Register – Crown Care Services

Registration

Fill in the form below for your registration

1Personal Details

2Additional Information

3Education & Employment

4Declarations

5Payment/Banking

6Employee/Employer

7Health Details

8GDPR Consent

Position Applied for(Required)

NMC PIN

Your Name

Title Surname Forename Middle Name(s) Previous Name(s) (if any)

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address House Number City Postal Code

Phone(Required)

Alternate Phone

Email(Required)

National Insurance Number(Required)

Professional Organisation (RCN, UNISON etc) Membership Details (if any)

Professional Indemnity

Yes

Next of Kin (NOK) to be notified in case of emergency

NOK Name

Phone

Relationship to you

Address

Street Address House Number City Postal Code

Have you ever been employed by this organization in the past?

Yes

What is your residential status in UK?

Upload UK Passport

Max. file size: 128 MB.

Upload Bio Metric (BRP)

Max. file size: 128 MB.

Upload BPR & Passport

Drop files here or

Max. file size: 128 MB, Max. files: 2.

Have you ever been disciplined by a professional body (NMC etc)?

Yes

If Yes, please explain:

Do you have a UK driving license?

Yes

Driving License No.

Convictions Details

Yes

Hidden

Convictions Details if yes

Convictions Details

Education

Name of School/College/University

Location (mailing address)

Years Completed

Grade

Degree/Diploma

Employment History (Most Recent to Oldest)

Name and Address of Employee

Date of Employment (From)

Date of Employment (To)

Position held and Summary of duties & responsibilities

Reason for leaving

References 1(Required)

Two References are normally taken up for candidates selected for interview. Give details of the names/addresses of your immediate supervisor or manager . One of the Referees should be your current employer, or if presently unemployed or self-employed, your last employer

Name, address and Post Code

Phone

Organizational Email

Position

May we contact the above person now?

References 2(Required)

Name, address and Post Code

Phone

Position

May we contact the above person now?

Confidentiality Declaration

Registration implies acceptance of our code of confidentiality. In the course of your duties you may have access to confidential information about our clients. On no account must information relating to identifiable client be divulged to anyone other than the manager. You should not disclose ANY information to your family, friends or neighbors. 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 YOUR MANAGER. Failure to observe these rules will be regarded as serious misconduct which could result in disciplinary dismissal. I have read and I understand the above and I agree to abide by the contents therein.

Name

Signature

1. Rehabilitation of Offenders Act

DBS DISCLAIMER A Disclosure and Barring Service check is necessary for the position you are applying for. Should you be successful in your application, you will be asked to sign a DBS disclaimer. This will be explained, in full, prior to signing the form. Rehabilitation of Offenders Act 1974 – Notice to Offenders Because of the nature of the work involved, the post for which you are applying is exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation Offenders Act (Exemption Order 1975). This means that you are not entitled to withhold information relating to any convictions you may have had.

Do you have any convictions to disclose?

Yes

If yes, please provide details of any convictions which are not spent under the terms of the Rehabilitation of Offenders Act 1974. This information will be treated as confidential and will not necessarily preclude you from employment. Details:

Details of any convictions

Name

Signature

2. DBS and Barring Checks

Do you have an Enhanced Disclosure from the Criminal Records Bureau (CRB) now known as Disclosure Baring Services?

If yes provide DBS certificate number:

Have you subscribed for the ‘DBS Update Service’?

Yes

I hearby give consent for Crown Care services to perform DBS check.

Name

Signature

3. Personal Declaration

I agree that Crown Care Services Limited can create and maintain computer and paper records of my personal data and that this will be processed and stored in accordance with the General Data Protection Regulations (GDPR). I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated. I declare that the information given is correct to the best of my knowledge. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.

Name

Signature

Date

MM slash DD slash YYYY

4. Name of assessment or Skills (Please tick as appropriate yes or no)

PEG Feed

Yes

Blood Pressure

Yes

Wound Management

Yes

Drug Administration

Yes

Insulin Administration

Yes

Injection S/C and I/M

Yes

Venepuncture

Yes

Managing Challenging Behaviours

Yes

Suctioning

Yes

Syringe Driver

Yes

Tracheostomy Care

Yes

Use of Glucometer (Blood Sugar Monitoring)

Yes

Urethral Catheterization and Supra Pubic Catheterization

Yes

Other………

Yes

I confirm that the above statement is correct to my knowledge

Name

Signature

Date

MM slash DD slash YYYY

Employment Payment/ Banking details

PAYE (Pay as You Earn) Employees

Name

Title Frist Name Middle (if any) Surname

Bank Name

Address

Sort code

Account no

PREVIOUS EMPLOYMENT STATUS/ TAX CODE INFORMATION

To be completed by the employee

Your details

National Insurance Number This is very important in getting your tax and benefits right

Title First Name Surname

Gender

Male

Female

Date of birth

MM slash DD slash YYYY

Address

House or flat number Rest of address including house name or flat number Postcode

Read all the following statements carefully and click in the one box that applies to you

A – This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance or taxable Incapacity Benefit or a state or occupational pension.

