Application Form - Standard

Application Form - v1.2

- Step 1 of 13

Thank you for applying for work with Better Healthcare Services. Your local recruiter will be in touch shortly to arrange time and date for your interview. Please allow about an hour for your interview and registration process.

To be able to complete the interview we will require you to bring documents and evidence from the below list. If you are able to upload the files, this will save time at interview

Name *

First

Last

Proof of ID - please choose 2 (one must be photo ID)

Passport
Driving License
Birth Certificate
Citizens Card
Work Permit

Proof of ID 1

Click or drag a file to this area to upload.

Proof of ID 2

Click or drag a file to this area to upload.

Proof of Address - please choose 2 (must be within the last 3 months)

Energy Bill
Bank Statement
Phone Bill (landline)
Credit Card Statement
P45 / P60

Proof of Address 1

Click or drag a file to this area to upload.

Proof of Address 2

Click or drag a file to this area to upload.

If you are unsure of your NI number you can find it from this HMRC site

https://www.gov.uk/government/publications/national-insurance-get-your-national-insurance-number-in-writing-ca5403

Please bring the below to your interview

Any relevant training certificates
Bank details
Passport photos
Driving License

Training Certificates (sent as one file)

Click or drag a file to this area to upload.

Driving License

Click or drag a file to this area to upload.

Passport photo (Please bring 2 passport photos with you when interviewed)

Click or drag a file to this area to upload.

All successful applicants will be subject to a DBS (Disclosing and Baring Service) at a cost of £60 which is non refundable. However if you have a current portable DB, please bring this along as this can be accepted.

Date *

Branch - please select *

Applying for the post of *

Sector - please select *

Name *

First

Last

Address *

Address line 1

Address

Address line 2

City

County

Post Code

Country

Home Phone

Mobile Phone *

Marital Status *

Single
Married
Divorced
Widowed
Civil Partnership
Other

Passport Number *

National Insurance Number *

Email *

Do you drive

Yes
No
I have another form of transport

Do you have your own car - or access to a car

If you have another form of transport please sate

How did you hear about Better Healthcare *

Please state *

Next of Kin

Name *

Next of Kin

Relationship *

Next of Kin

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Next of Kin

Home Phone

Next of Kin

Mobile *

Next of Kin

Professional / Vocational Qualifications:

Name of Professional Body - GMC, NMC, Professions Allied to Medicine etc

Membership Grade and/or Registration

Date of expiry MM/YY

Name of Professional Body

Membership Grade and/or Registration

Date of expiry MM/YY

Name of Professional Body

Membership Grade and/or Registration

Date of expiry MM/YY

Name of Professional Body

Membership Grade and/or Registration

Date of expiry MM/YY

Employment History

If this is your first job please enter in the following fields: 'Name and Address of Present Employer' - FIRST JOB 'Position held' - IF YOU HAVE DONE ANY UNPAID WORK IN RELATION TO CARING FOR SOMEONE PLEASE GIVE DETAILS 'Date from' - TODAY'S DATE

Name and address of present (or most recent) employer and nature of business *

Position held *

Employed date from MM/YY *

Employed date to MM/YY

Previous Employers (full employment history explaining any gaps - please use additional sheet if necessary)

If there is not enough room to type all in the cell, please continue to type as everything entered will show when the results are subitted

Prev employer & role *

Position held by you *

Ward or department

Employed from MM/YY *

Employed to MM/YY *

Reason for Leaving *

Prev employer & role (2)

Position held by you (2)

Ward or department (2)

Employed from MM/YY (2)

Employed to MM/YY (2)

Reason for leaving (2)

Prev employer & role (3)

Position held by you (3)

Ward or department (3)

Employed from MM/YY (3)

Employed to MM/YY (3)

Reason for leaving (3)

Prev employer & role (4)

Position held by you (4)

Ward or department (4)

Employed from MM/YY (4)

Employed to MM/YY (4)

Reason for leaving (4)

Prev employer & role (5)

Position held by you (5)

Ward or department (5)

Employed from MM/YY (5)

Employed to MM/YY (5)

Reason for leaving (5)

Prev employer & role (6)

Position held by you (6)

Ward or department (6)

Employed from MM/YY (6)

Employed to MM/YY (6)

Reason for leaving (6)

Do you have more roles to enter

Prev employer & role (7)

Position held by you (7)

Ward or department (7)

Employed from MM/YY (7)

Employed to MM/YY (7)

Reason for Leaving (7)

Previous employer & role (8)

Position held by you (8)

Ward or department (8)

Employed from MM/YY (8)

Employed to MM/YY (8)

Reason for leaving (8)

