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Intro
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Personal
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Education
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Medical
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Disclosure
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Declaration
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Qualified Nurse Online Registration

Estimated Time for form complition is 35 mins

Welcome to Seek Staffing Ltd online Qualified Nurse registration form! We are thrilled to have you here and appreciate your interest in becoming a part of our dynamic team of healthcare professionals.

Whether you're an experienced nurse looking for flexibility in your schedule or a newly graduated nurse eager to gain valuable experience, our agency is dedicated to helping you achieve your professional goals. We value your commitment to delivering high-quality healthcare services, and we're committed to supporting your career growth and personal development.

Please take a few moments to provide accurate and detailed information, as it will help us better understand your unique skills and preferences. Thank you for choosing our agency to further your nursing career

Registration Requirements

To complete your registration as an agency nurse, please ensure you provide the following essential documentation and information:

Right to Work: British, Northern Ireland, Wales, and Scotland Citizens should provide a current valid passport. Non-UK citizens should provide current & valid international passport, Biometric Residence Permit (BRP) & Share code and any Home Office correspondence. We also accept a full UK drivers licence.

Proof of National Insurance Number (NI): Submit a copy of you NI document

Proof of Address: We require two recent documents that confirm your current address, with dates within the last three months. Accepted document are :

  • Bank statement
  • Utility bill (e.g., gas, electricity, water)
  • Tenancy agreement
  • Council tax statement

Enhanced DBS: Evidence of an Enhanced Disclosure and Barring Service (DBS) check.

Proof of Immunization: submit documentation that confirms your immunization status.

Mandatory Training / Other Training Certificates: Include certificates or proof of completion for mandatory training and any additional relevant training or certifications.

References: You should submit 2 Clinical Professional References & 1 Character Refeference

Updated CV: Please submit an updated CV that provides a comprehensive overview of your education and employment history, covering the past 10 years.

Passport-Size Picture: Provide a passport-size picture with a plain background for identification purposes.

Your compliance with these requirements will enable us to expedite the registration process and match you with suitable nursing assignments. Please ensure the accuracy and completeness of the documents and information you provide.


Equal Opportunity Monitoring Form - PR26


Seek Staffing ltd is committed to equality of opportunity and fair treatment in all aspects of employment. We aim to provide a working and learning environment which is free from unfair discrimination and will enable staff to fulfil their personal potential. The Equality Act 2010 protects people from discrimination and promotes equality on the basis of a number of ‘protected characteristics’. We ask for information on your ‘protected characteristics’ in order to help us monitor our performance on equality. In line with Government policy, and in accordance with the provisions of GDPR, the information you provide will be held confidentially and It will help us to comply with the law under the relevant Acts and to ensure that our employment policies and practices are fair and effective.

IMPORTANT - Please Note: You do not have to complete this section of the form. The information is given on a voluntary basis and the information provided will only be used for the monitoring purpose. Please do not enter any identifying marks on this form, so that your information remains confidential. This information will be stored on a database.

Ethnic Origin

Please indicate your Ethnic Origin

Asian or Asian Brtitish
Black or Black British
Mixed
White
Other Ethnic Background
c
Gender

Please indicate your Gender

Religion or Belief

Please indicate your Religion or Belief

Marital Status

Please indicate your Marital Status

As per Equality Act 2010

Under the terms of the Act, a disability is defined as a “physical or mental impairment which has a substantial and long- term effect on a person’s ability to carry out day-to-day activities”.

Do you consider yourself to have a disability
Give details

Qualified Nurse Online Registration Form



Data Protection Statement

The personal information (data) collected on this form, and on the attachments, (which includes the collection of
sensitive personal data) are collected for the purposes of recruitment, personnel administration (for new employees)
and monitoring. Unless you direct otherwise (for example in a situation where you would like this Application kept on
file for future vacancies) the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6
months. It is the policy of the Agency to protect, and keep secure, all personal data collected. All personal data is
processed for the purposes of recruitment, and, in the case of successful Applicants, for the satisfactory
administration of their employment, and for no other purpose

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.


Personal Information
Upload your profile picture
Maximum file size: 256 MB
Qualified Nurse Type
Title
Surname
Maiden
Forenames
Previous Surname
Marital Status
Place of Birth
Date of Birth
Gender
National Insurance
Nationality
Passport Number
Religion
Phone
Email
Current Address
Address Line 2
City
County
Post Code

General Information
Upload your Documents
Maximum file size: 20 MB
Uploads accepted: CV, 2 Proofs of address (within last 3 months), Sharecode, DBS, Mandatory Training, Passport / Right to work, Proof of NMC, Immunisation results
Are you a UK Citizen or From European Community / European Economic Area?
Please select your Visa Category
Does your visa have a condition restricting employment or occupation in the UK?
Restriction Details
Visa Number
Issue Date
Expiry Date
Work Preference
Client Preference
Shift Pattern Preference



Next of Kin
Please provide contact details of at least one person we can contact incase of emergency
First Name
First Name
Whats your Relationship?
Next of Kin Address
Next of Kin Address Line 2
Next of Kin City
Next of Kin County
Next of Kin Post Code
Next of Kin Phone Number
Next of Kin Email

