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ACCESS 24- Application Form- RN & HCA- Public & Private Sector

Thank you for choosing Access247 Care Ltd! We’ve tried to make our Application Form as easy to complete as possible but if you have any issues, please click here to contact us and we’ll guide you through.

If you can’t complete the form immediately, that’s fine! At any time, simply click “save” at the bottom of the page and you’ll receive an e-mail with a link to your form, enabling you to continue where you left off.

Don’t worry if you can’t upload all the requested documents at this stage, we will need you to present originals at your interview.

Once you’ve completed the form, hit the Submit button and we’ll be in touch to schedule your interview.

About You

Title *

Mr
Mrs
Miss
Ms

Name

Known as

Maiden Name

What is your gender (Assigned at birth)

Male
Female

Date of Birth

National Insurance Number

Home Phone Number

Email *

Confirm Email

Are you a car driver with a valid licence and access to a car / motorcycle for work purposes?

Number / Name of Property

Street Name

City

County

Country

Postcode

Do you have any Dependants? (Children)

Where did you hear about us?

How long have you worked in Health / Social Care?

Please tick any of the below that you have experience in (You may select multiple)

Adolescent
Adults
Dementia
Orthopaedics
Oncology
Neuro (Medical)
Health Visitor
School Nurse
Venepuncture
ITU Cardiac
Surgical

Job Title

Have you ever been suspended from the register or dismissed, or have there ever been any proceedings of medical negligence made against you? *

If yes, please supply the details:

Have you ever been restricted from working at any Trust?

If yes, please supply the details:

Are you aware of any investigations against you with your current or any previous employers?

If yes, please supply the details:

What is your Ethnic Group?

White
Mixed
Asian
Black or Black British Mixed
Chinese

Any other group not listed above, please state;

Next of Kin Name *

First

Last

Relationship

Phone

Nationality

Do you have any Right to Work in the UK restrictions? *

Do you have a visa or permit? *

Status *

Employed
Trainning / Education
Other

Referee Name 1 *

First

Last

Company

Job Title

Phone

Email *

Referee Name 2 *

First

Last

Email (please use your business email) *

Phone

Company name

Company Size

Country

Postal Code

I am a...

Care home manager or similar (looking for staff to fill shifts)
Nurse, carer or support worker (looking for shifts)
NHS Trust
Other (I do not work in healthcare)

All candidates will be required to have an enhanced DBS unless registered with the Update service. Have you had a DBS check?

Type of Disclosure

DBS Issued Date

Reference Number

Are you on the Update Service

Have you ever been convicted of a criminal offence which is not 'protected'?

If you have answered yes, please supply full details of all convictions

Protection Of Children And Vulnerable Adults Declaration Has any Social Service Department or Police Service ever conducted an enquiry or investigation into any allegations or concerns that you may pose an actual or potential risk to children or vulnerable adults?

Have you ever been convicted of any offence relating to children or vulnerable adults?

Have you ever been the subject of any disciplinary procedure or been asked to leave employment or voluntary activity due to inappropriate behaviour towards a child or vulnerable adult?

If yes to any of these questions please give details below

Date

Mandatory Care Training

NOTE: We require the following Mandatory Care Training modules to be completed annually: Basic Life Support, Safeguarding Children & Adults 1 & 2, Complaints Management, Equality & Diversity, Fire Safety, Food Hygiene, Health & Safety, Infection Control, Information Governance, Learning Disability Awareness (Inc Autism), Lone Worker, Medicine Management, Mental Capacity Act, Mental Health Act, Moving & Handling.

PMVA (Prevention and Management of Violence and Aggression)

Safeguarding Level 3 (Adults & Children)

Immediate Life Support

Attestation

I understand that I must at all times, avoid moving and handling any person or object which may put my physical health or the clients well-being at risk
I understand that I may have to complete training in order to work with Access 247 Care Ltd and I must pay for any training I undertake

1) Have you knowingly been in contact with MRSA? If yes, were you swabbed and what were your results and dates?

PRE-EMPLOYMENT DECLARATION OF HEALTH Please answer all of the following questions accurately. If you answer ‘YES' to any, please provide details. It is your responsibility to inform Access 247 Care Ltd immediately if any of the following changes:

2) Have you ever had either a drug or alcohol problem?

3) Have you got any allergies?

4) Have you got any impairments that may affect your ability to work safely?

5) Is there any aspect of your medical history that an employer should know?

6) Have you ever suffered any mental illness episodes and / or psychological problems, including stress related disorders?

7) Are you pregnant?

8) Are you currently taking any prescribed medication?

9) Are you currently receiving any treatment?

10) Have you any reason to believe that you may be infected by a high risk infection or disease?

HAVE YOU EVER, INCLUDING YOUR CHILDHOOD, SUFFERED FROM OR RECEIVED TREATMENT FOR:

11) Chicken Pox or Varicella Zoster virus?

12) German Measles?

13) TB,Tuberculosis?

14) Hepatitis A, B or C / Jaundice?

15) Skin disorders,skin disease,skin reactions?

16) Diabetes?

17) Thyroid problems or other glandular problems?

18) Cardiovascular disorders or diseases or symptoms, including, high blood pressure, angina, low blood pressure?

19) Epilepsy, fainting attacks?

20) Any kind of back or joint problems?

21) Respiratory symptoms, including asthma, bronchitis, pneumonia, pleurisy?

Rubella

Immunisation

Measles

Immunisation

Tetanus

Immunisation

Tuberculosis

Immunisation

Hep B

Immunisation

Polio

Immunisation

COVID- 19 Vaccination Status Have you received both doses of your COVID- 19 vaccine?

Will you be working as 'Pay As You Earn' or paid through a Limited Company?

PAYE
LIMITED COMPANY

Sort Code

Account Number

Attestation

I authorise Access247 Care Ltd to pay my weekly earnings directly to the bank or building society whose details I have given above. I confirm that I will notify Access247 Care Ltd in writing of any changes to these details.

If you were referred by someone who is registered with Access 247 Care Ltd, please specify their name

Full name

Date

ACCESS 24- Application Form- RN & HCA- Public & Private Sector

About You

Thank you for taking the time to complete our Application Form!