Prev employer & role (9)

Position held by you (9)

Ward or department (9)

Employed from MM/YY (9)

Employed to MM/YY (9)

Reason for leaving

Prev employer & role (10)

Position held by you

Ward or department (10)

Employed from MM/YY (10)

Employed to MM/YY (10)

Reason for leaving (10)

Prev employer & role

Previous employer & role

Position held by you

Ward or department

Employed MM/YY

Employed to MM/YY

Reason fro leaving

Prev employer & role

Previous employer & role

Position held by you

Ward or department

Employed MM/YY

Employed to MM/YY

Reason fro leaving

Do you have more roles to enter

Prev employer & role

Position held by you

Ward or department

From MM/YY

Employed to MM/YY

Reason for Leaving

Previous employer & role

Position held by you

Ward or department

Employed MM/YY

Employed to MM/YY (copy)

Employed to MM/YY

Reason for leaving

Previous employer & role

Position held by you

Ward or department

Employed MM/YY

Employed to MM/YY (copy) (copy)

Employed to MM/YY

Reason for leaving

Previous employer & role

Position held by you

Ward or department

Employed MM/YY

Employed to MM/YY (copy) (copy) (copy)

Employed to MM/YY

Reason fro leaving

Previous employer & role

Position held by you

Ward or department

Employed MM/YY

Employed to MM/YY (copy) (copy) (copy) (copy)

Employed to MM/YY

Reason for leaving

Special Interests / Additional Comments

What is the main quality that you have that would enhance the experience that Service Users have from the Agency

Referees (Must be your line manager, we require references for your previous 5 years (must be continuous))

Reference 1

Name:

Position:

Organisation:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Fax

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Reference 2

Name:

Reference 2

Position:

Organisation:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Fax

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Reference 3

Name:

Reference 3

Position:

Organisation:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Fax

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Reference 4

Name:

Reference 4

Position:

Organisation:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile (if known)

Fax

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Do you require a further reference form

Ref 5 Name:

Reference 5

Position:

Organisation:

Phone

Mobile (if known)

Fax

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Ref 6 Name:

Reference 6

Position:

Organisation:

Phone

Mobile (if known)

Fax

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Do you require a further reference form

Ref 7 Name:

Reference 7

Position:

Organisation:

Phone

Mobile (if known)

Fax

Fax (copy)

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Ref 8 Name:

Reference 8

Organisation:

Position:

Phone

Mobile (if known)

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Have you previously worked for another employment/nursing agency?

Please state the name of the agency

Ethnic Origin - Choose one section, then tick the appropriate box to indicate your cultural background

White

White
Scottish
Irish
Welsh

Other please state

Mixed

White and Black Caribbean
White and Black African
African

Other please state

Black or Black British

Caribbean
White and Asian

Other please state

Asian or Asian British

Indian
Pakistani
Bangladeshi

Other please state

Chinese or other ethnic group

Chinese

Other please state

Courses attended

Checkboxes

Moving and Handling

Expiry date

Infection Control

Infection Control

Expiry date

Checkboxes (copy)

Basic Life Support

Expiry date

Infection Control (copy)

Fire Safety

Expiry date

SOVA

SOVA

Expiry date

Infection Control

Food Hygiene

Expiry date

SOCA

SOCA

Expiry date

Infection Control (copy)

Violence and Aggression

Expiry date

SOVA (copy) (copy)

Health and Safety

Expiry date

SOVA

Loneworker

Expiry date

SOVA

COSHH

Expiry date

SOVA (copy)

Complaints

Expiry date

SOVA (copy)

RIDDOR

Expiry date

Caldicott Protocol

Caldicott Protocol

Expiry date

SOVA (copy) (copy)

Medication

Expiry date

SOVA (copy) (copy) (copy)

Dementia

Expiry date

SOVA (copy) (copy) (copy)

Care and Observation

Expiry date

SOVA (copy) (copy) (copy) (copy)

Palliative Care

Expiry date

SOVA (copy) (copy) (copy) (copy)

Peg Feed

Expiry date

Learning Disability

Learning Disability

Expiry date

Stoma

Stoma

Expiry date

Learning Disability (copy)

ECC&R (Restraint Training)

Expiry date

Stoma (copy)

Tracheostomy care

Expiry date

Learning Disability (copy) (copy)

Spinal cord injury

Expiry date

Stoma (copy) (copy)

Catheter

Expiry date

Learning Disability (copy) (copy) (copy)

Mental health

Expiry date

NVQ - Have you taken an NVQ

Have you taken an NVQ *

Level achieved

Subject

Date

Additional Training / Qualifications

Name/Address of Training Establishment

Qualifications Obtained

Date

Name/Address of Training Establishment

Qualifications Obtained

Date

Right to Work in the UK

I confirm I am entitled to work in the UK on the following basis:

I am a UK Citizen

Date from - (if from birth, please enter your Date of Birth)

I hold a valid work permit

Date from

I hold a Working Holiday Visa

Date to

I hold an Ancestral Visa

Date to

I am eligible to work in the UK under my spouses Visa

Date to

I hold a highly skilled Migrant Programme Visa

I hold a Student Visa

Other - please specify

Single Line Text

Is your partner, any member of your family or household employed by the company?

