absence in the past 12 months? YesNo If so how much per day High Blood Pressure YesNo If yes, give detals Kidney problem YesNo If yes, give detals Are you currently being treated for any other medical conditions? if so please ginve the details... FirstPrevious Next Job References Please list below the names, addresses & contact details of 3 referees whom we can approach in confidence to vouch for you. There should be two from your last employer and at least one from an employer in a Care environment (Not Related to You) Referee 1 Organisation Contact Name Relationship Phone number E-Mail Full Address With Postcode Referee 2 Organisation Contact Name Relationship Phone number E-Mail Full Address With Postcode Referee 3 Organisation Contact Name Relationship Phone number E-Mail Full Address With Postcode Experience Assessment Please indicate below any of the areas that you have experience in. This will help us to find suitable assignments for you. Adults Learning Disabilities NoneLowModerateHigh Adults Physical Disablement NoneLowModerateHigh Adult Mental Health NoneLowModerateHigh Children Learning Disabilities NoneLowModerateHigh Children Physical Disablement NoneLowModerateHigh Children’s Home NoneLowModerateHigh Community NoneLowModerateHigh Elderly NoneLowModerateHigh Hospitals NoneLowModerateHigh Nurseries NoneLowModerateHigh Schools NoneLowModerateHigh Shelters NoneLowModerateHigh Special Education Schools NoneLowModerateHigh Autism NoneLowModerateHigh Alzheimer’s NoneLowModerateHigh Cancer NoneLowModerateHigh Challenging Behaviour NoneLowModerateHigh Diabetes NoneLowModerateHigh Epilepsy NoneLowModerateHigh Hoisting NoneLowModerateHigh Motor Neuron Diseases NoneLowModerateHigh Personal Care NoneLowModerateHigh Practical Care NoneLowModerateHigh Substance Misuse NoneLowModerateHigh Other: Please List Other areas that you have experience Options NoneLowModerateHigh Other areas that you have experience Options NoneLowModerateHigh Other areas that you have experience Options NoneLowModerateHigh Your Present circumstance(s) Please read all the following statements carefully and tick the one that applies to you This is my first job since last 6th April and I have not been receiving taxable job seeker’s allowance or taxable incapacity Benefits or a stay or occupational Pension A This is now my only job, but since last 6th April I have an another job, or have received taxable job seeker’s Allowance or Incapacity Benefit. I do not receive a state or occupational pension. B I have another job or receive a state or occupational pension. C Student Loan If you left a course of Higher Education before last 6th April and receiving your first Student loan installment on or after 1st September 1998 and you have not fully repaid your student loan, tick box D ( if you are required to repay your Student loan through your bank or building society do not tick box . D FirstPrevious Next Equal Opportunities The organisation is committed to a policy of equal opportunities for all and requires all employees to abide by and adhere to this general principle and to the requirements of the Code of Practice laid down by the Equal Opportunities Commission and the Commission for Racial Equality. In particular in this organisation: (a) Discrimination on the grounds of race, colour, ethnic or national origin, religion, class, disability, special needs, on grounds of sex or marital status or membership or non-membership of a trade union will not be practiced or tolerated (b) The organisation expects all employees, of whatever grade or authority, to abide by and adhere to this general principle. (c) Staff will be promoted, employed and treated fairly on the basis_ of their ability and merits and accordingly to their suitability and no one will be disadvantaged by a condition or requirement, which is not justified by the genuine needs of their job or of the proposed job (d) The organisation is committed to challenge any form of discrimination it encounters (e) In order to provide equal employment and advancement opportunities to all individuals, employment decisions at the organisation will be based on merit, qualifications and abilities (f) Employees or service users with questions or concerns about any type of discrimination in the organisation are encouraged to bring these issues to the attention of the Nurse Manager or Managing Director. (g) Any breach of this policy should be reported to the Nurse Manager or to a senior, responsible member of organisation staff; breaches will be dealt with through the organisation's disciplinary procedures. Recruitment of Ex-Offenders As an organisation using the Criminal Records Bureau (CRB) Disclosure service to assess an applicants' suitability for positions of trust, NYS Nursing Agency complies fully with the CRB Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a Disclosure on the basis of a conviction or other information revealed. NYS Nursing Agency is committed to the fair treatment of its staff, potential staff or users of its services, regardless of race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental disability or offending Background. We do not discriminate against ex-offenders and they will receive fair treatment throughout the recruitment process. At interview, or in a separate discussion, we ensure that an open and measured discussion takes place on the subject of any offences or other matter that might be relevant to the position. Failure to reveal information that is directly relevant to the position sought could lead to withdrawal of an offer of employment. We make every subject of a CRB Disclosure aware of the existence of the CRB Code of Practice and make a copy available on request. Having a criminal record will not necessarily bar you from working with NYS Nursing Agency Ltd. This will depend on the nature of the position and the circumstances and background of your offences. I confirm that I have read and aware of this policy. Have you ever been convicted of or cautioned for a criminal offence? (required) YesNo If yes , please give details and dates. I certify that to the best of my knowledge, all the information provided on this form is correct. I understand that any misrepresentation or withholding of relevant information on this form will be sufficient to invalidate this application and / or terminate any employment which may have begun. Signature of Applicant Date FirstPrevious Δ
