Nurse Application Form "*" indicates required fields Step 1 of 7 – Personal Information 0% Personal DetailsMarital Status*SingleMarriedDivorcedWidowedSeparatedDomestic PartnershipNationality*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsName* Title Mr.Mrs.MissMs.Dr.Prof.Rev. First Name Surname Date of Birth* Day Month Year Email* National Insurance Number* Mobile Number*Home TelHome Address* Street Address Address Line 2 Town/City County Post Code Next of Kin (NOK)Please provide details for who should be contacted in case of emergency.NOK Name* NOK First Name NOK Surname Relationship* NOK Mobile Number*NOK Email Address NOK Home Address Address Line 1 Address Line 2 (optional) Town County Post Code Professional DetailsQualification(s) Held* NMC PIN* Has there been any proceedings of medical negligence or professional misconduct against you, and have you ever been suspended or dismissed from your employment?* Yes No Briefly Supply Details*Clinical Experience*Tick any boxes to indicate your areas of expertise A&E (ANP)Advanced Nurse Practitioner Cardiac Chemotherapy Clinics Community Nurse Complex Care (Homecare) Diagnostic imaging x-ray Dialysis Elderly Care (ENP)Emergency Nurse Practitioner Endoscopy General Wards Gynaecology HDU Health Visitor Homecare ITU Learning Disabilities Medical Mental Health Midwifery Neonatal NICU Nurse Assessor Nurse Practitioner Nursing Homes Occupational Health ODP Oncology Orthopaedics Paediatrics A&E Paediatrics Palliative Practice Nurse Prison Radiology Recovery Renal SCBU School Nursing Surgical Theatre Triage Urology Walk-in Centre’s Homecare Experience*As you have indicated you have Homecare experience, Please tick the boxes next to each of the following care areas where you have received formal training or have experience. This information will help us match service users with the most appropriate care professionals to meet their specific needs. Bowel Management Brain Injuries Cerebral Palsy Chronic Pain Management Colostomy Congenital Disorders Management Cough Assist Deep Suctioning Dementia Care Dermatological Care Diabetes Management Dysphasia Elderly Care Epilepsy Female Catheter Care Gastrostomy Care/PEG – Feeding ileostomy Immunocompromised Patient Care Invasive Ventilation IV Therapy Male Catheter Care Medication Administration Nebuliser Administration NG Tube Management NJ Tube Management Non-Invasive Ventilation Oral Suctioning Oxygen Therapy Paediatric Care Palliative and End-of-Life Care Personal Care Post-operative Care Seizure Management Speech and Language Impairment Spina Bifida Tracheostomy Care Wound Management Travel & Work PreferencesDo you have a valid driver's licence and do you use a vehicle for commuting to work?* Yes No If yes, please provide your vehicle registration number.Optional: This information will be used only in emergencies, such as if you cannot be reached by us or your next of kin following a scheduled shift. Would you temporarily relocate for work (with accommodation)?* Yes No How many hours are you available to work each week?* Under 12 Hours 12 – 24 Hours 24 – 36 Hours 36+ Hours How far are you willing to travel for work?Enter Distance or Travel Time. Please choose your preferred shift patterns Days Nights Weekends Flexible for any Bank DetailsPlease inform us how you wish to be paid. If you prefer, you can submit this information after completing your registration.Payment Method PAYE (Standard method for payment) Umbrella Limited Company (Only available if the job role falls outside IR35) Umbrella Company Name Limited Company Name Bank Name e.g Barclays BankBank Account Name Account Number Sort Code Rehabilitation of Offenders ActBecause 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 applies. 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.Have you at any time been convicted of an offense?* Yes No If 'Yes', Briefly Supply Details*Disclosure & Barring ServiceDo you have a DBS Certificate that is registered on the Update Service? Yes No DBS Consent 1* I agree that Center Healthcare can access the DBS update service portal to check for any changes to my DBS clearances as and when necessary.*DBS Consent 2* I undertake to inform Center Healthcare should I be convicted of an offence in the future.* ReferencesWe require the names and work contact information for two referees from your current or most recent employers, including at least one who is in a senior position relative to you. These references should cover a collective period of at least three years to verify your employment history.Do you wish to provide your reference details at this stage?*You can choose to provide your referee details at a later date. Yes No First Reference* First Name Surname Employment Position* Email* PhoneWhat was/is your professional relationship with this person?* Date From* Day Month Year Date To*Use today’s date if you still work with them. Day Month Year Second Reference* First Name Surname Employment Position* Email* PhoneWhat was/is your professional relationship with this person?* Date From* Day Month Year Date To*Use today’s date if you still work with them. Day Month Year HiddenInductionHiddenInduction I have received a copy of the induction pack and can confirm that I am aware that more information can be found in the Agency Worker Handbook and all Policies can be obtained directly from www.centerhc.com/policies. HiddenInduction I have received (or downloaded) the company handbook and have understood and will always comply with it. I am aware that any amendments or new versions will be available at www.centerhc.com/downloads HiddenHepatitis BHiddenHep B I have been advised at registration of the importance of having the Hepatitis B vaccine.HiddenHep B I acknowledge that I have been/am being vaccinated against Hepatitis B and will continue to maintain my immunity.HiddenHep B I accept responsibility for my decision, and I will ensure that I take all precautions to avoid contracting the illness and avoid accepting work within environments which are hazardous. Data ProtectionGDPR1* I agree that Center Healthcare retains the right to hold this application and any other data required to process it and to pass on to any authorised third party for the purposes of audit and work placements. *GDPR2 I agree that Center Healthcare can retain these details for as long as reasonably necessary in accordance with the Data Protection ActGDPR3* I understand that I am responsible for ensuring that my personal compliance such as my NMC registration, re-validation, DBS update service and mandatory annual training are kept up to date. If any of my compliance items lapse, it may cause the suspension and/or termination of my placement and I will be unable to work until my compliance items are updated.*The 48 Hour Maximum Average Working WeekIn accordance with the Working Time Regulations 1998, the average working week, including overtime, should not exceed 48 hours. By law, you have the option to either adhere to this limit or choose to work more hours if you prefer. How do you wish to proceed with the 48-hour work week limit?*Should you change your mind at any time, you can email us at [email protected] to inform us of this. Opt-Out: I choose to opt-out, allowing me to work more than 48 hours per week at my convenience. Opt-In: I choose to opt-in, and i understand this means I cannot and will not work more than 48 hours per week. Terms & ConditionsT&C 1* I confirm that the information given in this application is, to the best of my knowledge, true.*T&C 2* I understand that my registration is subject to the receipt of at least two satisfactory references and an enhanced disclosure from the Disclosure and Barring Service (DBS).*T&C 3* I undertake to inform Center Healthcare immediately if I am engaged through their introduction, including the offer of permanent employment following a temporary assignment.*T&C 4* I agree to respect the confidentiality of patients and any other information I may have access to, at all times.*T&C 5* I understand that Center Healthcare cannot guarantee assignments and that they have no responsibility to pay for hours not worked no matter the situation.*HiddenHep B I have read, understood and agree to the terms & conditions of work for temporary nurses, of which I have been given a copy or have downloaded from Center Healthcare’s website.CAPTCHASignature*Sign Date* DD slash MM slash YYYY