Bank Details
We pay your wages directly into your bank account weekly  
Bank Name
Bank Address
Bank Address Line 2
City
County
Post code
Account Name
Sort Code
Account Number




Education History


Primary Education

Please supply details of your Education History

Institution
Date From
Date To
City and Country
Qualification
Grade






Secondary Education
Institution
Date From
Date To
City & Country
Qualification
Grade





College & University Education
Institution
Date From
Date To
City & Country
Qualification
Grade





Mandatory & Other Training
Course
Date Completed
Expiry Date
Training Provider




Professional Membership
Please supply details of your Professional Membership
Select All professional bodies you belong
Nursing & Midwifery Council (NMC)
NMC PIN Number
Where Obtained
Registration Date
Expiry Date
Is there an ongoing investigation or regulatory proceeding involving your fitness to practice in the UK or any other country?
Give details of Incident
Have you experienced registration removal or had conditions imposed on your registration by a fitness to practice committee or a licensing/regulatory body, either in the UK or any other country?



Give details of Incident
Employment History



Most Recent Employment

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained. Click on the Add employment button to add more employment history.

Date From
Date To
Employer & Address
Duties
Band
Reason For Leaving
Past Employment


Employment Gap
Explanation of Gaps - Use this section to detail any gaps in employment and why


Additional Infomation
Have you previously experienced termination from a job, undergone disciplinary procedures, or are you currently in a pending hearing/investigation process?
Give Details
Could you verify whether you grant permission for the agency to reach out to your former employers?
Advice When you think it will be convenient
Referees will be approached prior to interview, unless you indicate otherwise above



References

Please provide names, addresses and telephone numbers for referees below whom we may approach for a reference. In line with CQC requirements, we require references (or other satisfactory evidence as the employer may determine) from all previous employers concerned with the provision of services relating to health or social care, or children or vulnerable adults which should include details of why their employment came to an end (note that this is not time limited). Please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.


Clinical Reference 1
Referee First Name
Referee Last Name
Job Title
Business Name
Referee Address
City
County
Post code
Referee Phone
Referee Email
Employment Start Date
Employment End Date




Clinical Reference 2


Referee First Name
Referee Last Name
Job Title
Business Name
Referee Address
City
County
Post code
Referee Phone
Referee Email
Employment Start Date
Employment End Date


Character Reference


First Name
Last Name
Referee Address
City
County
Post code
Referee Phone
Referee Email
What is your relationship with this person?




Medical History



Clinical Medical Questionnaire (Confidential)

The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by Healthier Business UK Ltd and may need to be seen by an occupational health advisor or physician. Your record will be held on file for a short period of time and may be subject to audit. Your file may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.


Worker Details

Title
First Name
Last Name
Phone
email
Full Address
full address should include city, county and post code
Your GP Details
full address should include city, county and post code




General Health
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
Give Details
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
Give details
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
Give Details
Do you think you may need any adjustments or assistance to help you to do the job?
Give Details



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 year
Please list all of the countries that you have lived in or visited over the last year
This MUST include duration of stay and dates or this form will be rejected
Have you had a BCG vaccination in relation to Tuberculosis?
Give Date
Have you had a cough which has lasted for more than 3 weeks?
Give Details
Have You experienced any unexplained weight loss?
Give Details
Have you experienced any unexplained Fever?
Give Details
Have you had tuberculosis (TB) or been in recent contact with open TB?
Give Details



Chicken Pox or Shingles

Have you ever had Chicken Pox or Shingls
Date
Give Details



Immunisation History

Have you had triple vaccination as a child (Diptheria/Tetanus/Whooping COUGH?
Give Date
Have you had Polio Vaccination?
Give Date
Have you had Tetanus Vaccination
Give Date

Have you had Hepatitis B



Proof of Immunity

VaricellaYou 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
TuberculosisWe require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)
Hepatitis BYou must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above
Rubella, Measles & MumpsCertificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles

EPP Candidates Only

Hepatitis B Surface AntigenEvidence of a negative Surface Antigen Test Report must be an identified validated sample. (IVS)
Hepatitis CEvidence of a negative antibody test. Report must be an identified validated sample. (IVS)
HIVEvidence of a negative antibody test. Report must be an identified validated sample. (IVS)
Will your role involve Exposure Prone Procedures (EPP)?



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. I also give consent for the Healthier Business UK Ltd to make recommendations to my employer.

First Name
Last Name
Dec Date
Signature
Disclosure

Safeguarding / Ex-Offenders Declaration

Please note this section will only be seen by those involved in the recruitment process and will be treated with the strictest confidence


The Rehabilitation of Offenders Act 1974 aims to promote equality of opportunity and is committed to treating all applicants fairly regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity and marriage or civil partnership. Seek Staffing ltd undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared.

Answering 'yes' to the question below will not necessarily prevent your employment. This will depend on the relevance of the information you provide in respect of the nature of the position and the particular circumstances.

Are you currently bound over or do you have any current UNSPENT convictions that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?
Give Details
Do you have any current UNSPENT police cautions, reprimands or final warnings in the United Kingdom or in any other country?
Give Details
Privacy Statement
We will only collect data for specified, explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to us holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you).

When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles. We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager to discuss
Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that can seek clarification regarding professional registration details.

Full Name
Signature
Date
oih

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