Benefits of becoming a Delta Nursing member: Flexible Hours to Suit On-going work Transportation to out of London clients Referral scheme 24 hours support 365 days a year In house mandatory training In house DBS checks Revalidation Application Form Preamble Statements DATA PROTECTON STATEMENT In order to comply with the terms of the Data Protection Act 1998 it is essential before completing this application form that you readthe following statement, as registration acts as an acceptance of the statement below.The agency will hold personal data relating to you. Such data will include your registration/ application form, references, address and contact details, bank details, work holiday and sickness records, next of kin details, pay and remuneration details and other records (which may, where necessary include sensitive data relating to your health and data held for equal opportunities purposes).The company will hold such information for personnel administration and compliance purposes and to comply with its obligations with regards to the retention of your records. Your right to access such data relating to you for personnel administration and compliance purposes and may, when necessary for those purposes, make such data available to its advisors, third parties providing produc ts and/ or services to the company and as required by law. I authorise Delta Nursing Agency Ltd to take references and to give its clients relevant information relating to my employment details or this registration. I confirm that to the best of my knowledge the information given on this form is correct. I understand that any misrepresentation or omission of any material fact or deception will be cause for immediate cancellation of membership and assignments. EQUALITY OF OPPORTUNITY STATEMENT The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background. I have read and understood the Data Protection Statement I have read and understood the Equality of Opportunity Statement Healthcare Application Form Qualified Application Form Continue Application Form Step 1 Personal Details TitleTitle Miss Mrs Mr Ms First name Last name Maiden name E-mail address Password Confirm password Address line 1 Address line 2 City / Town County Postcode Date of Birth Place of Birth Phone - mobile Phone - home GradePlease select your Grade HCA MW RGN RMN SUP_WK TransportTransport CAR / BIKE PUBLIC NationalitySelect nationality Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian British Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Central African Chadian Chilean Chinese Colombian Comoran Congolese Costa Rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dutch East Timorese Ecuadorean Egyptian Emirian Equatorial Guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-Bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian Icelander Indian Indonesian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and Nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese New Zealander Ni-Vanuatu Nicaraguan Nigerian Nigerien North Korean Northern Irish Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Polish Portuguese Qatari Romanian Russian Rwandan Saint Lucian Salvadoran Samoan San Marinese Sao Tomean Saudi Scottish Senegalese Serbian Seychellois Sierra Leonean Singaporean Slovakian Slovenian Solomon Islander Somali South African South Korean Spanish Sri Lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or Tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Yemenite Zambian Zimbabwean Passport No National Insurance Number Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National? Yes No If you have answered ‘no’ above, you must answer these questions: Please select the category that relates to your current immigration status. This status will be subject to checking before interview. Immigration status Indefinite Leave to remain / enter Tier 1 / HSMP (Highly Skilled Migrant Programme) Tier 2 / HSMP Tier 4 Student Tier 5 Temporary Workers Tier 5 Youth Mobility / Working holiday visa Dependant / Spouse visa Clinical visa Visitor Post Graduate Doctors and Dentists Refugee Other, please specify Other: Does your visa have a condition restricting employment or occupation in the UK? Yes No Visa No Visa start date Visa expiry date Details of any Restrictions Next of Kin First Name: Last Name: Address #1: Address #2: Town: County: Postcode: Phone - home: Phone - mobile: Bank Details Bank name: Sort Code: Bank Address: Account name: Account No: BackContinue Application Form Step 2 Education Primary School Name of School City/Country From mm/yyyy To mm/yyyy Grades Obtained Age of completion Secondary School Name of School City/Country From mm/yyyy To mm/yyyy Grades Obtained Age