Personal Details
Yes
No
Next of Kin
Work Experience & Training
Please give details of your employent history from the last 10 years starting from your most recent
Name & Address Position Date From Date To Reason for Leaving Add
Please list any other agencies you are working for seperated by a comma (,)
Mandatory Requirements
Please provide the dates that you last undertook the following training courses and provide copies of certificates
Training Course Date of Last Training Date Update Required
Moving and handling
Fire precautions
Health and Safety
Infection Control
CPR (including newborns)
(1974/1999 Acts including COSSH/RIDDOR Other
Secondary Education
Please provide details of your Secondary Education
Qualification Grade
Further Education
Please provide details of your Further Education / Training
Qualification Grade
Work Preference
General Information
Yes
No
Yes
No
Yes
No
Please enter any other languages and your level in them.
Health Declaration
Have you ever suffered from any of the following
Please Answer all the Following Yes Additional Information
Tuberculosis, Asthma, Bronchitis, German Measles, Typhoid, Dysentery, Poliomyelitis, Rheumatic Fever, Jaundice/Hepatitis
Varicella (Chickenpox \ Shingles)
Chest pain, heart condition or high or low blood pressure
Epilepsy, fits, attacks of giddiness, blackouts, fainting, migraine
Depression, mental illness or nervous breakdown
Diabetes, thyroid or other gland trouble
Dermatitis, skin sensitivity (allergies), psoriasis, or eczema
Back or neck injury, back or neck problems or back or neck pain
Gastric problems, ulcers, irritable bowel syndrome, kidney or urinary conditions
Have you any reason to believe you may have been infected by by any communicable disease?
Any other current or recent medical condition or treatment which might affect your attendance or performance at work?
Any illness, condition or surgical operation that prevented you from attending work or your normal activities for more that a week during the past year?
Any physical abilities including defect of sight or hearing?
Please give details of any relevant or ongoing medication you are taking
Have you recently been resident outside the UK?
Are you registered under the Disabled Persons Act?
Have you ever knowingly been in contact with MRSA or worked in an MRSA environment?
Are you aware of the need to understand and be screened for MRSA?
Are you or have you ever been infected with tuberculosis (TB)?
Do you agree to abide by the government guidelines on AIDS / HIV infected healthcare Workers? (HSC 1998 / 226 ‘Guidance on the Management of AIDS / HIV Infected Health Care Workers and Patient Notification’)
Record of Immunisations
(Lab report from Occupational Health Department or letter from G.P. confirming your immunisation status is required)
Types of Immunisation Yes No Date / Results
Tetanus
Diptheria Schick Test
Rubella (German Measles)
Poliomyelitis
Hepatitis B
Antibodies Date of Result
Tuberculosis BCG
Chest X-Ray
Varicella
Do you agree to being health screened or to obtaining a certificate of fitness from your G.P. or an Occupational Health Service of required?
Yes
No
Rehabilitation 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 such 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 separate sheet even if you believe them to be "spent" or "out of date" or some other reason.
Have you ever been convicted of a criminal offence?
Yes
No
Have you ever been cautioned or issued with a formal warning for any criminal offence?
Yes
No
The Criminal Records Bureau, CRB, is the executive agency of the Home Office responsible for conducting checks on criminal records. We are a registered body for receipt of CRB 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 on all staff. It is a condition of proceeding with your application that you apply for a CRB disclosure (or that you produce an acceptable original disclosure which you have obtained). The Disclosure will be compared with the information given above in Section 7 and any inconsistencies could invalidate your application or lead to the cancellation of your registration with us.
.
Reference
Please give the names of two professional people of a senior / grade position to you, including your present and most recent employer whom we may approach for a nursing reference (not relatives or friends). They must be able to provide a credible comment on your ability to undertake the duties of the post applied for.
Home addresses of referees are not acceptable
Can we contact your referees before we interview?
Yes
No
reference 1
Was This person senior to you
Yes
No
reference 2
Was This person senior to you
Yes
No
Passport and Work Permits
People with an automatic right to work are citizens of the U.K., European Union and E.E.A. and certain Commonwealth citizens.
Do you need permission to work in the U.K.?
Yes
No
If yes please answer the following questions
Are you visiting Britain on a working holiday?
Yes
No
Do you hold a Student Visa
Yes
No
Do you require a work permit?
Yes
No
On entering Britain what entry was put on your passport by immigration? Write in full ORIGINAL DOCUMENTATION MUST BE SHOWN
Do you require a work permit or other permission to take employment in the U.K.
Yes
No
Work Permit
Yes
No
Working Time Directives
The European Union has laid down guidelines for all workers, governing the length of the maximum working week that it is safe 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 would you sign below to confirm that you have read and understood this information, indicating your preference by ticking the most appropriate box.
I DO NOT wish to work more than 48 hours per week.
I DO wish to work more than 48 hours per week.
Data Protection Act 1998 and Inspection
We are required to hold personal information on staff e.g. 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. From 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.
We would therefore be grateful if you would complete and sign the declaration below. If you have any concerns about this or want to discuss it further, please contact your branch manager.
I consent to the disclosure of information required to place me on assignments.
Yes
No
Note: Regulatory bodies such as Social Services, Care Standards Commission have the right to access personal files for inspection purposes in order to verify compliance with legislation and NCSC Regulations
Declaration
The information that I have given in this registration 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 Lucam Consultancy advised of any changes to any of the information supplied
Please ensure you include the following documentation with your completed registration form in the envelope provided.
No stamp required. N.B. Please note that if you send photocopies original documents must be brought with you on interview so consultants can sign photocopies as “original seen”.
Document Required Cross Box
2 Passport photographs
Proof of identity (birth and marriage cert, or new style driving licence photocard, passport
Copy of work permit, visa stamp and entry stamp in your passport for overseas applicants
Completed abilities form
Valid lab report or letter from doctor regarding your immunisation status
Relevant certificates of training
Proof of National Insurance Number
A copy of your Criminal Records Bureau Certificate or your completed CRB form and relevant original documentation