Step 1 of 7 - ABOUT YOU 0% Experience type* I AM A REGISTERED NURSE I AM A HEALTHCARE ASSISTANT I AM A LIVE-IN CARER PLEASE NOTE: ORIGINAL DOCUMENTS WILL BE VERIFIED WHEN YOU COME TO THE OFFICEPERSONAL DETAILSName First Last Date of Birth* DD slash MM slash YYYY Email Contact numberAddress Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Upload proof of address: Utility bill or bank statement dated within the past 3 months* Drop files here or Select files Max. file size: 32 MB. ADDITIONAL DETAILSNational Insurance Number Upload proof of National Insurance: P45, P60, NI card or old payslip* Drop files here or Select files Max. file size: 32 MB. Are you Self-employed?* Yes No Please provide your Unique Tax Reference number Nationality Current passportChoose...YesNoCountry of Passport Upload proof of identification: Passport or FULL UK birth certificate. Visa or proof of right to work in the UK.* Drop files here or Select files Max. file size: 32 MB. Upload a Passport sized photo* Drop files here or Select files Max. file size: 32 MB. Convictions/CautionsChoose...YesNoPlease give details about the conviction/cautionsDo you have a current Disclosure Barring Service (DBS) Ceritifcate ?Choose...YesNoUpload a copy of your FULL DBS certificate* Drop files here or Select files Max. file size: 32 MB. UK Driving LicenceChoose...YesNoHow did you hear about HLR Ltd?Choose...Social mediaJob board advert/NewspaperReferral/Word of MouthWebsiteInternetLeaflet or posterEMERGENCY CONTACTFull name Relationship type Contact numberAddress Street Address Address Line 2 City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country QUALIFICATIONS & EDUCATIONMANDATORY TRAINING *REQUIRED* All healthcare professionals must have up to date Mandatory Training. This covers CPR, Manual Handling, Nutrition & Dysphagia (Feeding), Safeguarding Vulnerable Adults, Health & Safety and Data Protection. If you have in-date training please list below along with any other relevant qualifications. Yes, I have in-date training No, I do not have any training Click + to add more qualificationsPlace of studyCourse/training completedDate startedDate completed Can you provide certificates for all the above courses/training?Choose...YesNoUpload copies of your certificates Drop files here or Select files Max. file size: 32 MB. Reason(s) for not being able to provide certificates for training/course EMPLOYMENT HISTORYClick on + to add employerCompany NameJob TitleStart DateFinish Date Upload CV Drop files here or Select files Max. file size: 32 MB. Tick to confirm you have completed a minimum of 5 years employment history or back to full time education.EMPLOYEE REFEREESPlease provide 2 professional referees below - they must be a previous or current supervisor / manager or employer and must cover the past 5 years of employment. 1ST REFERENCE NAME* First Last Company/Organisation* Dates of employment (From - To)* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Number*Email* How long has this person known you?* 2ND REFERENCE NAME* First Last Company/Organisation* Dates of employment (From - To)* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Number*Email How long has this person known you?* PLEASE NOTE: ORIGINAL DOCUMENTS WILL BE VERIFIED WHEN YOU COME TO THE OFFICESkip if NOT a nurseDate when first qualified MM slash DD slash YYYY Country where qualified Grade/ Band NMC PIN NMC PIN expiry date MM slash DD slash YYYY Revalidation date Day Month Year Indemnity Insurance - do you have cover?Choose...YesNoIndemnity Insurance - please give details of providerPlease upload proof of NMC PIN and Indemnity Insurance Drop files here or Select files Max. file size: 32 MB. Are you a limited company?Choose...YesNoCompany name and addressUpload Ceritificate of Incorportation and Business Bank Account Drop files here or Select files Max. file size: 32 MB. Have you completed the National Early Warning Score (NEWS) training?Choose...YesNoPlease upload your NEWS Certificates Drop files here or Select files Max. file size: 32 MB. Please tick if you have received training for the following: Tracheostomy Ventilation Please upload copies of your certificates Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 32 MB. EXPERIENCE CHECKLISTPlease select experience type: Registered Nurse Healthcare Assistant Please tick the box to indicate your level of competence: I am experienced and competent in this I am familiar with this procedure but will need supervision I understand the procedure but have no experience I have no knowledge of this procedure PROCEDUREAssisting/enabling a patient with medication* 1 2 3 4 Answering the telephone, taking and conveying messages* 1 2 3 4 Bathing/washing patients* 1 2 3 4 Bed making* 1 2 3 4 Blood pressure taking/recording, understanding* 1 2 3 4 Care of patient’s hair* 1 2 3 4 Care of patient’s finger nails* 1 2 3 4 Care of patient’s bladder & bowels* 1 2 3 4 Care of patient’s