Registration Form

Please complete this form.

All the information on the form will be treated in strict confidence and will not be divulged to any third party without written consent.

NAME

Surname

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

Proof of ID 1

Proof of ID 2

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

Proof of Address 1

Proof of Address 2

Please bring the below to your interview

Any relevant training certificates Bank details Passport photos Driving License

Training Certificates (sent as one file)

Driving License

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

Date

Applying for the post of ....

Sector - please select

Name

Last Name

Address

Address line 2

County

Post Code

Telephone

Passport Number

National Insurance Number

Do you drive

Yes No I have another form of transport

Name

Relationship

Address

City

County

PostCode

Telephone

Mobile

E-mail

Professional / Vocational Qualifications:

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

Membership Grade and / or Registration

Date of Expiry

Name of Professional Body

Membership Grade and / or Registration

Date of Expiry

Name of Professional Body

Membership Grade and / or Registration

Date of Expiry

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)

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

Yes No

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)

Referee 1

Name:

Position:

Organisation:

Address

Address Line 1

Address Line 2

City

Postcode

Telephone

Worked From MM/YY

Worked to MM/YY

When can we approach this referee

Reference 2

Name:

Position:

Organisation:

Address:

Address Line 1

Address Line 2

City

Postcode

Telephone

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Reference 3

Name:

Position:

Organisation:

Address

Address Line 1

Address Line 2

City

PostCode

Telephone

Worked From MM/YY

Worked To MM/YY

When can we approach this referee

Reference 4

Name:

Position:

Organisation:

Address

Address Line 1

Address Line 2

City

Postcode

Telephone

Worked From MM/YY

Worked to MM/YY

When can we approach this referee

Do you require a further reference form

Yes no

Have you previously worked for another employment/nursing agency?

Yes no

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

White and Black Caribbean White and Black African African

Other please state

Asian or Asian British

Indian Pakistani Bangladeshi

Other please state

Chinese or other ethnic group

Chinese

Other please state

Courses attended

Moving and Handling

Expiry date

Infection Control

Expiry date

Basic Life Support

Expiry date

Fire Safety

Expiry date

SOVA

Expiry date

Food Hygiene

Expiry date

SOCA

Expiry date

Violence and Aggression

Expiry date

Health and Safety

Expiry date

Loneworker

Expiry date

COSHH

Expiry date

Complaints

Expiry date

RIDDOR

Expiry date

Caldicott Protocol

Expiry date

Medication

Expiry date

Dementia

Expiry date

Care and Observation

Expiry date

Palliative Care

Expiry date

Peg Feed

Expiry date

Learning Disability

Expiry date

Stoma

Expiry date

ECC&R (Restraint Training)

Expiry date

Tracheostomy care

Expiry date

ECC&R (Restraint Training)

Expiry date

Spinal cord injury

Expiry date

Catheter

Expiry date

Mental health

Expiry date

NVQ - Have you taken an NVQ

Have you taken an NVQ

Yes No

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 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

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

Yes No

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

Yes No

Do you have a current driving license?

Yes No

Do you have your own transport?

Yes No

Availability for work

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?

Yes No

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

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 OnTrack Care 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 OnTrack Care Services to verify all the information given on this form and to process the information as described above under 'Data Protection Consen.

I have read and understood the Standard/ Enhanced DBS Check Privacy Policy for applicants

I agree to abide by OnTrack care Services's Polocies and Procedures

Declaration

I confirm the declaration above

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

1 2 3 4

Use of bath aids

1 2 3 4

Mouth Care (including dentures)

1 2 3 4

Care of feet (excluding toe nails)