Yes

B – This is my only job, but since last 6 April I have had another job, or have received taxable Jobseeker’s Allowance or taxable Incapacity Benefit. I do not receive a state or occupational pension.

Yes

C – I have another job or receive a state or occupational pension

Yes

D – Student Loans

If you left a course of Higher Education before last 6 April and received your first Student Loan instalment on or after 1 September 1998 and you have not fully repaid your student loan, tick box D. (If you are required to repay your Student Loan through your bank or building society account, do not tick box D.)

Yes

I can confirm that this information is correct

Signature

Date

MM slash DD slash YYYY

Tax code used

If you do not know the tax code to use or the current National Insurance contributions (NICs) lower earnings limit, go to www.businesslink.gov.uk/payeratesandthresholds

Box A ticked Emergency code on a cumulative basis

Yes

Box B ticked Emergency code on non-cumulative basis Week 1 / Month 1 basis

Yes

Box C ticked Code CBR

Yes

Tax code used

Health related matters

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?

Yes

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?

Yes

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

Do you think you may need any adjustments or assistance to help you to do the job?

Yes

If you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected.

TB DECLARATION

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 year (Include Holidays/ Vacations)

Yes

If you answered NO to the above, 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 will be rejected.

Have you had a BCG vaccination in relation to Tuberculosis?

Yes

If you answered yes please state when

Date

MM slash DD slash YYYY

Do you have any of the following

A cough which has lasted for more than 3 weeks

Yes

Unexplained weight loss

Yes

Unexplained fever

Yes

Have you had tuberculosis (TB) or been in recent contact with open TB

Yes

Immunisation History

Triple vaccination as a child (Diphtheria / Tetanus / Whooping cough)

Yes

Date

MM slash DD slash YYYY

Polio

Yes

Date

MM slash DD slash YYYY

Tetanus

Yes

Date

MM slash DD slash YYYY

Hepatitis B (If Yes is ticked please give dates below)

Yes

Date

MM slash DD slash YYYY

Course

Boosters

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 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 and Measles

Hepatitis B

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

Proof of Immunity (Please send the following) EPP Candidates Only

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 sample. (IVS)

Health Assessment for Night Worker and policy statement

Definition of “a night worker”? A “night worker” is someone whose daily work includes at least three hours of night time:

• On most days they work;
• On a proportion of the days they work which is specified in a collective or workforce agreement; or often enough for it to be said that they work such hours “as a normal course”.

The words “as a normal course”, means on a regular basis. A Court ruling asserted that a worker who has worked at night for one third of his working time was a night worker. Occasional, or ad hoc, work at night does not make the employee a night worker. At Crown Care Services every employee who wishes to work at nights and deemed as “a night worker” is offered an assessment in two parts,

a) Screening questionnaire
b) An Occupational Health Assessment

Q1. Do you suffer from any of the following conditions (you do not have to disclose which one(s) to your manager)?

Diabetes Heart or circulatory disorders Stomach or intestinal disorders Any health condition which causes difficulties sleeping (except occasional insomnia) Chronic chest disorders, especially if night-time symptoms are troublesome Any medical condition requiring medication to a strict timetable or medication that Causes side effects that could be unpleasant or dangerous if working at night?

Yes

Q2. If you answered yes to question 1, has this been assessed by GP and/or other health professional, and were you assessed as fit for nights with or without adjustments?

Yes

Q3. Has your condition deteriorated or treatment changed since your last assessment?

Yes

Q4. Is there any other health factors that might affect fitness at work such as pregnancy or would you otherwise like to discuss your health and night work in confidence with an HR/recruitment consultant?

Yes

Declaration

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Name

Signature

Date

MM slash DD slash YYYY

GDPR Consent Form

Company Name:

Crown Care Services Ltd. 53 Deardengate, Haslingden, BB4 5QN

Document:

Consent declaration

Topic:

Data protection GDPR

Version:

Consent

I hereby by give my consent to crown care service to process the following information

All Personal data including

• Name
• Date of birth
• Contact details, including telephone number, email address and postal address
• Experience, training and qualifications
• Professional Membership and NMC Registration
• CV
• National Insurance number
• Appraisal and Assessment records
• References
• Pension – auto-enrolment
• LCC / Umbrella Company details
• Biometric Data – Right to Work

Sensitive personal data

• Disability/health condition relevant to the role including health screening and immunisation history
• Equal Opportunity Monitoring Data
• Enhanced DBS Check

Signed by member

Date

MM slash DD slash YYYY

To be completed by the employer (Note for Employer, this section is part of P46)

Employee's details Please use Capitals

Date employment started

MM slash DD slash YYYY

Job title

Works/Payroll Number and department or branch (if any)

Employer's details Please use capitals

Employer’s PAY reference

Employer’s name

Address

Building number Rest of Address Post code

Declaration

I confirm that the above information is correct to the best of my knowledge

Signed

Date

MM slash DD slash YYYY