Application form – Epty Care

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About Us
Care Services
Our Carers
How We Work
Available Jobs
Contact us

Application Form

This form should be completed and all the supporting documentation should be uploaded where required.

1Your Personal Details

2Employment & Education

3Skills & Training

4Declaration & Terms

Company
This field is for validation purposes and should be left unchanged.
Post Applying for:*
Personal Details 1
Name*
Title First Name Middle Name Last Name
Home Phone
Mobile No*
Email*
Date of birth*
National Insurance No:*
NMC Pin No:*
RCN Number:*
HPC Number:*
Band*
Address
Your Current Address*
Street Address City County / State / Region ZIP / Postal Code
Personal Details 2
Nationality*
Gender
Religion
Race/Ethnicity
Sexual Orientation*
Upload ID Photo
Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 2 GB.

This photo will be used for both your ID badge and your profile. Please make sure your face is clear in the photo.
Employment Eligibility
Are you permitted to work in the United Kingdom?*
- Yes
- No
Can you provide evidence to prove eligibility?:*
- Yes
- No
What proof of Right of Work in the UK do you hold?:*
- British Birth Certificate
- British Passport
- Settled Status/Leave to Remain
- Visa / Work Permit
- Other
Please state what visa/permit you hold:
Permit/Document No:
Passport No:*
Visa/Permit Expiry Date:*

If it has no expiry please put a day 10 years from today.
Upload a copy of your passport/permit
Drop files here or

Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 128 MB, Max. files: 10.
If you wish you can upload a clear photo of the document/s from your phone and bring along your original document/s if and when invited to the interview.
Upload a proof of address and other relevant documents (Recent Bank Statement, Utility Bill, Driving License, etc.)
Drop files here or

Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 128 MB, Max. files: 10.
If you wish you can upload a clear photo of the document/s from your phone and bring along your original document/s if and when invited to the interview.
Driving Details
Do you have full Driving Licence that allows you to drive in the UK?*
- Yes
- No
Driving Licence No:*
Do you have access to a car that you can use for work?*
- Yes
- No
Have you been banned from driving or do you have any current endorsements on you licence?*
- Yes
- No
Are all your vehicle documents up to date and valid?*
- Yes
- No
How would you travel to work if assigned?*
Please note: you have to provide copies of all IELTS certificates held by you.
Next of kin details
Full Name*
Prefix First Last
Relationship to you:*
Home/Work Phone
Mobile No*
Email
Address*
Street Address City County / State / Region ZIP / Postal Code
Your Work Preference
When are you able to work?*
- Mornings
- Evenings
- Afternoons
- Occasional Weeks
- Full Time
- Part Time
- Nights
- Weekends
- Anytime

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EDUCATION & EMPLOYMENT HISTORY
Please ensure you complete this section even if you have a CV. The NHS states that “Employment history should be recorded on an Application Form which is signed” Please ensure that you leave no gaps unaccounted for and it covers full work history including your education. Please use extra paper if required.

Full work history including your education
Dates to and from are shown in a mm/yy format
Dates are continual with NO gaps
Where there have been gaps in work history please state the reason for the gaps
Lists all relevant training undertaken
Employment History*
Employer Position Duties Date From - To Salary on leaving
Education
Please supply documentary evidence.
Education*
Institution Course Year Grade
Upload CV if you have one.
Accepted file types: jpg, gif, png, pdf, jpeg, docx, Max. file size: 128 MB.
REFERENCES
Please supply us with two professional referees. One must be from your present or most recent employer and must be a senior grade to yourself and you must have worked for that person for a period of not less than three months duration. By entering the referees' details, you give us permission to contact them.
Reference 1
Relationship*
Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Address*
Street Address City County / State / Region ZIP / Postal Code
Reference 2
Relationship*
Name*
First Last
Phone*
Email*
Enter Email Confirm Email
Address*
Street Address City County / State / Region ZIP / Postal Code