Is your partner, any member of your family or household employed by the company? *

Name

Job Title

Branch

Transport

Do you have a current driving license? *

Do you have your own transport? *

Availability for work

When would you like / be willing to work

Weekday
Saturday days
Sunday days

When would you like / be willing to work (

Nights
Saturday nights
Sunday nights

Rehabilitation of Offenders Act 1974

By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, the provisions 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 kind as to enable the holder to have access to persons in receipt of such services in the course of his normal duties. Your answer to the following question should include any ‘spent’ convictions.

Have you ever been convicted of a criminal offence? *

Please give details below

Have you ever been convicted of a criminal offence?

Data Protection Consent Form (GDPR)

I hereby give my consent to Better Healthcare Services to process the following information about me:

• Name
• Date of Birth
• Contact details, including telephone number, email address and postal address
• Experience, Staff Performance, training and qualifications
• CV
• National Insurance Number
• Payroll / Tax
• Bank Details
• GP Details
• Next of Kin Detail
• Passport
• Driving License
• Right to Work in the United Kingdom/ Visa
• Proof of references

Sensitive Personal Detail

• Disability/health condition relevant to the role
• DBS / Criminal conviction
• Disciplinary Information
• Religion
• Ethnic Origin

Contact

• I am happy to be contacted by email, text message, phone or post

I consent to Better Healthcare processing the above personal data for the following purposes:

Where I have delivered care on behalf of the company, I also consent to the Company processing my personal data with third parties for the purposes of internal audits and investigations carried out on the Company to ensure that the Company is complying with all relevant laws and

obligations - this includes CQC, local authority, NHS. Managed Service Providers and clients within the care industry.

The consent I give to the Company will last for 3 years or 6 years (from the time I leave Better Healthcare) where I have worked as a carer.

I am aware that I have the right to withdraw my consent at any time by informing the Company that I wish to do so.

Data Protection Consent - I hereby give my consent

Data Protection Consent Form

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Declaration

I affirm that the information set out in this form is true and correct, is not misleading and that no material information has been omitted. I understand and agree that if I submit any false or misleading information or omit any material information this may result in an offer of employment being withdrawn or, if I have already
I understand and agree that I have read the conditions of Better Healthcare Services and agree to be bound and comply with the same.
I confirm that under the General Data Protection Regulation (GDPR) 2018, I hereby give my full consent to Better Healthcare Services to verify all the information given on this form and to process the information as described above under 'Data Protection Consent'.
I have read and understood the Standard/ Enhanced DBS Check Privacy Policy for applicants (this can be found in our Policies and Procedures file or on the Better Healthcare web site under 'downloads' www.betterhealthcare.co.uk/ downloads
I agree to abide by Better Healthcare Services's Polocies and Procedures

I confirm the declaration above

Declaration

Associate Skills Profile

Care Assistant / Support Worker

PLEASE READ

Please tick the box in accordance with the level of expertise as indicated below:

1 Familiar with the procedure and can perform alone

2 Familiar with the procedure but need supervision

3 Understand the theory of the procedure but never performed the task

4 No knowledge of the procedure

PERSONAL HYGIENE

Bath / Shower / Assisted Wash

Use of bath aids

Mouth Care (including dentures)

Care of feet (excluding toe nails)

