Application Form

To be completed for positions at All Saints Support Health Care Agency.

SECTION 1: PERSONAL DETAILS

Title: Mr Daytime Phone 07394079916

Number:
First Gaius Mobile number: 07394079916
Name(s):
Surname: Dahunsi Email Address: Gaiusoluwaseyi33@gm
ail.com

Preferred Gaius Date of Birth: 05/05/2000

to be
known as:
Address: 15 upperhead row
Dundas street
Dundas work

Postcode HD12HE Do you hold a No

current UK Driving
Licence?

SECTION 2: Role Applying for

Role
Registered Nurse: Mental Health
(RMN) or Learning Disabilities (RNLD)
Registered General Nurse (RGN)

Healthcare Assistant (Meds Comp)

Healthcare Assistant/ Support Worker
Complex Care Support Worker
NMC Number
NMC or HPC Expiry date
Membership other professional
bodies

DBS Number
 DBS expiry date

SECTION 3: EMERGENCY CONTACT:

Title: Mr Daytime Phone 07312 647714

Number:
First Oluwaseun Mobile Number: 07312 647714
Name:
Surname: Adekanye Relationship: Brother
Address: Dundas work Postcode: HD1 2HE

Please tick the box that applies to you:

I am eligible to work in the UK and do not require a

work permit
I am already in possession of a work permit to work
in the UK
I need to obtain a work permit to work in the UK
Other (Please specify)

SECTION 4: INFORMATION FOR DBS CHECK

Please circle the answer that applies to you:

Does your DBS display any Cautions or Convictions? Yes / No

Do you have any unspent criminal convictions? Yes / No

If yes, please provide a statement include any convictions and their dates.
(continue to a separate piece of paper if necessary)
SECTION 5: EDUCATION HISTORY
Include in this section all the relevant qualifications. Please also indicate subjects
currently being studied

Subject/Qualification Place of Study Grade/Result Year

SECTION 6: EMPLOYMENT REFERENCES
Please provide the full name and work address of two professional clinical
referees that All Saints Support Health Care Agency can contact. These
should be your current / most recent employer and they must be able to
comment on your ability to do the job you are applying for. Your referees must
be a senior grade to yourself and you must have worked for the person for a
period of more than three months.
Reference 1

Full Name:
Establishment:
Position:
Address:

Postcode:
Telephone:
Email Address:
Reference 2

Full Name:
Establishment:
Position:
Address:

Postcode:
Telephone:
Email Address:

Can we contact for references prior to Yes / No

interview?

Have you applied to or worked for All Yes / No

Saints Support ltd previously?

SECTION 7: EMPLOYMENT HISTORY

Please give details of your full employment from time of leaving education. All
gaps must be accounted for. Include the month and the year, starting with your
current or last job
(continue to a separate piece of paper if necessary).

Date Date To Employer’s Job Title Reason for Leaving

From Name

Date Date To Employer’s Job Title Reason for Leaving

From Name

Date Date To Employer’s Job Title Reason for Leaving

 From Name

Date Date To Employer’s Job Title Reason for Leaving

From Name

Date Date To Employer’s Job Title Reason for Leaving

From Name

Date Date To Employer’s Job Title Reason for Leaving

From Name

Date Date To Employer’s Job Title Reason for Leaving

From Name

SECTION 8: CONSENT FORM

CONSENT TO RELEASE INFORMATION

I give my permission for All Saints Support Health Care Agency to;

 Approach all referees given on my application form. (This may include any
educational establishments I may have attended and any periods of unemployment
to be confirmed via the Job Centre or any Gap referees I may have also provided)
  Apply for a criminal record check on my behalf.
 Verify my right to work documents by using the online government verification
websites on my behalf.
 Check my Driving Licence on the DVLA website on my behalf (which may be
required to be sent to the client I am working for, if applicable)

PRINT FULL NAME:

SIGNATURE:
 SECTION 9: DECLARATIONS

Please ensure that all declarations are ticked

DATA PROTECTION
I agree that All Saints Support Health Care Agency retains the right to hold this application
and any other data associated to process it and pass on to any authorised third party the
details held within, also to retain the details for as long as reasonably necessary in
accordance with the Data Protection Act □

WORKING TIME REGULATIONS 1998

The European Union has laid down guidelines for all workers, governing the length of the
maximum working week that is safe to work. The current limit is 48 hours per week. You
are under no obligation to accept any work offered, and you will not be compelled to work
more than 48 hours per week, however you may choose to do so. A full explanation of the
Working Times Regulations 1998 can be found in your Staff Handbook. Please tick the
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 □

WORKING HOLIDAY ENTITLEMENT CLAUSE

Whilst working for the agency, the temporary worker will accumulate Holiday Pay
calculated as a percentage of the hourly rate of pay and this is incorporated in the gross
hourly rate. This is paid weekly or you can decide with the Umbrella Company if you would
prefer to accumulate this.

