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Domiciliary Care
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1
Personal Details
2
Additional Information
3
Education & Employment
4
Declarations
5
Payment/Banking
6
Employee/Employer
7
Health Details
Comments
This field is for validation purposes and should be left unchanged.
Position Applying for
(Required)
Nurse
Senior Carer
Carer
NMC PIN
Your Name
(Required)
Title
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First Name
Surname
Date of Birth
(Required)
DD slash MM slash YYYY
Address
(Required)
House Number
Street / Road Name
City / Town
Post Code
Home Phone
Mobile No
(Required)
Email
(Required)
National Insurance Number
(Required)
Gender
Male
Female
Religion
Race / Ethinicity
Professional Organisation (RCN, UNISON etc) Membership Details (if any)
Professional Indemnity
Yes
No
Next of Kin (NOK) to be notified in case of emergency
Next of Kin Name
(Required)
Mobile No
(Required)
Home / Work Phone
Relationship to you
(Required)
Address
(Required)
House Number
Street / Road Name
City / Town
Post Code
Have you ever been employed by this organisation SNS HEALTHCARE SERVICES in the past?
(Required)
Yes
No
What is your residential status in UK?
(Required)
Upload Passport / Bio Metric
(Required)
Max. file size: 1 GB.
Upload two utility bills for proof of address (Recent Bank Statement, Utility Bill, Driving License, etc.)
(Required)
Drop files here or
Select files
Max. file size: 1 GB, Max. files: 2.
Have you ever been disciplined by a professional body (NMC etc)?
Yes
No
If Yes, please explain:
Do you have a UK driving license?
Yes
No
Driving License No.
Convictions Details
Yes
No
This field is hidden when viewing the form
Convictions Details if yes
Convictions Details
Are you subject to any restrictions or covenants which might restrict your working activity? If yes please write why but if no leave the question blank.
(Required)
Education
(Required)
Name of School/College/University
Location (mailing address)
From Month/ Year To Month / Year
Degree/Diploma
Add
Remove
Employment History (Most Recent to Oldest)
(Required)
Employer Name and Full Address
Dates From Month / Year To month / Year
Position held/Main duties
Reason for leaving
Add
Remove
Number 1 Referee Name
(Required)
Two References are normally taken up for candidates selected for interview. Give details of the names/addresses of your immediate supervisor or manager . One of the Referees should be your current employer, or if presently unemployed or self-employed, your last employer
Company Name and Full Address with Post Code.
(Required)
Position
(Required)
Phone Number
(Required)
Organizational /Employer Email
(Required)
May we contact the above person now?
(Required)
Yes
No
Number 2 Referee Name
(Required)
Company Name and Full Address with Post Code.
(Required)
Position
(Required)
Phone Number
(Required)
Organizational /Employer Email
(Required)
May we contact the above person now?
(Required)
Yes
No
Confidentiality Declaration
Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about our clients. On no account must information relating to identifiable client be divulged to anyone other than the manager. You should not disclose ANY information to your family, friends or neighbors. If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in disciplinary dismissal. I have read and I understand the above and I agree to abide by the contents therein.
Name
(Required)
Signature
(Required)
1. Rehabilitation of Offenders Act
DBS DISCLAIMER
A Disclosure and Barring Service check is necessary for the position you are applying for. Should you be successful in your application, you will be asked to sign a DBS disclaimer. This will be explained, in full, prior to signing the form. Rehabilitation of Offenders Act 1974 – Notice to Offenders Because of the nature of the work involved, the post for which you are applying is exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (Exemption Order 1975). This means that you are not entitled to withhold information relating to any convictions you may have had.
Do you have any convictions to disclose?
(Required)
Yes
No
If yes, please provide details of any convictions which are not spent under the terms of the Rehabilitation of Offenders Act 1974. This information will be treated as confidential and will not necessarily preclude you from employment. Details:
Details of any convictions
Name
(Required)
Signature
(Required)
2. DBS and Barring Checks
Do you have an Enhanced Disclosure Certificate from the Criminal Records Bureau (CRB) now known as Disclosure Baring Services?
Yes
No
If yes please provide DBS certificate number:
Have you subscribed for the ‘DBS Update Service’?
(Required)
Yes
No
I hereby give consent for SNS Healthcare to perform DBS check.
Name
Signature
3. Personal Declaration
I agree that SNS Healthcare Services Limited can create and maintain computer and paper records of my personal data and that this will be processed and stored in accordance with the General Data Protection Regulations (GDPR). I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated. I declare that the information given is correct to the best of my knowledge. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.
