Please complete all details in block capitals and return to us as soon as possible
Names should be in full, in print as appearing on HPC/NMC registration and passport
*We require one of the following original documents showing your NI number: a pay slip from a previous employer; a P45; a P60; a NINO card; a letter from a previous employer or government department. If you are unable to provide this information, please contact the Department for Work Pensions in order to obtain a National Insurance Number.
*I can confirm that I am entitled to work in the UK and will provide TEMPCARE24 with the relevant original documents in accordance with the Asylum and Immigration Act (1997)
Please be particularly careful to provide details of all previous employment and gaps in employment if any. This record should include all your work history. Please use the continuation sheet provided.
Please give the names of two professional referees (from you 2 most recent engagements). Referees must be your Line Managers.
May we contact your current employer?
Yes
No
Manual Handling
Health and Safety
Fire Safety
Infection Control
Data Protection
Basic Life Support
COSHH / RIDDOR
Safeguarding of Vulnerable adults
Lone Worker
Mental Health Act
Other Relevant Training
The Working Time Regulations 1998 (“The Regulation”) require TEMPCARE24 also trading as Red Nursing Limited to limit your average weekly working time unless you agree with Red Nursing that the limit shall not apply to contract with us.
The 48hr time limit will not apply to you
Either party may terminate the agreement (so that the time limit will apply to you) by giving the person at TEMPCARE24 to whom you usually report 4 weeks written notice. Unless it is terminated in this way, this agreement shall remain in force until your contract with us terminates.
Under regulation, TEMPCARE24 must keep records relating to your working time. This is the case whether or not you reach an agreement with Red Nursing about waiving time limits.
Please sign below to confirm you agree that this time limit on your working hours will not apply to your contract with TEMPCARE24 & that your average working week may therefore exceed 48 hours in any given period.
If you are intereated in joining a Limited/ Umbrella Company please tick this box and We will have a representative call you with more information about this service:
I am Interested in Joining
Limited Company
Umbrella Company
If you require to be paid through a UK limited or Composite, then the following details are required. N.B.Please leave blank if you wish to be paid under PAYE.
How would you like to be paid?
PAYE
Applicants for healthcare positions are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare prosecutions or convictions, including those considered ‘spent’ under this Act.
Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations, which might lead to a conviction, an order binding you over or a caution in the UK or any other country?
If yes, please provide details of the criminal offence, order binding you over a caution, including approximate date, the offence and the authority and country which dealt with the offence.
All candidates registering with TEMPCARE24 must have a pre-appointment health checks are carried out to: ensure that prospective agency workers are psychologically capable of doing the work proposed, taking into account any current or previous illness, Identify anyone likely to be at excess risk of developing work-related diseases from hazardous agents present in the workplace and ensure, as far as possible, that prospective agency workers do not represent a risk to patients and that they will be doing work that is suitable and safe for them.
I am not aware of any health conditions or disability which might impair my ability to undertake effectively the duties of the position which i have been offered.
I do have a health condition or disability which might affect my work and which might require special adjustments to my work or at my place of work.
I Declare that the information in this form is true and complete to the best of my knowledge. I agree that any deliberate omission, falsification or misrepresentation in application for registration may be grounds for rejecting my applicaion or subsequent removal from Red Nursing active Register of workers. I hereby agree to inform Red Nursing any changes in my health circumstances that may affect my ability to work.
I acknowledge that my personal details will be stored and handled by the Occupational health provider of choice in accordance with the data protection ACT 1998. I agree that they may be made available for audit or other legitimate purposes to NHS Bodies and hospitals
* Yes I Agree
You answers to this questionnaire will be CONFIDENTIAL to Occupational Health and will not be given to anyone else without your written permission. The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you wish to register for or place you at any risk in the workplace. Occupational Health may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Please help us to help you by completing the questionnaire as fully as possible.