I have read, understand and will comply with the Working Holiday Entitlement Clause. For
the purposes of your employment with us, the holiday year will be the 12-month period
commencing on the 6th April (and, if applicable, each subsequent 12-month period).
For further details please discuss with your chosen Umbrella Company.

PROFESSIONAL REGISTRATION AGREEMENT

You are expected to adhere to the NMC / HPC code of conduct and drug administration
guidance. Are you fully aware of these and agree that you will always apply them during
your employment?
Yes □ No □

REHABILITATION OF OFFENDERS ACT AND UNSPENT CRIMINAL CONVICTIONS

Due to the nature of the work you are applying for, this post is exempt from the provision
of section 4 (2) the rehabilitation of offenders act 1974 by virtue of the rehabilitation of
offenders act 1975 (exception) order 1975 applicants are therefore, not entitled to
withhold information about convictions which for any other purpose are ‘spent’ or
‘unspent’ under the provisions of the act and in the event of employment. Failure to
declare a conviction may require us to exclude you from our register or terminate an
assignment if the offence is not declared but later comes to light. Any information given
will be completely confidential and will be considered only in relation to an application for
the positions where the order applies and should be entered at the end of any you give in
support to this application. □
PERMISSION TO WORK IN THE UK

In line with U.K.B.A. guidance on the prevention of illegal working we will need to verify
and take a copy of your original ID documentation as evidence of your right to work in the
UK if you are to be engaged by us for temporary work. □

MEMBERSHIP OF PROFESSIONAL BODIES

If you are applying for a post that requires professional registration you are required to
provide the following information: Are you currently the subject of a fitness to practise
investigation or proceedings by a licensing or regulatory body in the UK or in any other
country?
Yes □ No □
Have you been removed from the register or have conditions been made on your
registration by a fitness to practise committee or the licensing or regulatory body in the UK
or in any other country?
Yes □ No □

TERMS AND CONDITIONS

I hereby confirm that the information given is true and correct. I consent to my personal
data and employment/educational history being forwarded to clients. I understand that
should the information I have given be untrue I accept full responsibility for any
consequences this may bring. I consent to references being passed onto potential
employers. If, during a temporary assignment, the client wishes to employ me direct, I
acknowledge that the agency will be entitled either to charge the client an
introduction/transfer fee or agree to an extension of the hiring period with the client (after
which I may be employed by the Client without further charge being applicable to the
Client). We may check the information collected, with third parties or with other
information held by us. We may also use or pass to certain third parties’ information to
prevent or detect crime, to protect public funds, or in other way permitted or required by
law. □
 CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT
POLICY & PROCEDURE

PURPOSE
It is the policy of All Saints Support Health Care Agency to ensure that all Directors, Consultants, Administrators
and employees of All Saints Support Health Care Agency are made aware of this agreement and that the
agreement is signed to ensure confidentiality of all of All Saints Support Health Care Agency clients, patients and
service users.

SCOPE
This policy will apply to all Directors, Consultants, Administrators and employees of All Saints Support Health
Care Agency who have a responsibility for the selection and recruitment of nurses and healthcare workers.

RESPONSIBILITIES

It is the responsibility of the Directors, Consultants, Administrators and Employees of All Saints Support Health
Care Agency, to ensure that all registrants complete this document and that the original copy is stored on
everyone’s file.

PROCEDURE

It is vital that all applicants who are supplied under a contract for services always ensure confidentiality,
therefore it is the policy of All Saints Support Health Care Agency to request all applicants sign the Non-
Disclosure Agreement to protect clients, patients and service users.

All Saints Support Health Care Agency accepts there are occasions and circumstances when confidential
information may need to be disclosed to the All Saints Directors, Consultants, Administrators, or the person in
charge at the healthcare establishment. All Saints Support Health Care Agency actively supports this disclosure of
certain information particularly when the protection of children and vulnerable adults are at risk. If a Director,
Consultant, Administrator, or Employee of All Saints Support Health Care Agency suspects abuse of any nature, it
is vital that the information is passed onto the relevant bodies, authorities and management to ensure the
matter is dealt with promptly and effectively.