of completion College & University Name of School City/Country From mm/yyyy To mm/yyyy Grades Obtained Age of completion Training Courses Attended Training courses that you have attended or details of courses that you are currently undertaking, together with the date completed or to be completed. Course Title Training Provider Duration Year obtained Membership of professional bodies Any relevant professional registrations or memberships. If you are registered then please enter the relevant details below; this information will be subject to a satisfactory check. Please indicate your UK Professional Registration status * I do not have the relevant UK professional registration status I have current UK professional registration UK professional registration required and applied for UK professional registration required but not yet applied for I am a student Not required for this post 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 If applicable, please provide details of any conditions / restrictions you may have. BackContinue Application Form Step 3 Current / most recent employer Name of Organisation Position Held Employment status Employment status Full-time employed Self-employed Unemployed Full-time education Homemaker Address line 1 Address line 2 Postcode County Telephone E-mail Address Main duties and responsibilities From mm/yyyy To mm/yyyy Reason of leaving Supervisor / Manager's Full name Hourly Rate (per hour £) Additional supporting information Previous employment in date order Please begin with the most recent first, including employment agencies. NOTE: Any gaps in employment history must be explained. Name of Organisation From mm/yyyy To mm/yyyy Position Main duties and responsibilities Reason for leaving Have you ever been dismissed from employment, faced disciplinary action or awaiting hearing / investigation? Yes No If Yes, give details Please confirm if you agree for the agency to contact your previous employers Yes No BackContinue Application Form Step 4 Clinical References Please provide the names and full contact details of the people who have agreed to supply references. References must include at least two positions with separate employers and, as a minimum, cover a period of three years employment and/or training history, where this is possible. Referees will be required to comment on your competence, personal qualities and suitability for the post. This may be you line/department manager, or someone in a position of responsibility for any work experience or placement undertaken. If you are a student or trainee this should include a teacher/tutor at your education institution. Please note: your consent is required in order for the agency to request references. Do you give consent for the agency to request and obtain references for the purposes of employment: Yes No Referees will be approached prior to interview, unless you indicate otherwise below. Referee 1 Type of ReferenceType of Reference Employer Educational Personal Company / Organisation TitleTitle Miss Mrs Mr Ms First name Surname / Family name Relationship Job Title Address line 1 Address line 2 Postcode / Zip Code County Country Telephone Email Can the referee be contacted prior the interview? Yes No Referee 2 Type of ReferenceType of Reference Employer Educational Personal Company / Organisation TitleTitle Miss Mrs Mr Ms First name Surname / Family name Relationship Job Title Address line 1 Address line 2 Postcode / Zip Code County Country Telephone Email Can the referee be contacted prior the interview? Yes No BackContinue Application Form Step 5 Applicant Skill Profile 1 I am experienced and competent in this 2 I am familar with this procedure but do not have experience 3 No knowledge Personal Hygiene 1 2 3 Bath, shower, assisted wash Use of bath aids Mounth care (inc. dentures) Care of feet (exc. toenails) Dressing / Undressing of patients Bed bath Shaving Care of hair Care of fingernails Care of eyes General Pressure area care Nutrition Preparation of meals Feeding a helpless patient Toileting Use of bedpans / commodes Recording fluid balance Emptying a catheter bag Care of incontinent patient Mobility Lifting / Transferring patient Use of walking aids Use of hoists Moving / Handling course (evidence required) Observation Temperature Respiration Blood pressure Pulse Urine testing Registered Nurse Skills Evaluation 1 I am experienced and competent in this 2 I am familar with this procedure but do not have experience 3 No knowledge Administration of Medicines 1 2 3 Oral administration Injections Administration of Drugs in other forms e.g. eye, ear, nose drops etc. Administration of rectal and vaginal preparations Topical application of drugs Cytotoxic