MNRA HEALTHCARE

MNRA HEALTHCARE
Employment Application Documents Checklist
PLEASE SUBMIT THE FOLLOWING DOCUMENTS WITH THE COMPLETED APPLICATION FORM
•
Passport
•
Work permit if required
•
Two passport size photographs
•
National Insurance Number Card
•
Valid U.K. Driving Licence
•
Birth/Marriage Certificate
•
Contact names and business addresses of three referees including one clinical at management level for whom you have worked during the
last 3 years (continuous history) as well as at least one clinical reference
•
Enhanced Disclosure from the Criminal Records Bureau (See over for details)
•
Immunisation details and tests results of Hepatitis B and C ESSENTIAL
•
Immunisation details and test results of Rubella, Varicella & BCG immunization ESSENTIAL
•
Proof of Membership to relevant Union, Trade or Professional Body cover liability whilst practising
•
Any and All relevant Certificates
•
For trained nurses, NMC Pin Card and Statement of Entry
•
For Doctors, GMC Registration No and Certificate
•
For Pharmacists or Pharmacy Technicians, MUR Certificate and GPhC No.
DOCUMENTS REQUIRED FOR CRB CHECK
List of Valid Identity Documents
A Criminal Records Bureau Disclosure is required prior to your eligibility to work. Each Application will cost you £60.00 and we recommend you
further apply to be on the update service. 3 Documents must be seen, one document from Group 1 plus any two from Groups 1 and 2.
GROUP ONE
GROUP TWO
PASSPORT
Bank/Building Society Statement
Any Nationality
Within the past 3 months
UK Birth Certificate
Utility Bill
Issues within 12 months of date of birth, full or short form acceptable
Gas/Water/Electricity/Landline Telephone Within the past 3 months
UK Issued Driving Licence
TV Licence
Both Photocard and Counterpart Required
Within the past 12 months
EU National Identity Card (Photocard)
A document from Central/Local Government
EU Countries only
E.G. Job Centre, DWP, Inland Revenue, HMRC etc.
HM Forces ID Card (UK)
Addressed Payslip
Both Photocard and Counterpart Required
Within the past 3 months
Adoption Certificate
NHS Card
UK Only
UK Only
MNRA HEALHCARE Ltd . ABBOTSBURY HOUSE . 156 UPPER NEW WALK . LEICESTER . LE1 7QA
Tel: 0116 210 4987 . Fax: 0116 212 6703 . Email: [email protected] . Website: www.mnrahealthcare.co.uk
MNRA Healthcare Ltd: Registered in England and Wales: 8999188
Photograph
Please print full
name on the
back of all
photographs
MNRA HEALTHCARE
Employment Application
APPLICANT INFORMATION
Position Applied for:
Title (Dr, Mr,
Mrs, Miss, Ms)
Surname
First Name
Middle Name
Other
Residential Address
City
Post Code
Home
Telephone
Mobile
Telephone
Date of
Birth
Email Address
Marital Status
Nationality
National Insurance No
NMC/GMC/HPC
(or Other) No.
Are you a citizen of the European
YES
NO
Union
If you are not a citizen of the European Union and you have limited
expiry date?
Passport Number
Expiry Date
If no, are you authorised to work in the United
Kingdom?
leave to remain, what is the VISA
YES
NO
YES
NO
Expiry
Have you ever worked for MNRA
Healthcare?
YES
NO
If so, when?
Do you hold a valid UK Driving Licence
YES
NO
If yes, are you a car owner?
NEXT OF KIN (for use in case of emergency)
Full Name
Relationship
Address
Home Telephone
Work Telephone
Mobile Telephone
TAX AND BANKING DETAILS
What are your current tax arrangements (choose as appropriate)
PAYE
Self Employed
Limited/Umbrella
Company Name
Account Type (choose as appropriate)
Limited
Company
Umbrella
Company
Registered No
Limited Company Business Account
Personal Back Account
Bank or Building Society Name
Account Name
Sort Code
Account Number
Roll Number (if applicable)
If you are self-employed or a limited company, you must provide us with the relevant proof please provide your latest P45 or P46 with this document
DECLARATION I declare that the information I have supplied is the truth
Signature
Date
MNRA HEALHCARE Ltd . ABBOTSBURY HOUSE . 156 UPPER NEW WALK . LEICESTER . LE1 7QA
Tel: 0116 210 4987 . Fax: 0116 212 6703 . Email: [email protected] . Website: www.mnrahealthcare.co.uk
MNRA Healthcare Ltd: Registered in England and Wales: 8999188
GP INFORMATION
GP Name
Address
Post Code
Telephone No
PROFESSIONAL INDEMNITY
Do you currently have any professional indemnity insurance?
