G15B Aston Court, Kingsmead Business Park
Frederick Place
HP11 1JU, High Wycombe
0333 7722 187
info@chromiumcare.com

PERSONAL DETAILS

Title: Mr/Mrs/Miss/Ms *

Sex *

Are you Male or Female

Name & Surname *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Home Number *

Mobile Number *

Email *

Confirm Email

Referrer *

Do you hold a current full UK driving licence? *

Drivers Licence Number (if applicable)

Upload CV (.jpg, .png, .pdf, .doc, .docx) *

Click or drag files to this area to upload. You can upload up to 2 files.

Bulk upload any qualifications you may have. P.S Please reduce the size of your documents if they are too big. You can make use of online tools to reduce sizes. e.g www.ilovepdf.com, https://imagecompressor.com. Allowed combined file(s) max size for upload is 1MB.

NEXT OF KIN (TO BE NOTIFIFIED IN CASE OF EMERGENCY)

Name *

Relationship to You *

Home Number

Mobile Number *

Next of Kin Address *

EDUCATION, TRAINING AND QUALIFICATIONS

SECONDARY AND FURTHER EDUCATION

(a) Name of School/College/University *

(a) Qualifications Currently Studying *

(a) Date From/ To *

(b) Name of School/College/University *

(b) Qualifications and Grade Obtained *

(b) Date From/ To

MANDATORY TRAINING

Course Training Date

Date of Next Update

Moving and Handling/Fire Safety: Training Date *

Moving and Handling/Fire Safety: Date of Next Update *

Health and Safety 1974/1999 Act Including COSSH/RIDDOR: Training Date *

Health and Safety 1974/1999 Act Including COSSH/RIDDOR: Date of Next Update *

Infection Prevention & Control: Training Date *

Infection Prevention & Control: Date of Next Update *

Basic Life Support/ First Aid: Training Date *

Basic Life Support/ First Aid: Date of Next Update *

Safeguarding Adults/ Children: Training Date *

Safeguarding Adults/ Children: Date of Next Update *

Management of Aggression & Violence: Training Date *

Management of Aggression & Violence: Date of Next Update *

Information Governance: Training Date *

Information Governance: Date of Next Update *

Lone Worker Training: Training Date *

Lone Worker Training: Date of Next Update *

Medication Management: Training Date *

Medication Management: Date of Next Update *

WORK HISTORY

Please ensure you complete this section even if you have a Curriculum Vitae. The NHS requires that ‘Employment history should be recorded on an application form which is signed’. Please ensure that you leave no gaps unaccounted for and it covers 10 years, or up to you education. Please use a continuation sheet if necessary.

Date From/To: *

Month and Year *

Employer *

Position/Title *

Work Address *

Grade *

Main Responsibilities *

Reason for Leaving *

WORK HISTORY (Additional Information)

If you have more than one work history, please add above for each using the below format:
Date From/To:
Employer:
Month & Year:
Position/Title:
Grade:
Main responsibilities:
Reason for Leaving

REFERENCES

CLINICAL REFERENCES

Please give the names and addresses of two clinical professional people of a senior/grade position to you from whom references may be obtained. One of these must be your present and most recent employer or agency whom we may approach for a nursing reference, excluding relatives. Please remember that the two references must cover the last 3 year period.

1. Name *

1. Position/Grade *

1. Phone Number *

1. Email *

1. Address *

1. Is this referee senior to you? *

1. May we contact this person prior to your interview? *

1. How long has this person known you? *

CLINICAL REFERENCES TWO

2. Name *

2. Position/Grade *

2. Phone Number (copy) *

2. Email *

2. Address *

2. Is this referee senior to you? *

2. May we contact this person prior to your interview? *

2. How long has this person known you? *

WORK PREFERENCES

When are you able to work? *

Date Available to start *

Please state the specialised areas in which you feel competent and confident to work: *

List your choices in this order:
1st Choice: 2nd Choice: 3rd Choice

Would you be willing to work at short notice? *

Yes or No

Do you have any commitments that reduce your flexibility to work? *

Yes or No

Please list any other agencies you are currently registered and work for: *

COMPETENCIES, SKILLS AND EXPERIENCE

General Competencies: Level of competency of the English Language

Written English *

Please pick one option: Fluent | Good | Fair

Spoken English *

Please pick one option: Fluent | Good | Fair

Have you passed each of the academic modules of the IELTS test? *

Yes or No

Please write down all skills/competencies in which you have experience.

Seperating your answers using commas, please select options from below e.g: Hair Care, Eye Care.......