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SKILLS, EXPERIENCE & TRAINING
Have you completed mandatory training within the last year?*
- Yes
- No
Mandatory Training
Please tick if you have completed the following training within the last 12 months*
- Moving & Handling
- Basic life support
- Health and Safety
- Fire Safety
- First Aid
- Infection Control
- Food Safety & Nutrition
- Medication Administration
- Safeguarding Vulnerable Adults & Children
Please enclose copies of your training certificates
Training Dates:
Please add dates of training.
Have you completed other health care training?*
- Yes
- No
Other Training/Courses & Qualifications
Please check which training you have completed and the date on the notes (certificates must be provided).
- Diploma in Health & Social Care L3
- Diploma in Health & Social Care L2
- Personal Safety (Mental Health & Learning Disability)
- Intermediate Life Support
- Advanced Life Support
- Complaints Handling
- Handling Violence and Aggression
- DOLLS & Mental Capacity
- COSHH
- Data Protection
- Equality & Inclusion
- Lone Worker Training
- Resuscitation of the Newborn (Midwifery)
- Interpretation of Cardiotocograph Traces (Midwifery)
Training Dates
Please add dates of training.
APRAISALS
In order to work in the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser” Please give details below of the Senior Practitioner who you have made arrangements with to act as your appraiser.
Please give the date of your last appraisal*
Name of Appraiser*
First Last
Position and Grade of Appraiser:*
Branch Address:*
Street Address City County / State / Region ZIP / Postal Code
Phone*
Fax
Email*
Enter Email Confirm Email
YOUR DBS STATUS & UNIFORM
DBS Status
Please send a copy of your most recent DBS Disclosure (formally known as CRB)
Do you have a current DBS (Disclosure Barring Service) (formally known as CRB)?*
- Yes
- No
Current DBS Disclosure (formally known as CRB)
Clear*
- Yes
- No
Date of issue:*
Disclosure number
All applicants who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost. The company will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate.
Uniform
Candidates will be required to purchase uniform if required at the cost of £20 this will be deducted from your timesheet once you have started working through us. Please fill in the box below stating your uniform size and quantity.
Your Tunic Size*
If other, please enter value:*
Your Tunic Size*
If other, please enter value:*
While we fully understand the value and importance of inclusivity in the workplace, our current uniform suppliers are only able to offer sizes in male and female. Please choose whichever size from either range that you feel would fit you best.

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DECLARATIONS
Health Declaration
Do you or have you ever suffered from long term illness?:*
- Yes
- No
Have you ever required sick leave for a back or neck injury?:*
- Yes
- No
Do you suffer from any back or neck injuries?:*
- Yes
- No
Have you been in contact with anyone who is suffering from a contagious illness within the last six weeks?:*
- Yes
- No
Do you suffer with a communicable disease?:*
- Yes
- No
Are you currently receiving active medical attention?:*
- Yes
- No
If you have answered ‘yes’ to any of the above, please give details:
Are you registered disabled?:*
- Yes
- No
How many days have you been absent from work due to illness in the last 12 months?:
State reason(s) for absence:
GP Details
GP Name:
GP Address
Street Address City County / State / Region ZIP / Postal Code
May we contact your Doctor for health check?:
- Yes
- No
The above information will be held in strict confidence. If you aware of any health issue that you feel may affect your ability to undertake responsibilities of the post it is your responsibility to inform the Care Manager immediately. Again any details discussed in the meeting will be held in strict confidence.
- I understand that my GP may be contacted for details about my health.
MEDICAL HISTORY
All staff groups complete this section
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
- Yes
- No
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
- Yes
- No
Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition, treatment and dates?
- Yes
- No
Do you think you may need any adjustments or assistance to help you to do the job?
- Yes
- No
Additional Information
(If you have answered yes to any questions above please provide additional information below)
Tuberculosis
Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006)
Have you lived continuously in the UK for the last 5 years
- Yes
- No
Please list all of the countries that you have lived in over the last 5 years*
Have you had a BCG vaccination in relation to Tuberculosis?
- Yes
- No
Please state when*
A cough which has lasted for more than 3 weeks
- Yes
- No
Unexplained weight loss
- Yes
- No
Unexplained fever
- Yes
- No
Have you had tuberculosis (TB) or been in recent contact with open TB
- Yes
- No
Additional Information (If you have answered yes to any questions above please provide additional information below)*
Chicken Pox or Shingles
Have you ever had chicken pox or shingles?
- Yes
- No
Date*