drugs Intravenous Therapy I.V. Rate calculations Admission of drugs by continuous infusion Admission of drugs by intermittent infusion Admission of drugs by direct injection e.g. bolus or push Heparinization of IV Cannula Administration of blood and blood products e.g. plasma Infusion pumps Syringe drivers Central venous catheter Central venous pressure readings (CVP) Venepuncture (taking blood) Arterial Lines Setting up for Taking blood sample from Removal of Wound care Changing wound dressings Aseptic technique Removal of Sutures Removal of Clips Removal of Staples Drain dressings (e.g. keyhole - redivac and closed drainage system) Change of vacuum bottle Shortening of drain (e.g. penrose / corrugate) Removal of pressure sores Orthopaedics Care of patient - In plaster of Paris Care of patient - With skin traction Care of patient - With skeletal traction Care of patient - Following amputation Halo traction Crutchrfield tongs Stryker frame Spinal lifts Leg rolls Respiratory (oxygen therapy) Suctioning - Oropharyngeal Suctioning - Endotracheal Tracheostomy care changing a dressing Suctioning a trachestomy Changing a trachestomy tube Managing of chest tubes (under water seal drainage) Changing drainage tubing and bottles (under water seal) Removal of drainage tube Care of ventilated patient Obtaining arterial blood gases Interpreting arterial blood gases Assisting with intubation Total parental nutrition 1 2 3 TPA Hyperalimentation knowledge of solutions Assistance with insertion Dressign change Gastrointestinal Naso-gastric tube insertion Care of naso-gastric tube Feeding via naso-gastric tube Stoma care Care of the patient with abdominal wounds / drains e.g. gastrostomy, PEG tube, caecostomy drain Care of patient undergoing abdominal paracentesis Care of patient during and after liver biopsy Administration of enemas Administration of suppositories Care of patient post abdominal surgery Rectal lavage Renal Insertion of catheter - Male Insertion of catheter - Female Catheter care Suprapubic catheter Nephrostomy tube Bladder lavage and irrigation Care of patient with renal transplant Care of patient on haemodialysis Care of patient with renal on peritoneal dialysis Care of patient - following nephfectomy Cardiac Arrest Knowledge of drugs used User of airway and ambu bag Cardiac compressions Neurological Care of patient with a head injury - following a CVA Care of patient with a head injury - with a spinal cord injury (e.g. quadraplegic/paraplegic) Care of patient with a head injury - following a spinal injury (e.g. laminectomy) Care of patient with a head injury - an unconscious patient Care of patient with a head injury - during or after a lumbar puncture Cardiovascular Perform 12 lead alectrocardiograms (ECG) Cardiac monitoring Telemetry Cardiopulmonary resuscitation Interpretation of basic arrhythmias Defibrillation Assisting with insertion of pacemaker Aortic balloon pump Swans-Ganz catheter Care of patient with acute myocardial infraction Care of patient with congestive cardiac failure Care of patient post cardiac surgery (e.g. coronary vein grafts, aortic valve replacement) Care of patient post cardiac catheterisation Others Barrier nursing – infectious or immunosuppressed patient Care of multiple trauma patients Care of multiple with eye problems Care of confused patient Knowledge of the NMC code of professional conduct Knowledge of the NMC guidelines for the administration of medicines Areas of speciality Worker experience Yes No Hospital Nursing home / residential Community Phlebotomy Mental Health Areas of Speciality A & E Theatre ITU Elderly Care Mental Health Other skills / comments BackContinue Application Form Step 6 Occupational Health Consent for Occupational Health Records to be copied I give consent for my Occupational Health records to be copied, including vaccinations and blood results to be used for assessment: Signature: Clear Date: PART A – Health Assessment Section Please complete this section if you have a health condition / impairment or disability which might affect your work and which might require special adjustments to your work or at your place of work 1) Do you have any health condition / impairment / disability (physical or psychological) which may affect your work? Yes No 2) Have you ever had any health condition / impairment / disability which may have been caused or made worse by your work? Yes No 3) Are you having, or waiting for treatment (including medication) or investigation at present? Yes No 4) Do you think you may need any adjustments for assistance to help you to do the job? Yes No PART B – Immunisation Assessment Section Please complete this section only if you are a health care worker involved in