Name
(Required)
Signature
(Required)
Date
(Required)
DD slash MM slash YYYY
I confirm that the above statement is correct to my knowledge
Name
Signature
Date
DD slash MM slash YYYY
Employment Payment/ Banking details
PAYE (Pay as You Earn) Employees
Name
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Title
Frist Name
Middle (if any)
Surname
Bank Name
(Required)
Address
(Required)
Sort code
(Required)
Account no
(Required)
Health related matters
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
(Required)
Yes
No
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
(Required)
Yes
No
Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition, treatment and dates
(Required)
Yes
No
Do you think you may need any adjustments or assistance to help you to do the job?
(Required)
Yes
No
If you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected.
TB DECLARATION
Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006)
Have you lived continuously in the UK for the last year (Include Holidays/ Vacations)
(Required)
Yes
No
Have you had a BCG vaccination in relation to Tuberculosis?
(Required)
Yes
No
If you answered yes please state when
Date
DD slash MM slash YYYY
A cough which has lasted for more than 3 weeks
(Required)
Yes
No
Unexplained weight loss
(Required)
Yes
No
Unexplained fever
(Required)
Yes
No
Have you had tuberculosis (TB) or been in recent contact with open TB
(Required)
Yes
No
Immunisation History
Triple vaccination as a child (Diphtheria / Tetanus / Whooping cough)
(Required)
Yes
No
Date
DD slash MM slash YYYY
Polio
(Required)
Yes
No
Date
DD slash MM slash YYYY
Tetanus
(Required)
Yes
No
Date
Day
Day
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Month
Month
1
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Year
Year
2027
2026
2025
2024
2023
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1920
Hepatitis B (If Yes is ticked please give dates below)
(Required)
Yes
No
Date
DD slash MM slash YYYY
Course
1
2
3
Boosters
1
2
3
Health Assessment for Night Worker and policy statement
Definition of “a night worker”? A “night worker” is someone whose daily work includes at least three hours of night time:
• On most days they work;
• On a proportion of the days they work which is specified in a collective or workforce agreement; or often enough for it to be said that they work such hours “as a normal course”.
The words “as a normal course”, means on a regular basis. A Court ruling asserted that a worker who has worked at night for one third of his working time was a night worker. Occasional, or ad hoc, work at night does not make the employee a night worker. At SNS Healthcare every employee who wishes to work at nights and deemed as “a night worker” is offered an assessment in two parts,
a) Screening questionnaire
b) An Occupational Health Assessment
Q1. Do you suffer from any of the following conditions (you do not have to disclose which one(s) to your manager)?
(Required)
Diabetes Heart or circulatory disorders Stomach or intestinal disorders Any health condition which causes difficulties sleeping (except occasional insomnia) Chronic chest disorders, especially if night-time symptoms are troublesome Any medical condition requiring medication to a strict timetable or medication that Causes side effects that could be unpleasant or dangerous if working at night?
Yes
No
Q2. If you answered yes to question 1, has this been assessed by GP and/or other health professional, and were you assessed as fit for nights with or without adjustments?
(Required)
Yes
No
Q3. Has your condition deteriorated or treatment changed since your last assessment?
(Required)
Yes
No
Q4. Is there any other health factors that might affect fitness at work such as pregnancy or would you otherwise like to discuss your health and night work in confidence with an HR/recruitment consultant?
(Required)
Yes
No
Declaration
I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.
Name
(Required)
Signature
(Required)
Date
(Required)
DD slash MM slash YYYY
GDPR Consent Form
Company Name:
SNS Healthcare Services Ltd, 5 Chorley New Road,Bolton,BL1 4QR
Document:
Consent declaration
Topic:
Data protection GDPR
Version:
1
Consent
(Required)
I hereby give my consent to SNS Healthcare to process the following information
All Personal data including
• Name
• Date of birth
• Contact details, including telephone number, email address and postal address
• Experience, training and qualifications
• Professional Membership and NMC Registration
• CV
• National Insurance number
• Appraisal and Assessment records
• References
• Pension – auto-enrolment
• LCC / Umbrella Company details
• Biometric Data – Right to Work
Sensitive personal data
• Disability/health condition relevant to the role including health screening and immunisation history
• Equal Opportunity Monitoring Data
• Enhanced DBS Check
Signed by member
(Required)
Date
(Required)
DD slash MM slash YYYY
Declaration
I confirm that the above information is correct to the best of my knowledge
Name
(Required)
First
Last
Sign by Member
(Required)
Date
(Required)
MM slash DD slash YYYY
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