eyes* 1 2 3 4 Care of pressure areas* 1 2 3 4 Changing colostomy bags* 1 2 3 4 Changing bed sheets with patient in/on them* 1 2 3 4 Dealing with relatives of ill/terminally ill patients* 1 2 3 4 Dressing and undressing of patients* 1 2 3 4 Emptying catheter bags* 1 2 3 4 Experience with dementia patients* 1 2 3 4 Experience in First Aid* 1 2 3 4 Experience in hospice/care of the terminally ill* 1 2 3 4 Feeding & assisting a patient who has difficulty feeding themselves* 1 2 3 4 Light housework* 1 2 3 4 Obtaining specimens* 1 2 3 4 Peg feeding* 1 2 3 4 Writing reports* 1 2 3 4 Moving & Handling patients with a variety of equipment* 1 2 3 4 Preparation of meals* 1 2 3 4 Recording fluid balance* 1 2 3 4 Recording pulse* 1 2 3 4 Recording respiration* 1 2 3 4 Recording instructions from GP/District Nurse* 1 2 3 4 Reporting to person in charge* 1 2 3 4 Shaving patients* 1 2 3 4 Shopping for patients* 1 2 3 4 Simple dressing procedures* 1 2 3 4 Taking temperatures/understanding* 1 2 3 4 Urine testing* 1 2 3 4 Use of bed pans/ commodes etc* 1 2 3 4 Use of walking aids/wheelchairs* 1 2 3 4 Washing/Ironing/Laundry* 1 2 3 4 AREAS OF WORKPlease indicate areas you have experience in HOSPITAL NURSING/ RESIDENTIAL HOMES PRIVATE HOUSE (CLIENT'S OWN HOME) COMMUNITY MENTAL HEALTH LEARNING DIFFICULTIIES OCCUPATIONAL HEALTH / INDUSTRY Provide details of experience gained in a hospital Provide details of experience gained in a nursing/residential home Provide details of experience gained in a private house (client's own home) Provide details of experience gained in community care Provide details of experience gained in mental health Provide details of experience gained working with people with learning disabilities Provide details of experience gained in occupational health MEDICATION ADMINISTRATIONOral* 1 2 3 4 Via Peg Route* 1 2 3 4 Topical* 1 2 3 4 Eye, Ear, Nose, Throat, Inhalation* 1 2 3 4 Injections – intra dermal, subcut, IMI* 1 2 3 4 PR, PV suppositories* 1 2 3 4 PARENTERAL FEEDINGAdministration management* 1 2 3 4 Knowledge of solutions* 1 2 3 4 Site dressing management* 1 2 3 4 GASTROINTESTINALColostomy/Ileostomy care* 1 2 3 4 Peg feeding* 1 2 3 4 BLADDERMale Catheterisation* 1 2 3 4 Female Catheterisation* 1 2 3 4 Catheter Care* 1 2 3 4 Suprapubic catheter management* 1 2 3 4 Bladder washout/instillation* 1 2 3 4 Urine testing* 1 2 3 4 Collection sterile specimen urine* 1 2 3 4 SUPPORT OF PATIENT LIVING WITHRestrictive airways disease* 1 2 3 4 Diabetes* 1 2 3 4 Stroke* 1 2 3 4 Lymphedema upper or lower limbs* 1 2 3 4 Pain* 1 2 3 4 BASIC NEUROLOGICAL ASSESSMENTSNeurological assessment using Glasgow coma scale or other* 1 2 3 4 Seizure monitoring/ precautions/ reporting* 1 2 3 4 CARE OF ASSISTED REHABILITATIONParaplegia* 1 2 3 4 Quadriplegia* 1 2 3 4 Hemiplegia* 1 2 3 4 Totally immobility* 1 2 3 4 Amputation of one or more limbs* 1 2 3 4 Crutches, walking frame* 1 2 3 4 Wheel chair* 1 2 3 4 Hoists and slide sheets* 1 2 3 4 Log rolling client* 1 2 3 4 CARE OF ASSISTED VENTILATIONOxygen equipment* 1 2 3 4 Nasal Cannula* 1 2 3 4 Face mask* 1 2 3 4 Vent mask* 1 2 3 4 ASSISTING ONCOLOGY CLIENTSTerminal care* 1 2 3 4 Client on chemotherapy treatment* 1 2 3 4 Client on Radiotherapy treatment* 1 2 3 4 COMMENTSConfirmation of skills I confirm that the above information is correct regarding my abilities MEDICALGP Name GP Telephone NumberGP Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please tick what vaccinations you have had Covid-19 Tuberculosis Hepatitis B MMR Varicella (Chickenpox) Please provide proof of vaccinations Drop files here or Select files Max. file size: 32 MB. Letter from GP/ Immunisation ReportTo protect you health at work please indicate, in confidence, to a member of staff if you are pregnant or breast feeding. Weight: Height: Have you ever had problems with:Raised blood pressure Yes No Please give detailsRecovery complete Yes No Heart or Circulatory problems Yes No Please give detailsRecovery complete Yes No Chest pain Yes No Please give detailsRecovery complete Yes No Blood disorders Yes No Please give detailsRecovery complete Yes No Chest Complaints e.g asthma, bronchitis, pleurisy, tuberculosis Yes No Please give detailsRecovery complete Yes No Chronic Indigestion Yes No Please give detailsRecovery complete Yes No Bowel Complaints Yes No Please give detailsRecovery complete Yes No Persistent abdominal pains Yes No Please give detailsRecovery complete Yes No Liver disease or Jaundice Yes No Please give detailsRecovery complete Yes No Diabetes, problems with Thyroid or other glands Yes No Please give detailsRecovery complete Yes No Kidney or bladder problems Yes No Please give detailsRecovery complete Yes No Epilepsy, blackouts or dizziness Yes No Please give detailsRecovery complete Yes No Any mental health problems including: Depression, Psychiatric treatment, eating disorders or attempted suicide Yes No Please give detailsRecovery complete Yes No