Please state date
Immunisation History
Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)?
- Yes
- No
Polio
- Yes
- No
Tetanus
- Yes
- No
Hepatitis B
- Yes
- No
Provide Details about your Hepatitis B immunisation, including dates.*
Varicella

You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity

Tuberculosis

We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)

Rubella, Measles & Mumps

Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella Measles & Mumps

Hepatitis B

You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above
Hepatitis B Surface Antigen

Evidence of a negative Surface Antigen Test 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 s ample. (IVS)
Exposure Prone Procedures
Will your role involve Exposure Prone Procedures*
- Yes
- No
Declaration
*
- I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for our appointed Occupational Health Services provider to make recommendations to my employer.
Disclosure Barring Service (DBS)
The Disclosure and Barring Service (DBS – formerly Criminal Records Bureau CRB) is the executive agency of the Home Office responsible for conducting checks on criminal records. We are registered body for receipt of DBS disclosure information. NHS Trust and Private Sector hospitals and nursing homes insist on agencies making information recruitment decisions which require DBS checks to be made on all staff. It is a condition of proceeding with your application that you apply for a DBS disclosure check. The disclosure will be compared with the information given below and any inconsistencies could invalidate your application or lead to the cancellation of your registration with us.
Have you been convicted of a criminal offence?*
- Yes
- No
Have you ever been cautioned or issued with a formal warning for a criminal offence?*
- Yes
- No
If you have answered ‘yes’ to either of the above questions please list details including dates below
*
- I confirm the above is true and I understand that a DBS check will be sort in the event of a successful application.
Rehabilitation of Offenders Act 1974 and Criminal Records
By the virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986 the provision of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. You should there force list all offences below even if you believe them to be ‘spent’ or ‘out of date’ for some other reason.
Right To Work
It is a legal requirement that before any offer of work can be made all candidates provide the company with confirmation of their eligibility to work in the UK by providing one of the original documents detailed below.
- A passport which describes the holder as a British Citizen or as having a right of abode in the United Kingdom or a passport or other travel document to show that the holder has a Settled Status or an Indefinite Leave to Remain in the United Kingdom and is not precluded from taking the work in question.
- A passport or identity card issued by a State which is party to the European Union and EEA Agreement and which describes the holder as a national or a state which is a party to that agreement.
- A letter issued by the Home Office or the Department of Education and Employment indicating that the person named in the letter has permission to take agency work in question or a biometric residence permit.
Work Time Directives
The Government's guidence on working hours states that you cannot work more than 48 hours per week on average. This law is also called the ‘working time directive.’ Adults can choose to opt out of the 48-hour week, but if you are under 18 you cannot work more than 8 hours per day or 40 hours per week. You may have to work more than 48 hours a week if you work: in a job where 24-hour staffing is required, in the armed forces, emergency services, police, or as a domestic servant in a private household. You may also exceed the working time directive if you do not measure your working time and you are in control of your schedule.
*
- I DO NOT wish to work more than 48 hours per week
- I DO wish to work more than 48 hours per week
Registration form Declaration
I declare that all information given in this registration form is to the best of my knowledge complete and accurate in all respects and that I am eligible to work in the UK. I understand that any false or misleading information may result in my removal from the register of members.
Today's Date*
Full Name:*
Signature
Your Name
Your Name
Your Name
Privacy*
- By using this form you agree with the storage and handling of your data by this website as defined in our Privacy Policy *

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