YES
Name of Insurer
Policy No
Limit of Indemnity
Expiry Date
REFERENCES
Please list three professional references. One should be from your last or most recent employer and at least ONE clinical reference
1 / Full Name
Relationship
Company
Address
Telephone No
Fax No
Position
Email Address
2 / Full Name
Relationship
Company
Address
Telephone No
Fax No
Position
Email Address
3 / Full Name
Relationship
Company
Address
Telephone No
Fax No
Position
Email Address
PROFESSIONAL REGISTRATIONS
Name of Professional
Body
Qualification/Specialty
Registration No
Expiry Date
Name of Professional
Body
Qualification/Specialty
Registration No
Expiry Date
MNRA HEALHCARE Ltd . ABBOTSBURY HOUSE . 156 UPPER NEW WALK . LEICESTER . LE1 7QA
Tel: 0116 210 4987 . Fax: 0116 212 6703 . Email: [email protected] . Website: www.mnrahealthcare.co.uk
MNRA Healthcare Ltd: Registered in England and Wales: 8999188
NO
PROFESSIONAL DEVELOPMENT
Name of Qualification
Training Institution
Date Gained
MANDATORY TRAININGS – PLEASE PROVIDE COPIES OF ALL CERTIFICATIONS
Name
Course Attended
Health & Safety at Work
YES
NO
COSHH
YES
NO
Caldicott Principles
YES
NO
Fire Safety Awareness
YES
NO
Infection Control
YES
NO
Food Hygiene
YES
NO
Manual Handling
YES
NO
Basic Life Support inc. CPR
YES
NO
Safeguarding Vulnerable Adults
YES
NO
Safeguarding Children
YES
NO
Conflict Management
YES
NO
Lone Working
YES
NO
Date
EMPLOYMENT HISTORY (History for the last 5 years, most recent first. Please include periods of unemployment)
Employer Name
Position
Address
Start Date
End Date
Pay Rate
Main Responsibilities
Reasons for leaving
MNRA HEALHCARE Ltd . ABBOTSBURY HOUSE . 156 UPPER NEW WALK . LEICESTER . LE1 7QA
Tel: 0116 210 4987 . Fax: 0116 212 6703 . Email: [email protected] . Website: www.mnrahealthcare.co.uk
MNRA Healthcare Ltd: Registered in England and Wales: 8999188
Employer Name
Position
Address
Start Date
End Date
Pay Rate
Main Responsibilities
Reasons for leaving
Employer Name
Position
Address
Start Date
End Date
Pay Rate
Main Responsibilities
Reasons for leaving
EQUAL OPPORTUNITIES INFORMATION
This information is included in this form to allow MNRA Healthcare to monitor its performance in achieved equal opportunities in employment,
and to further improve equal opportunities for all. The information provided will be treated in the strictest confidence.
DISABILITY
In order to comply with the Discrimination Act of 1995, MNRA Healthcare requires information regarding disabilities, which affect an
individual’s ability to carry out normal day-to-day activities. This will help us to monitor progress of our Disabilities Policy. MNRA Healthcare
will give fair consideration to applications for employment received from disabled people who have appropriate qualifications and skills for
vacancies available. MNRA Healthcare will also give equal consideration for career development and training and promotion of employees with
a disability.
Do you consider that you have a disability as defined by the disability act? YES
NO
(If yes please give a description below)
MNRA HEALHCARE Ltd . ABBOTSBURY HOUSE . 156 UPPER NEW WALK . LEICESTER . LE1 7QA
Tel: 0116 210 4987 . Fax: 0116 212 6703 . Email: [email protected] . Website: www.mnrahealthcare.co.uk
MNRA Healthcare Ltd: Registered in England and Wales: 8999188
REHABILITATION OF OFFENDERS
The post for which you applying is exempt from the provisions of Section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption Order
1975). Applicants are therefore, not entitled to withhold information about convictions which for other purposes are “spent” under the
provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action.