Personal Hygiene *

Toileting *

Emptying of catheter bag | Care of bladder and bowels | Use of bedpans/commodes etc | Recording fluid balance | Changing a colostomy bag

Mobility *

Lifting and transferring of patients | Lifting and handling course | Use of hoists | Use of walking aids

Observation *

Temperature | Respiration | Pulse | Urine Testing

Nutrition *

Recording & Observation *

Record instruction from GP/District Nurse | Observe changes in patient/client’s condition and report to the person in charge of their care

DECLARATIONS

DISCLOSURE AND BARRING SERVICE (DBS)

The Disclosure and Barring Service (DBS - formerly 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 DBS disclosure information. NHS Trust and Private Sector hospitals and nursing homes insist on agencies making information recruitment decisions which require DBS checks to be made on all staff. It is a condition of proceeding with your application that you apply for a DBS disclosure check. The disclosure will be compared with the information given below and any inconsistencies could invalidate your application or lead to the cancellation of your registration with us.

REHABILITaTION OF OFFENDERS ACT 1974 AND CRIMINAL RECORDS

By virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986 the provi- sion 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 there- fore list all offences below even if you believe them to be ‘spent’ or ‘out of date’ for some other reason.

Have you been convicted of a criminal offence? *

Yes or No

Have you ever been cautioned or issued with a formal warning for a criminal offence? *

Yes or No

Signature *

Please use a stylus or your finger to sign above as accurately as possible.

Date *

RIGHT TO WORK

It is a legal requirement that before any offer of work can be made all candidates provide the company with confirmation of their eligibility to work in the UK by providing one of the original documents detailed below

A passport which describes the holder as a British Citizen or as having a right of abode in the United King- dom or a passport or other travel document to show that the holder has INDEFINITE LEAVE TO REMAIN in the United Kingdom and is not precluded from taking the work in question. *

Yes or No

A passport or identity card issued by a State which is a party to the European Union and EEA agreement and which describes the holder as a national or a state which is a Party to that agreement. *

Yes or No

A letter issued by the Home Office or the Department of Education and Employment indicating that the per- son named in the letter has permission to take agency work in question or a biometric residence permit. *

Yes or 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. You are under no obligation to accept work offered to, therefore you will never be compelled to work more than 48 hours per week but you may choose to do so. Please confirm that you have read and understood this information by indication your preference below.

Do you wish to work more than 48 hours per week *

Yes or No

Signature *

Please use a stylus or your finger to sign above as accurately as possible.

Date *

REGISTRATION FORM DECLARATION

I declare that all information given in this registration form is to the best of my knowledge complete and accurate in all respects and that I am eligible to work in the UK. I understand that any false or misleading information may result in my removal from SNA’s register of members.

Signature *

Please use a stylus or your finger to sign above as accurately as possible.

Date *

Full Name & Surname *

FOR OFFICE USE ONLY

REFERENCE ONE

Date Sent:

Signature 1:

Use finger or stylus to sign above on dotted line

Date Received

Signature 2:

Use finger or stylus to sign above on dotted line

REFERENCE TWO

Please select only the areas in which you wish to be offered Locum work.

Date Sent:

Signature 1:

Use finger or stylus to sign above on dotted line

Date Received:

Signature 2:

Use finger or stylus to sign above on dotted line

Job Application Form

PERSONAL DETAILS

NEXT OF KIN (TO BE NOTIFIFIED IN CASE OF EMERGENCY)

EDUCATION, TRAINING AND QUALIFICATIONS

MANDATORY TRAINING

Course Training Date

Date of Next Update

WORK HISTORY

REFERENCES

CLINICAL REFERENCES

CLINICAL REFERENCES TWO

WORK PREFERENCES

COMPETENCIES, SKILLS AND EXPERIENCE

Please write down all skills/competencies in which you have experience.

DECLARATIONS

DISCLOSURE AND BARRING SERVICE (DBS)

REHABILITaTION OF OFFENDERS ACT 1974 AND CRIMINAL RECORDS

RIGHT TO WORK

WORKING TIME DIRECTIVES

REGISTRATION FORM DECLARATION

FOR OFFICE USE ONLY

REFERENCE ONE

REFERENCE TWO

PERSONAL DETAILS

NEXT OF KIN (TO BE NOTIFIFIED IN CASE OF EMERGENCY)

EDUCATION, TRAINING AND QUALIFICATIONS

MANDATORY TRAINING

WORK HISTORY

REFERENCES

WORK PREFERENCES

COMPETENCIES, SKILLS AND EXPERIENCE

Please write down all skills/competencies in which you have experience.

DECLARATIONS

DISCLOSURE AND BARRING SERVICE (DBS)

REHABILITATION OF OFFENDERS ACT 1974 AND CRIMINAL RECORDS

RIGHT TO WORK

WORKING TIME DIRECTIVES

REGISTRATION FORM DECLARATION