1. Where were you born and raised? *
2. Have you arrived in UK within the past 12 months? *
3. If Yes, Where and when did you have the vaccine? *
4. Do You have a history of or any current symptoms of tuberculosis? *
5. Do You have a family history of tuberculosis? *
6. Have you had an interferon gamma test within the past 12 months? *
7. Have you had chicken pox or shingles infection? *
8. If Yes, in what country did you contract the disease? *
Dates of immunisations and blood tests Please provide the following details of your immunisation record and enclose your most recent certificates or laboratory reports: Please Email any records or certificates seperatley to enquries@tempcare24.co.uk
9. Measles, Mumps & Rubella MMR, Vaccines x 2 : *
10. Mantoux text within the last 5 years, chest X-ray or interferon gamma test: *
11. Hapatitis B vaccine first course: *
12. Hapatitis B 5 year booster (Post Primary Course): *
13. Hapatitis B (showing titre levels > 10miu/ml): *
14. Rubella antibodies (German Measles): *
15. Varicella antibodies (if you have never suffered from chicken pox or shingles): *
16. BCG (Tuberculosis Vaccination): *
If yes, do you have evidence of a BCG scar?(Please note this needs to be viewed and documented by a UK Occupational Health department in your health screening)
17. Does the position you are being offered require you to undertake exposure prone procedures (EPP) as defined in the accompanying guidance : *
If yes you cannot perform EPP until you have supplied suitable test certificates from a UK Occupational Health Department for HIV. Hepatitis C and Hepatitis 8 (if you do not have the required documentation we will be able to perform the relevant test for you). These are mandatory for any EPP post. Results must be less than six months old and indicate that it was an identity validated sample (IVS) on the serology report.
18. Does the position you are applying for require you to assist with renal dialysis? *
If you must supply suitable identity validated test certificates from a UK Occupational Health Department before you can start for Hepatitis B. Results must be less than six months old and indicate that it was an identity validated sample (IVS) on the serology report.
19. Do You think you may need any adjustments or assistance to help you to do the job? if Yes, Please give details below. *
If Yes, please give details below.
20. Are you having or waiting for treatment including medication or investigation at present? *
If YES please provide future details of the condition, treatment and dates.
a) A cough which has lasted for more than 3 weeks? *
b) Unexplained weight loss? *
c) Unexplained fever? *
Have you had tuberculosis(TB) or has been in recent contact with open TB?: *
If yes, please give details below.
I give permission for a member of the Occupational Health team to communicate with my own general practitioner, or any other health professional, if further information is required and for that GP or healthcare professional to give details of my clinical condition or other relevant information to the OH advisor/physician. I understand that I shall be contacted to obtain my fully informed consent before any report is requested and that under the Access to Medical Reports Act, 1988: I have the right to see the report before it is sent. I am entitled to ask the doctor to amend or modify information which I consider is inaccurate. I have 21 days from notification to seek access to the report.
Would you like to access this report? *
Declaration I declare *
I Declare
Date *
I understand that if any recommendations to my employer are necessary as a result of a Work Health Assessment, Occupational Health will discuss the recommendations with me before making them to TEMPCARE24.
I give consent for IH@W to make recommendations to TEMPCARE24, without me having seen a written copy of the recommendations first. *
I would like to see a written copy of any recommendations Occpational Health may make to Red Nursing before they are sent. *
Declaration *
By completing this form, you agree to join our Group of Agencies.
* All public and private organisations request that an Enhanced Disclosure be obtained for all healthcare personnel which is acquired from the Criminal Records Bureau or Disclosure Scotland through TEMPCARE24. Copies of Red Nursing policies on the Rehabilitation of Offenders Act and Storage and Disposal of CRB Disclosures are available on request.
Have you been, or are you currently subject to, any fitness or practice proceedings, or suspension from an employer, or are such pending of threatened against you either in the UK or any other country?
If yes, please provide details of the nature of the proceedings undertaken, or contemplated, including the approximate date of proceedings, country where the proceedings were undertaken and the name and address of the licensing or regulatory body concerned.
There are positions which you may be offered, for which Professional Indemnity is mandatory. In all cases, we strongly recommend that healthcare workers take out and maintain Medical Insurance.
*I do not currently hold Professional Indemnity Insurance
*I confirm that I have read this document fully and that all the information given to TEMPCARE24 is correct to the best of my knowledge and belief. I understand that a false declaration may lead to refusal of this application. If, while I am working with TEMPCARE24, any of the information provided changes, I agree to notify TEMPCARE24 in writing immediately. I understand and agree to TEMPCARE24 disclosing this information to their clients for the purpose of finding me assignments. I have read, understood and accept the information contained within the Staff Handbook I have read and agree to adhere to the Red Nursing Terms of Engagement.
*I consent to TEMPCARE24 and its associated partners/ companies for storing my details securely on its UK database to find suitable assignments and advise me regarding related medical services. The information I have provided is accurate and up-to-date.
*I Agree "Terms and Conditions"
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