NON-DISCLOSURE AGREEMENT
This agreement adopts the above code of practice/policy and is required to help safeguard the confidentiality of
clients, patients and service users. This includes identifiable data, financial data or any other personal
information held at client’s premises, service user’s home or any other healthcare establishment where All Saints
Support Health Care Agency provide services. The code applies where access may be gained to sensitive data
(e.g. patient records, clinical information systems, staff records etc.)
1. The access referred to may include:
 Access to paper information
 Access to personal information
 Access to financial data
 Access to information held on a computer or another electronic format
 Access to information from a remote site
2. Access to personal identifiable information held at a care establishment is not permitted unless there has
been formal authorisation from a senior Manager or Doctor.
3. Person identifiable information could include any of the following:
 Name, address or post code
 Date of birth, other dates (i.e. death, diagnosis)
 Sex
 NHS/NI or GP Practice number
 Ethnic group
 Occupation

4. All information will be treated as confidential and will not be disclosed to any other persons and/or
organisations.

5. Confidential information will only be passed to relevant bodies when there is a ‟need to know″ this
information, to ensure the best possible care for the patient or service user.

6. Any breach of these terms of this code of practice will result in the termination of our contract for
services and the company may take legal action.

I confirm that I have read and understand the code of practice on Confidentiality and
Non-Disclosure. I agree to abide by the above code.

Name Signature Date

Equal Opportunities Statement
All Saints Support Health Care Agency is committed to a policy of equal opportunities for all work seekers and
shall always adhere to such a policy and review on an on-going basis on all aspects of recruitment to avoid
unlawful or undesirable discrimination. We will treat everyone equally irrespective of sex, sexual orientation,
marital status, age, disability, race, colour, ethnic or national origin, religion, political beliefs or membership or
non-membership of a Trade Union and we place an obligation upon all staff to respect and act in accordance
with the policy.

All Saints Support Health Care Agency shall not discriminate unlawfully when deciding which temporary worker is
submitted for a vacancy or assignment, or in any terms of employment or terms of engagement for temporary
workers. All Saints Support Health Care Agency will ensure that each candidate is assessed only in accordance
with the candidate’s merits, qualifications and ability to perform the relevant duties required by the vacancy.

Criminal Records Bureau

I understand that for me to work for All Saints Support Health Care Agency, I am required to complete a DBS
check and details of any convictions may be discussed with relevant clients.
If you do not have the update service for DBS, then we will send you a link for this to be completed online at the
cost of £54.40.
Please tick the sentence that DOES applies to you
  I have no spent or unspent criminal convictions □

 I have been convicted and /or cautioned by the police □

When working in position involving children or vulnerable adults, details for all criminal convictions must be
given. The information given will be treated in strictest of confidence and only considered where, in the
reasonable opinion of All Saints Support Health Care Agency, the offence is relevant to the post to which you are
applying, Failure to declare a conviction may require us to exclude you from our register or terminate an
assignment if the offence is not declared but later comes to light.

Personal Protective Equipment (PPE)

I understand that for certain roles/ assignments I may be provided with uniform, ID badge or locker key. Any
items supplied must be returned once am assignment has been completed. Should I fail to return any of these
items, this may result in a deduction being made from my final pay to cover their cost and I sign below to confirm
my agreement.

Immigration
I hereby give permission to All Saints Support Health Care Agency to contact the Home Office/ United Kingdom
Immigration Service to establish my immigration Status and eligibility to work in the UK.

Name Signature Date

Personal/Financial Details Form

NEW STARTERS: please fully complete this form. Existing candidates, please only complete the
sections that you wish to amend Please tick one of the statements below

PERSONAL DETAILS Please complete in BLOCK CAPITALS

Title Date of birth

First Name National Insurance (NI)

number

Surname
 Address

Postcode

Next of Kin/ Person to contact in case of Emergency

Title Relationship
First Name Surname
Address Telephone
Number
Postcode

BANK DETAILS

Bank/Building Society Name

Bank/Building Society Address

Postcode

Account Holders Name

Sort code (always 6 digits)

Account Number

I confirm the above information is correct:

Signed
Date
 Night Shift Health Assessment

The purpose of this questionnaire is to make sure that you are suited to working
at night. All the information you provide will be kept confidential.

First Name:
Surname:
Date of Birth:
Health Conditions: Do you suffer from any of the following health conditions?

Diabetes Yes / No

Heart or circulatory disorders Yes / No

Stomach or intestinal disorders Yes / No

Any condition which causes Yes / No

difficulties sleeping
Chronic chest disorders Yes / No
(especially if night-time
symptoms are troublesome)

Any medical condition requiring Yes / No

medication to a strict timetable

Please disclose any other health

factors that you feel might
impact on your role with All
Saints Support Health Care
Agency.