Dressing / Undressing of patients

Bed bath

Shaving

Care of hair

Care of finger nails

Care of eyes

Pressure area care

TOILETING

Emptying & changing a catheter

Catheter care

Stoma care

Use of bedpans / urine bottles / commodes

Collection of stool / urine / sputum specimen

Incontinence care

MOBILITY

Moving & handling

Use of hoists

Use of walking aids

Use of wheel chairs

NUTRITION

Preparation of food

Special diets

Supervision / assistance with feeding

Food chat

INFECTION CONTROL

Caring for MRSA positive patients

Barrier Nursing

Isolation

Universal precautions

Hand Washing

Cross infection

GENERAL

First Aid

Awareness of Health & Safety precautions

Bed making

Simple dressing

Report writing / handover

Laundry

Shopping

Domestic duties

KNOWLEDGE OF SERVICE USER GROUPS

Elderly people

Dementia

Palliative care / care of terminally ill

People with physical disabilities

People with mental health problems

People living with HIV / AIDS

Children / families

Learning disability

Mental Health

Acute

Moving & Handling Course

Basic Care & Observation Course

First Aid Course

Basic Food Hygiene Certificate

EXPERIENCE

Hospital / NHS

Nursing Home

Residential Home

Hospice

Private Hospital

Home Care

Escort

Specialising

OBSERVATIONS

Observe patient confidentiality

Taking temperatures

Checking blood pressure

TPR / BP recording chart

Checking pulse respiration

Pressure area care

Blood sugar testing

Urine testing

Observing/recording changes in patient condition & reporting to senior staff

Other Skills / Comments

Skill Profile *

I confirm that the skills that are ticked are a true and accurate representation of my skill and experience

EPP for Nurse applications only

Are you a Nurse looking to join Better Healthcare

If you answered yes to the above, please enter the dates for the following sections (evidence will be required at interview stage. It will need to be on letter headed paper from their doctors / hospital for traceability):

Immunisations (enter date of immunisations MM/YY)

BCG

Rubella (MMR)

Measles

Mumps

Flu jab

Hepatitis B (date of all 3 - #1)

Hepatitis B (date of all 3 - #2)

Hepatitis B (date of all 3 - #3)

Blood test results (enter date of blood test MM/YY)

Hep B Test (Heaf, Tine, Mantoux) Surface Anitbody

Hepatitis B - Surface Antigen

Rubella

Varicella (Chicken Pox)

HIV / Aids

Hepatitis C

Loan Agreement

I hereby confirm that Better Healthcare Services (BHC) have provided me with a loan for the following (stated below), however BHC agrees to waive this loan should the aforementioned carer stay with and work for the company for a minimum of 480 hours.

Should I leave BHC prior to having worked a minimum of 480 hours or I do not join BHC having attended any part of the training, I will be responsible for reimbursing BHC the full cost of training as stated below.

Should the above criteria for free training not be met, BHC will require full payment within 30 days of the leaving date.

I understand that failure to repay all training costs within these timescale will result in BHC taking legal action against me to claim monies owed. I will be held responsible for all additional costs plus interest from the date of the loan agreement.

Please note by signing this form you are committing to attend the training course/s (subject to successful interview) - should you wish to cancel, you must do so no later than 24 hours prior to commencement of the course. Should you not cancel (in writing) within 24 hours, a cancellation fee of £50 will be applied.

Please note all training certificates are the property of Better Healthcare Services. If you wish to receive your training certificates before you have completed a minimum of 480 hours, then the cost of training must be paid.

Cost of training if not completing the agreed hours:

Title	Cost
Induction Training	£110.00
Staff uniform - Tunic	£19.00
Staff uniform -Polo	£15.00
On line training	£22.00

Loan agreement *

I confirm that I agree to the terms of the loan agreement as stated above

Declaration

I declare that the information on this form is true to the best of my knowledge. Further, I understand that if I should be found to knowingly make a false statement regarding my medical history either in answering the above questions or to the Company's Director of Quality and Training, or should I conceal any material fact, the Company can terminate my contract without notice.

Phone

Next of Kin

Professional / Vocational Qualifications:

Employment History

Previous Employers (full employment history explaining any gaps - please use additional sheet if necessary)

Referees (Must be your line manager, we require references for your previous 5 years (must be continuous))

Reference 1

Reference 2

Reference 3

Reference 4

Ethnic Origin - Choose one section, then tick the appropriate box to indicate your cultural background

Courses attended

NVQ - Have you taken an NVQ

Additional Training / Qualifications

Right to Work in the UK

Is your partner, any member of your family or household employed by the company?

Transport

Availability for work

Rehabilitation of Offenders Act 1974

Data Protection Consent Form (GDPR)

Declaration

Associate Skills Profile

PERSONAL HYGIENE

TOILETING

MOBILITY

NUTRITION

INFECTION CONTROL

GENERAL

KNOWLEDGE OF SERVICE USER GROUPS

EXPERIENCE

OBSERVATIONS

EPP for Nurse applications only

If you answered yes to the above, please enter the dates for the following sections (evidence will be required at interview stage. It will need to be on letter headed paper from their doctors / hospital for traceability):

Immunisations (enter date of immunisations MM/YY)

Blood test results (enter date of blood test MM/YY)

Loan Agreement

Declaration

Sonderwell Life

Sonderflex

Learning and Training Academy

Sonderwell Care

Sonderwell People