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Personal Details |
Forenames: |
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Surname: |
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National Insurance number: |
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Telephone: |
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Account number: |
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Mobile |
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Sort code: |
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Address: |
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Bank address: |
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Postcode: |
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Drivers licence number: |
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Date of birth: |
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Car registration number: |
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Employment record (starting most recently) |
Name/address of employer: |
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Job title/responsibilities: |
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Education/Further Education/Membership of Professional Organisations |
Dates from/to: |
School/College |
Examinations/Qualifications |
Grade/result |
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Relevant Training Record & dates courses attended |
Course Title: |
Training Provider/Location: |
Dates: |
e.g. First Aid |
e.g. NHS - Hull |
e.g. May 2008 |
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Professional referees |
Name: |
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Company: |
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Address: |
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Telephone: |
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Relationship: |
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Relationship: |
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Health declaration |
All personnel are required to complete this health declaration. |
Have you ever had any of the following? (including childhood) |
Heart/Circulatory illness |
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Blood disorders |
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Asthma/hayfever |
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Bronchition, pneumonia, pleurisy |
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Tuberculosis |
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Epilepsy |
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Diabetes - recent onset |
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Migraine, headaches |
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Diabetes - since childhood |
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Anxiety, depression |
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Dermatitis, psoriasis, eczema |
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Hearing loss |
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Frequent sore throat |
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Vision defects |
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Hepatitis/jaundice |
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Colour blind |
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Bladder/kidney disorder |
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Any deformities (movement) |
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Indigestion/stomach ulcers |
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Treated for weight loss |
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Any current infection |
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Diarrhoea/vomiting (6 months) |
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Any contact with MRSA |
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Any regular prescriptions |
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Are you registered disabled |
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Recent hospital treatment |
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Any major operations/illness |
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Any other physical disabilities |
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Date of last chest X-ray |
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Have you ever been vaccinated, immunised or tested for the following: |
Hepatitis B |
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Heaf, mantoux or tine |
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Hepatitis B Antibodies |
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Tuberculosis inc BCG |
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Rubella (German measles) |
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Poliomyelitis |
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Typhoid |
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MRSA |
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Tetanus |
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Other |
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GP's Name/Address: |
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Declaration: |
I declare the information given in this form is true. I am permitted to work in the United Kingdom. |
I have read and understood and agree to the conditions of work for temporary workers. |
I understand my application is subject to the receipt of satisfactory references & other checks. |
I undertake to inform you should I be convicted of any criminal offence in the future. |
I undertake to inform you immediately if I am engaged through your introduction, including the offer of permanent employment following a temporary assignment. |
I also acknowledge this information I will have access to as determined by the Data Protection Act 1984. |
I agree to respect the confidentiality of patients and any other information I have access to at all times.
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Professional Indemnity Insurance for carers |
Contribution to the scheme is compulsory and is currently £1 per week and automatically deducted from your wage payment. |
Under the terms of the scheme you are covered for negligence claims arising out of malpractice to a maximum value. |
Initials: |
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Role Suitability: |
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Availability/other interests/commitments/work preferences: |
Full or part time hours? |
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Early/late/nights/weekends? |
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Any hobbies? e.g. darts Weds night, football Saturday etc |
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Any part time college course? |
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Children - school hours? |
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Disability Discrimination Act 1995: |
Section one of this act describes a disabled person as a person with a 'physical or mental impairment which has a substantial or long term effect on his/her ability to carry out normal day-to-day activities'. |
Using this definition, would you consider yourself disabled? |
Tick the box for "Yes". |
If yes, do you require any special arrangements to be made to assist you if/when called for interview? |
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Verification of information: |
By initialling below, I certify that all inforation I have provided is correct and I understand that any false information I have given may result in a job offer being withdrawn. |
Initials: |
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Name: |
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Date |
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Additional information required for criminal record check purposes: |
Have you lived anywhere other than your current address in the last 5 years? If yes please list the details below. |
Address inc post code:
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Address inc post code:: |
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Have you ever been known by any other name? If yes please list the details below. |
Name: |
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Place of birth: |
Town: |
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By initialling below, I agree to give my permission for Staff Call UK to use my information within an online application to seek a Criminal Record Check prior to employment. |
Initials: |
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Name: |
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Date |
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