If you have answered 'yes' to any of the above questions, you may be
asked to seek medical advice before commencing work for All Saints
Support Health Care Agency.

I, the undersigned, confirm that the above is correct to the best of

knowledge

Signed
Date
 JL CONFIDENTIAL
NEW EMPLOYEE CLINICAL MEDICAL QUESTIONAIRE

The purpose of this questionnaire is to see whether you have any health
problems that could affect your ability to undertake the duties of the post that
you have been offered or place you at risk in the workplace. We may recommend
adjustments or assistance because of this assessment to enable you to do the
job. Our aim is to promote and maintain the health of all people at work.

I am a new starter to All Saints Support Health Care Agency

I wish to amend my existing personal details

PERSONAL DETAILS Please complete in BLOCK CAPITALS

Title Date of Birth

First Name Surname

Address

GP Address

Work Tel:

Home Tel:

Mobile Tel: Postcode

Do you have any illness/impairment/

disability (physical or psychological) which
may affect your work?
Have you ever had any illness/impairment/
disability (physical or psychological) which
may affect your work?
Are you having, or waiting for treatment
(including medication) or investigations at
present? If yes, please provide further
details of the condition, treatment and dates
of any appointments.
Do you think you may need any adjustments
or assistance to help you to carry out your
job?
Any additional information?
Tuberculosis
Have you had a clinical diagnosis and
management of tuberculosis, and measures Yes / No
for its prevention and control? (NICE 2006)
Please circle
Have you lived continuously in the UK for
the last year? (include holidays/vacations) Yes / No
If you answered NO please list all of the
countries that you have lived in/visited over
the last year, including holidays and
vacations. This MUST include duration of
stay and dates or this form may be rejected.
Do you have a cough which has lasted more Yes / No
than 3 weeks?
Any unexplained weight loss? Yes / No
Any unexplained fever? Yes / No
Have you had tuberculosis (TB) or been in Yes / No
recent contact with open TB
EVD (Ebola Virus Disease)
Any person who has been in West Africa in Yes / No
the previous 21 days or those visiting the
affected areas must ensure that those
deemed the employer are made aware prior
to travel and return. You will be provided
with a separate screening questionnaire to
complete as applicable.
Have you travelled to any countries affected Yes / No
by Ebola? (Guinea, Sierra Leone, Liberia,
Mali)
If you have answered YES to the above,
please list all the countries that you have
lived in/visited in the last 21 days including
holidays and vacations.
 Chicken Pox or Shingles
Have you ever had chicken Pox? Yes / No
Date:
Have you had Shingles? Yes / No
Date:

Immunisation history Have you had any of the

following immunisations?
Triple Vaccination as a child Yes / No
(diphtheria/Tetanus/Whooping Cough)
Date:
Polio? Yes / No
Date:
Tetanus? Yes / No
Date:
Hepatitis B Yes / No
Date:
If yes is ticked, please provide details
below

Course: 1 2 3
Boosters: 1 2 3

Proof of Immunity
Please Send the following:

Varicella You must provide a written statement to confirm that you have had
chicken pox or shingles however we strongly recommend that you
provide serology test results showing varicella immunity
Tuberculosis We require an occupational health/GP certificate of a positive scar or
record of a positive skin test result (do not self-declare)
Rubella, Measles Certificate of ‘two’ MMR Vaccinations or proof of positive antibody
and Mumps for Rubella and Measles
Hepatitis B You must provide a copy of the most recent pathology report
showing titre levels of 100lu/l or above
Coronavirus You must provide us with a copy of your COVD-19 vaccination card
stating the dates of your first and second dose of the vaccine.
 The following are for EEP Candidates only
Hepatitis B Evidence of a negative Surface Antigen Test
Surface Antigen Report must be an identified validated sample (IVS)

Hepatitis C Evidence of a negative antibody test

Report must be an identified validated sample (IVS)
HIV Evidence of a negative antibody test
Report must be an identified validated sample (IVS)

Exposure Prone Procedure

Will your role involve exposure prone procedures? Yes / No

Declaration

I will inform my employer if I am planning to or leave the UK for longer than three months
to enable a reassessment of my health to be conducted upon my return.

I declare that the answer to the above questions are true and complete to the best of my
knowledge and belief. I also give consent for All Saints Support Health Care Agency to
make recommendations to my employer.

Name Signature Date

Thank you for registering with All Saints Support Health Care Agency.