Remity Staffing -Clinical Application Form

Remity Staffing - Clinical Application Form

Clinical Application Form

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Step 6

Personal Details

Title*

Surname*

Forename(s)*

Nationality*

Contact Address*

Postcode*

National Insurance No*

Home Phone

Mobile Phone*

Email*

Do you own a car YesNo

Date of Birth*

Gender

Registration No

Grade*

Professional Misconduct

Have there been any proceedings of medical negligence or professional misconduct against you and have you ever been suspended YesNo

If “YES” please supply details:

Next of Kin Details

Name*

Telephone*

Relation*

Contact Address*

Immigration Status

Your entitlement for working as a Healthcare Professional in the UK is based upon what status*

Please provide a right to work share code to prove your immigratation status if you do not have UK Passport

Rehabilitation of Offenders Act - Because of the nature of the work for which you are applying, Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies.

Have you at any time been convicted of an offence YesNo

If “Yes”, please give details in the box provided.

It is a condition of proceeding with your application that we apply for an “Enhanced” DBS disclosure or produce a disclosure which you have already obtained. Convictions and any other criminal record information obtained through the Disclosure and Barring Service will not necessarily be a bar to employment. All circumstances will be taken into account. However, any inconsistencies compared with the information given above may invalidate your application. It is a condition of engagement that clients will be informed of details of criminal convictions so that they may make an informed decision as to whether or not to engage a candidate on a temporary assignment.

Declaration - I am willing for Remity Staffing to apply for a Criminal Records Bureau for “Disclosure” and, if requested, forward confirmation of such to any hospital where I may be assigned.

Signature*

DrawType

Date*

References - We require two Clinical Professional Referees. One must be from your present or most recent employer and must be a senior grade to yourself.

Name (Ref1)*

Position (Ref1)*

Work Address (Ref1)*

Telephone (Ref1)*

Email (Ref1) - must be NHS or a Business emaill address*

May we contact your referee prior to an interview? (Ref1) YesNo

Name (Ref2)

Position (Ref2)

Work Address (Ref2)

Telephone (Ref2)

Email (Ref2) - must be NHS or a Business emaill address

May we contact your referee prior to an interview? (Ref2)* YesNo

COVID-19 & Flu Vaccination Declarations

Under the current guidelines, its recommended that every healthcare worker should have annual flu vaccination and also at-least 2 jabs of COVID-19 Vaccination to work within NHS.

Did you receive Flu vaccination within last 12 months? If yes, please supply the date. If no please explain why.*

Did you have your both COVID-19 Jab now? If Yes please supply the dates. If no please explain why and also when you going to have these.

Date of First Jab (Covid-19)

Date of 2nd Jab

If you did not receive any Jabs for Covid-19 vaccinations, please explain here why.

Appraisal & Revalidation – (Nurses Only)

Last Appraisal Date

Next Appraisal Date

Name of Appraiser

NMC No. of Appraiser

Last Revalidation Date

Next Revalidation Date

Professional Indemnity- (Nurses only) - We recommend that you take membership with a Medical Defence Organisation. If you are already a member, please provide details of your membership. Please forward copy with your application.

Defence Body (RCN / Unison)

Policy Number

Expiry Date

TUNIC DETAILS - Please tick your tunic & scrub size below in UK sizes, such as XS - XXL and ladies 8 – 24.

Male

Female

Declarations & Consent

To provide you with a compliant and efficient recruitment service, Remity Staffing will need to undertake a range of checks which will involve accessing, processing, sharing and storing your personal data. We will also be required to share your personal data with our customers and their auditors to find you work, manage your placements and pay you as well as complying with our legal and contractual obligations.

I have read a copy of the Agency Worker Handbook which outlines the goals, policies, benefits and expectations of Remity Staffing and its Clients, as well as my responsibilities as an Agency Worker. I have familiarised myself with the contents of this handbook. By my signature below, I acknowledge, understand, accept and agree to comply with the information contained in the Agency Worker Handbook provided to me by Remity Staffing. I understand this handbook is not intended to cover every situation which may arise whilst on assignment, but is simply a general guide to the goals, policies, practices, benefits and expectations of Remity Staffing.

I give permission for Remity Staffing to send me marketing information. This may include details about vacancies and referral initiatives.

I give permission for Remity Staffing to process my personal data to undertake a check of my identity and address to facilitate provision of job search and placement services.

I give permission for Remity Staffing to process my personal data to undertake a check of my Professional Registration status (and if appropriate revalidation status) with the relevant Professional / Regulatory Body to facilitate provision of job search and placement services.

I give permission for Remity Staffing to apply for an Enhanced DBS Check / verify my existing DBS certificate with the DBS Update Service or check my Disclosure Scotland membership when I register and on an ongoing basis as required to ensure compliance to facilitate provision of job search and placement services.

I give my permission for Remity Staffing to process my personal data to check my right to work in the UK status with the UKBA / Home Office / Embassy to facilitate provision of job search and placement services.

I give my permission for Remity Staffing to contact and share my personal data with any organisation where I have worked to verify my employment history or to obtain/validate a reference to facilitate provision of job search and placement services.

I give permission for Remity Staffing to process my personal data to obtain a work health assessment or validate my occupational health and vaccination status to facilitate provision of job search and placement services.

I give permission for Remity Staffing to process my personal data to verify my qualifications and training certificates to facilitate provision of job search and placement services.

I give permission for Remity Staffing to process my personal data and sensitive personal data including bank details and NI number to facilitate payment into my account. I also give permission for such data to be shared with Remity Staffing’s accountants and payroll/factoring suppliers.

I consent to all the data contained in my personal file being made available to external framework auditors, organisations where I have been placed and any prospective customers for audit, review and inspection purposes.

I give consent to Remity Staffing to disclose any matter regarding pervious dismissals, warnings, complaints or professional body referrals to prospective employers.

I explicitly agree to abide by all Data Protection Laws with regard to all information regarding Remity Staffing and its clients, candidates, patients and any other third party who I interact with during my registration or service with Remity Staffing. I will not discuss information either verbally or in writing and if I am unsure about how to treat any information, I shall immediately contact Remity Staffing for advice and clarification

For the purpose of the Working Time Regulations 1998 (as amended), You must consent to work in excess of an average of 48 hours per week or Opt opt using the tick boxes below. I understand that I may withdraw this consent by giving Remity Staffing not less than three months‟ notice. Your registration with Remity Staffing can be terminated at any time following unsatisfactory work reports.

Remity Staffing has a legal basis to process data and will do so in line with all Data Protection Laws. By signing this declaration, I agree to the above declarations and confirm I understand I have the right to: be informed of, withhold access, amend/rectify, erase and withdraw my data at any time.

Did you receive Flu vaccination within last 12 months? If yes, please supply the date. If no please explain why.

Print Name*

Profession*

Registration No

Signature*

DrawType

Date*

Candidate Payment Method

Full Name: (I confirm that my chosen payment method is the below)

*Subject to approval by Remity Staffing prior to payment method being approved. Umbrella companies are required to comply with IR35 guidelines. Please check with your consultant if your chosen Umbrella company meets those requirements.

Umbrella Company (please mention)

Please confirm you

Agree to the terms and conditions of the above mentioned Umbrella Company. YesNo

Understand that regulation with my mentioned Umbrella Company is my responsibility and that a delay in registration may delay payment. YesNo

Consent to Remity Staffing sharing your personal details with your mentioned Umbrella Company for payment for work completed. YesNo

Please provide your bank details if you wish to be paid via PAYE

Payee Name (as it appears on account)

Account Number

Sort Code

Date

Signature*

DrawType