Step 1 of 10 10% PERSONAL DETAILSName* First Middle Last Email* Phone* Address* Street Address City Post Code Telephone*National Insurance Number*Are you legally eligible to work in the United Kingdom?*YesNoREHABILITATION OF OFFENDERS ACT Because of the nature of the work for which you are applying, this post is exempt from the provisions section 2.4 of the ehabilitation of Offenders Act 1974 (Exemption order 1975). Applicants are therefore not entitled to withhold information about convictions which for other purposes are “spent” under the provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the order applies, and should be entered at the end of any articulars you give in support of your application. A copy of our written policies is available on request. A criminal record will not necessarily be a bar obtaining position. Do you hold a full UK Driver's Licence?YesNoDo you have daily use of a car?YesNoREHABILITATION OF OFFENDERS ACT Because of the nature of the work for which you are applying, this post is exempt from the provisions section 2.4 of the Rehabilitation of Offenders Act 1974 (Exemption order 1975). Applicants are therefore not entitled to withhold information about convictions which for other purposes are “spent” under the provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the order applies, and should be entered at the end of any particulars you give in support of your application. A copy of our written policies is available on request. A criminal record will not necessarily be a bar obtaining position. Do you have any convictions, cautions or reprimands that are not protected as defined by the Rehabilitation of Offenders Act (amended 2013)*YesNoAre you aware of any Police enquiries undertaken following allegations made against you which may have bearing on your suitability for the role you are applying for ?YesNoDo you have a full and Enhanced DBS certificate from the last 12 months*YesNo MANDATORY TRAININGBasic life supportYesNoEquality, Diversity & Human RightsYesNoHealth, Safety & WelfareYesNoHandling Violence & Aggression/Conflict ResolutionYesNoFire SafetyYesNoInfection Prevention & Control Level 1 & 2YesNoMoving & Handling Level 1 & 2YesNoSafeguarding Adults (Inclusive of Mental Health & Mental Capacity)YesNoSafeguarding Children Level 1 & 2YesNoPreventing RadicalisationYesNoInformation Governance (Inclusive of Counter Fraud)YesNoFood HygieneYesNoPhysical Restraint AwarenessYesNoYour Healthcare CareerYesNoDuty Of CareYesNoPerson Centred CareYesNoCommunicationYesNoConsentYesNoPrivacy & DignityYesNoFluids & NutritionYesNoDementia AwarenessYesNoBlood Component TransfusionYesNo SKILL SETLEVEL OF COMPETENCE Enter number in accordance with your level of expertise as indicated below: 1: I am familiar with this procedure and can perform independently. 2: I am familiar with this procedure but would need supervision. 3: Understand the theory behind the procedure, but have not performed it. 4: No contact with the equipment of this situation. No knowledge of procedure.PERSONAL HYGIENE: Bath, shower, assisted wash Use of bath aids Mouth care (inc dentures) Care of feet (exc. toenails) Dressing/Undressing of patients Bed bath Shaving Care of hair Care of fingernails Care of eyesPlease enter a value between 1 and 4.TOILETING: Use of bedpans/commodes Recording fluid balance Emptying a catheter bag Care of incontinent patientPlease enter a value between 1 and 4.NUTRITION: Preparation of meals Feeding a helpless patientPlease enter a value between 1 and 4.MOBILITY: Lifting/Transferring patient Use of walking aids Use of hoists Lifting/handling course (evidence required)Please enter a value between 1 and 4.GENERAL Pressure area care Washing of personal laundry Bed making: changing a bed or drawer sheet with patient in/on it Light housework Shopping Care of terminally illPlease enter a value between 1 and 4.OBSERVATION: Temperature Respiration Blood pressure Pulse Urine testingPlease enter a value between 1 and 4.Do you have experience working in Hospital?YesNoDo you have experience working in Nursing Homes?YesNoDo you have experience working in Hospice?YesNoDo you have experience working with patients with dementia?YesNoDo you have First Aid experience?YesNoDo you have experience in (Report writing/giving)YesNoDo you have experience in (Report writing/giving)YesNoOther Skills/CommentsNight Worker Health AssessmentDo you suffer from any of these conditions?Diabetes?YesNoHeart or circulatory problems?YesNoStomach or intestinal problems, such as ulcers?YesNoAny