direct patient care or body fluid sample handling. ONLY HEALTH CARE WORKERS INVOLVED IN PATIENT CARE / CONTACT / BODY FLUID SAMPLE HANDLING COMPLETE THIS SECTION (INCLUDING LABORATORY WORKERS) Immunisation and Blood Tests - Please provide the following details of your immunisation. If this information is not provided with the relevant copies an appointment to attend Occupational Health will be required. Hepatitis B (showing titre levels >10iu/ml or indicate if non-responder to vaccine) Yes No Dates: Results: Measles antibodies Yes No Dates: Results: Mumps antibodies Yes No Dates: Results: Rubella antibodies (German Measles) Yes No Dates: Results: Varicella antibodies tested Yes No Dates: Results: Tested positive for infection for HIV, Hepatitis B or Hepatitis C? Yes No Dates: Results: BCG (Tuberculosis Vaccination) Yes No Dates: Results: Exposure Prone Procedures (EPP) are those procedures where the workers gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. EPP staff MUST provide documentary evidence of Hepatitis B status. Documentary evidence of Hepatitis C and HIV status is also required for staff undertaking EPP’s for the first time. This must be an identified validated sample (IVS). Health clearance for EPP work cannot be given until these results have been received and processed by Occupational Health. IF YOU HAVE PREVIOUS BLOOD RESULTS AND/OR DOCUMENTED EVIDENCE OF RELEVANT VACCINATIONS PLEASE SUPPLY A COPY WHEN YOU SUBMIT THIS FORM. If results are not available you will be asked to visit the Occupational Health Department and health clearance for EPP work will be delayed until these results are processed. You will be asked to show formal photographic ID i.e. valid driver’s license, passport for this procedure. This is to comply with the department of health’s standards’ for identified validated samples. Hepatitis B surface antibodies ( from 1993 ) and antigen ( from 2007 ) Yes No Dates: Results: Hepatitis C antibodies ( from 2002 ) Yes No Dates: Results: HIV antibodies ( from 2007 ) Yes No Dates: Results: DECLARATION I declare that all the answers to the above questions and information are true to the best of my knowledge. I agree to comply with immunisations and screening requirements of the post and any failure to comply will result in my manager being informed and may result in restrictions on clinical practice. Signature: Clear Date: BackContinue Application Form Step 7 Working Time Regulations I agree that I may work for more than an average of 48 hours a week. If I change my mind, I will give my employer 14 days notice in writing to end this agreement. I Agree I Disagree REHABILITATION 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 criminal record will not necessarily be a bar obtaining position. Have you ever been convicted or cautioned for any offence? Yes No If Yes, give details Please note that this application will require a criminal background check by the criminal records bureau disclosure procedure at enhanced level. A charge of £54 is required for the Criminal Records Bureau check. It may be the case that you already have a DBS disclosure for other employment but legal requirements are that agency workers must obtain a new check unless it is portable. If you hold a portable DBS certificate please provide us with the original copy of your DBS certificate in order for the agency to verify the information is still current and correct. Do you agree for Delta Nursing Agency Ltd to carry out a criminal records bureau check on you? Yes No PLEASE GIVE ANY ADDITIONAL INFORMATION WHICH YOU THINK MAY BE RELEVANT IN SUPPORT OF YOUR APPLICATION: PORTABLE DBS I give consent for Delta Nursing Agency Ltd to perform regular (monthly / annual) DBS checks on my existing certificate in accordance with my application / registration form and as outlined within the terms and conditions of employment stated above Signature: Clear Date: BackContinue Application Form Step 8 CONFIDENTIALITY DECLARATION Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about your clients. On no account must information relating to identifiable client be divulged to anyone other than the manger of the agency. You should not disclose ANY information to your family, friends or neighbours. If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO THE AGENCY ON SITE NURSE. Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register. I have read and I understand the above and I agree to abide by the contents therein. Signature: Clear Date: Don’t miss out! Please tick this box if you would like to receive regular updates and the latest job vacancies from Delta Nursing Agency Limited. Please see our Privacy Policy for full Ts & Cs. BackSubmit Application