1 2 3 4

Dressing / Undressing of patients

1 2 3 4

Bed bath

1 2 3 4

Shaving

1 2 3 4

Care of hair

1 2 3 4

Care of finger nails

1 2 3 4

Care of eyes

1 2 3 4

Pressure area care

1 2 3 4

TOILETING

Emptying & changing a catheter

1 2 3 4

Catheter care

1 2 3 4

Stoma care

1 2 3 4

Use of bedpans / urine bottles / commodes

1 2 3 4

Collection of stool / urine / sputum specimen

1 2 3 4

Incontinence care

1 2 3 4

MOBILITY

Moving & handling

1 2 3 4

Use of hoists

1 2 3 4

Use of walking aids

1 2 3 4

Use of wheel chairs

1 2 3 4

NUTRITION

Preparation of food

1 2 3 4

Special diets

1 2 3 4

Supervision / assistance with feeding

1 2 3 4

Food chat

1 2 3 4

INFECTION CONTROL

Caring for MRSA positive patients

1 2 3 4

Barrier Nursing

1 2 3 4

Isolation

1 2 3 4

Universal precautions

1 2 3 4

Hand Washing

1 2 3 4

Cross infection

1 2 3 4

GENERAL

First Aid

1 2 3 4

Awareness of Health & Safety precautions

1 2 3 4

Bed making

1 2 3 4

Simple dressing

1 2 3 4

Report writing / handover

1 2 3 4

Laundry

1 2 3 4

Shopping

1 2 3 4

Domestic duties

1 2 3 4

KNOWLEDGE OF SERVICE USER GROUPS

Elderly people

1 2 3 4

Dementia

1 2 3 4

Palliative care / care of terminally ill

1 2 3 4

People with physical disabilities

1 2 3 4

People with mental health problems

1 2 3 4

People living with HIV / AIDS

1 2 3 4

Children / families

1 2 3 4

Learning disability

1 2 3 4

Mental Health

1 2 3 4

Acute

1 2 3 4

Moving & Handling Course

1 2 3 4

Basic Care & Observation Course

1 2 3 4

First Aid Course

1 2 3 4

Basic Food Hygiene Certificate

1 2 3 4

EXPERIENCE

Hospital / NHS

1 2 3 4

Nursing Home

1 2 3 4

Residential Home

1 2 3 4

Hospice

1 2 3 4

Private Hospital

1 2 3 4

Home Care

1 2 3 4

Escort

1 2 3 4

Specialising

1 2 3 4

OBSERVATIONS

Observe patient confidentiality

1 2 3 4

Taking temperatures

1 2 3 4

Checking blood pressure

1 2 3 4

TPR / BP recording chart

1 2 3 4

Checking pulse respiration

1 2 3 4

Pressure area care

1 2 3 4

Blood sugar testing

1 2 3 4

Urine testing

1 2 3 4

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

1 2 3 4

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

Yes No

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

I hereby confirm that OnTrack Care Services have provided me with a loan for the following (stated below), however OnTrack Care Services 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 OnTrack Care Services prior to having worked a minimum of 480 hours or I do not join OnTrack Care Services having attended any part of the training, I will be responsible for reimbursing OnTrack Care Services the full cost of training as stated below.

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

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 Ontrack Care 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:
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.

Thank you for applying for work with on track care 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

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.

Registration Form

Please complete this form.

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

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

Referees

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

Referee 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

Right to Work in the UK

Availability for work

Rehabilitation of Offenders Act 1974

Data Protection Consent Form (GDPR)

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

TOILETING

MOBILITY

NUTRITION

INFECTION CONTROL

GENERAL

KNOWLEDGE OF SERVICE USER GROUPS

EXPERIENCE

OBSERVATIONS

EPP for Nurse applications only

Loan Agreement

OUR SERVICES

CONTACT US

On Track Care Services Copyright 2018 All Right Reserved

Registration Form

Please complete this form.

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

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

Referees

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

Referee 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

Right to Work in the UK

Availability for work

Rehabilitation of Offenders Act 1974

Data Protection Consent Form (GDPR)

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

TOILETING

MOBILITY

NUTRITION

INFECTION CONTROL

GENERAL

KNOWLEDGE OF SERVICE USER GROUPS

EXPERIENCE

OBSERVATIONS

EPP for Nurse applications only

Loan Agreement

OUR SERVICES

CONTACT US

On Track Care Services Copyright 2018 All Right Reserved

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

(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

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