medical condition which causes difficulty sleeping?YesNoChronic chest disorders where night time symptoms may be particularly troublesome?YesNoAny medical condition where the timing of meals is particularly important?YesNoAny mental health problems which may be affected by night work?YesNoAny other medical condition which may affect your ability to work safely at night?YesNoAre you a new or expectant mother? (optional question)YesNoIf you have worked at night before, did this cause any ill health?YesNoIf you have answered 'yes' to any of the above, please give more details i.e when condition developed, is this new, how severe, its effect on you, how well controlled and treatment so far. NEXT OF KIN DETAILSName First Surname Address Street Address City Post Code Phone EQUALITY MONITORING FORMPriority Professional Placements Ltd operates an equal opportunity policy. To help us monitor the effectiveness of this policy, please complete this section of the form. This monitoring form will be detached from your application form and will be kept separately from the information to be used in the selection process. How would you describe your national identity?EnglishBritishWelshScottishNorthern IrishOtherWhat is your gender?MaleFemalePrefere not to sayPlease state if you have any long-term physical or mental condition that affects your ability to carry out day-to-day activities. (Advice can be obtained from the EHRC 0845 604 6610):Please state your date of birth (leave it blank if you prefer not to disclose) Religion or belief: Please state your religionChristianBuddhistProtestantHinduJewishMuslimSikhother denominationsNo religion or BeliefSexual Orientation: Please indicate your sexual orientationHetrosexual/StraightGay woman/ LesbianGay ManBiosexualOtherPrefer not DiscloseAre you married or in a civil partnership?YesNo REFERENCESPlease give the names, addresses and telephone numbers of TWO referees,current employer and previous/most recent employer, who is in a position to comment on your work experience and suitability for the post to which you have applied. If you have been unemployed or did not work for a period of time, you could provide the name of a Head teacher or course tutor, supervisor etc. PLEASE DO NOT GIVE NAMES OF FAMILY MEMBERS OR FRIENDS. Reference 1Name First Name Surname Company Name*job title*Email Address Street Address City ZIP / Postal Code Reference 2Name* First Last Company Namejob titleEmail Address Street Address City ZIP / Postal Code I declare that the information given by me on this application form to be accurate and correct. I can confirm that I am of sound physical and mental health and accept full responsibility for maintaining my general fitness to practice. I am entitled to take up paid employment in the U.K. I hereby give permission for Priority Professional Placements Ltd to contact the Home Office/Border Immigration Agency in order to establish my current and ongoing immigration status and eligibility to work. I agree to complete an application at an enhanced level to the DBS. This will include a check against the children and adult barred list. I also agree to complete a pre-registration health declaration and full immunisation check in accordance with the Department of Health (DOH) and NHS Employer guidelines. I understand that in this form I may have supplied information which constitutes sensitive personal data, as defined in the Data Protection Act 1998. I give my consent to the Agency to process such data for the purposes of health and safety and also as may be necessary for NHS audit and law and tax enforcement or assessment purposes. I consent to such information being passed on to such persons as shall be necessary for the purpose of assessing my suitability for an assignment.*Agree DBS CertificationCV should contain: 1. Education History covering at least 11 years (any gaps must be explained). Dates should be (mm/yyyy) format. And should include name of Institution, certificate awarded, grades obtained and country of study. 2. Current or previous employer. (Please begin with the most recent first, including employment agencies). NOTE: Any gaps in employment history must be explained. )Certificates or qualifications Drop files here or Right to work (passport or biometric residence permit)Banking DetailsProof of address (Utility Bill)*Please feel free to contact the bookings department on 01223491391 or email us on bookings@ppplacements.co.uk if you have any questions or queries.* NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