Have you received or are you receiving counselling Yes No Please give detailsRecovery complete Yes No Substance misuse including alcohol Yes No Please give detailsRecovery complete Yes No Persistent or recurrent back ache or injury Yes No Please give detailsRecovery complete Yes No Neck injury / problems with neck Yes No Please give detailsRecovery complete Yes No Eczema, Dermatitis or other skin disease ( latex allergy) Yes No Please give detailsRecovery complete Yes No Ear, Nose, Throat problems Yes No Please give detailsRecovery complete Yes No Rheumatism, Arthritis or other joint problems Yes No Please give detailsRecovery complete Yes No Vision problems or eye disease Yes No Please give detailsRecovery complete Yes No Hay fever or allergies Yes No Please give detailsRecovery complete Yes No Any other serious illness Yes No Please give detailsRecovery complete Yes No Any operations Yes No Please give detailsRecovery complete Yes No Admissions to hospitals Yes No Please give detailsRecovery complete Yes No Serious accidents/ visits to casualty. If yes? How may times have you attended a casualty department in the last 3 years. Yes No Please give detailsRecovery complete Yes No Please note: If there is a possibility that you may be suffering from an infection, you are requested to discuss this-in confidence with a member of the branch staff taking up employment. Declaration I declare that I am fit for work and that all information is correct and accurate to the best of my knowledge.HLR OFFICE NOTES ONLYFit without restrictions Fit without restrictions Fit with restrictions Fit without restrictions Fit with restrictions Needs GP/Specialist Report 8. DECLARATIONBy submitting your application and providing your name, postal address, email address, telephone and mobile numbers, you are allowing HLR Ltd to contact you via mail, email, phone or SMS in connection with this or future job applications or job enquiries. Your data will be held securely either in an electronic or manual paper file. If you wish to unsubscribe from future contact in connection with job applications, you can do so at anytime by emailing info@hlrltd.com or telephoning 020 8274 8625. CONFIDENTIALITY If you are successful in your application for employment with HLR Ltd: All information you see or hear in the course of your duty is confidential. You must not disclose any personal details or information relating to clients, their medical conditions or information which is deemed to be commercially sensitive to the organisation. DATA PROTECTION ACT 1998 HLR Ltd is committed to operating under the ‘Guidance for employers’ in relation to the sharing of appropriate and relevant information between healthcare organisations about the conduct or performance of a healthcare worker where there is an identified risk to public and/or patient safety.” Personal information collected on this declaration will be processed and stored in full accordance with the Data Protection Act 1998. In line with the act HLR Ltd files are kept securely in a safe and secure location. You understand that any personal detail held by HLR Ltd may be accessed from time to time by inspectors from the care quality commission, other regulatory bodies and designated individuals in line with contractual obligations. If declaration is completed during a successful job application, the declaration will be stored in an individual’s permanent employment record. If a prospective employee does not start employment the declaration will be kept for no longer than necessary and then destroyed. This is usually for a period of up to six months to allow for the consideration and resolution of any disputes or complaints. WORKING TIME REGULATIONS 1998 The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will not be compelled to work more than 48 hours per week, however you may choose to do so.48 HOUR OPT OUT I DO wish to work more than 48 hours per week* I DO NOT wish to work more than 48 hrs per week* EMPLOYMENT WITH HLR LTDIt is HLR Ltd policy to employ the most suitably qualified personnel and to ensure equal opportunity for the advancement of employee. This includes promotion and training and to prohibit discrimination against any individual on the basis of race, colour, ethnicity, nationality, sexual orientation, gender, religion, belief, pregnancy, marital or civil partnership status, age or disability. In completion of this application form, I authorise HLR Ltd to obtain references to support this application once an offer has been made and accepted. I release HLR Ltd and submitted referees from any liability caused by giving and receiving any information. I confirm that the information given on this form is to the best of my knowledge, true and complete and that the provision of any false statement(s) will be sufficient cause for rejection or if employed, dismissal. I agree to the above Name First Last Date DD slash MM slash YYYY