Any information given will be completely confidential and will be considered only in relation to an application for positions to which the Order
applies, and should be entered at the end of any particulars you give in support of your application. Information given will be treated in the
strictest confidence.
By Signing the below I confirm I have read and understood the statement above.
Signed
Date
HEALTH DECLARATIONS
Please tick Yes, No and give details
Do you smoke?
Details
YES
NO
YES
NO
YES
NO
YES
NO
Have you lost significant time from work in the last 5 years?
YES
NO
Are you currently taking any medication?
YES
NO
Have you or do you suffer from, Diabetes?
YES
NO
Have you or do you suffer from, heart illness or hypertension?
YES
NO
Have you or do you suffer from, asthma or hay fever?
YES
NO
Have you or do you suffer from, tuberculosis, pneumonia or
bronchitis?
YES
NO
Have you or do you suffer from, eyesight problems including colour
blindness?
YES
NO
Have you or do you suffer from, headaches or migraines?
YES
NO
Have you or do you suffer from, recurrent fits, blackouts, fainting or
dizzy spells?
YES
NO
Have you or do you suffer from, back problems or back pain?
YES
NO
Have you or do you suffer from, allergies, eczema, dermatitis or
psoriasis?
YES
NO
Have you or do you suffer from, depression or psychiatric illness?
YES
NO
Have you or do you suffer from, jaundice or hepatitis?
YES
NO
Have you ever been treated at hospital for serious illness or injury?
Are you a registered disabled person?
Have you had a chest x-ray in the last 5 years?
Other:
I declare that the particulars I have given on this application form are true in every respect.
I also agree to notify the MNRA Healthcare of any changes that may necessitate the completion of a further health declaration.
I agree that I may be asked to pay a fee that my doctor/medical practitioner may charge for a medical report.
Signed
Date
MNRA HEALHCARE Ltd . ABBOTSBURY HOUSE . 156 UPPER NEW WALK . LEICESTER . LE1 7QA
Tel: 0116 210 4987 . Fax: 0116 212 6703 . Email: [email protected] . Website: www.mnrahealthcare.co.uk
MNRA Healthcare Ltd: Registered in England and Wales: 8999188
GENERAL TERMS OF MEMBER ENGAGEMENT
The MNRA general terms and conditions of member engagement below shall govern the working relationship between MNRA Healthcare Ltd
and the Member.
The general terms of member engagement for all staff are also found in the MNRA Handbook. It is the responsibility of all staff to familirise
themselves with the terms and the contents of the handbook.
Contract
A contract for services between MNRA Healthcare and the member shall govern all
assignments undertaken by MNRA Healthcare members. Members are self-employed
although MNRA Healthcare is required to make statutory deductions from member’s
remuneration in accordance with clause Payment VI
Policies and Procedures
Policies and procedures and any other professional organisation code of conduct to which
you belong is encouraged. MNRA Healthcare has written policies and set procedures in
place. For further information and copies, please ask the Manager for:
i.
Complaints Procedure
ii.
Health and Safety at work Policy and Procedure
iii.
Moving and Handling Procedure
iv.
Equal opportunities Policy
v.
Harassment Policy
vi.
Abuse Policy etc.
Assignment
All assignments should be booked through the MNRA Healthcare Agency’s office. If you
are booked directly please let us know. Members must keep work appointments that are
made for them. Please telephone the MNRA Healthcare Agency’s Manager immediately if
you are unable to meet your work appointment so that a replacement can be made.
Persistent cancellation of shifts without a good period of notice may suggest unreliability.
Timesheets
Please ensure that timesheets are correctly and completely filled in, including actual start
and finishing times, plus break time which is usually unpaid. A nurse in charge of a
ward/situation works as an E grade. If you are not in charge please state D grade.
Authorisation by client as proof of your work is vital. Payment may be delayed due to
incorrect or incomplete timesheets. If unpaid, please let us know by telephone or in
writing. Likewise if overpaid please let us know to allow us to change the payment. The
money will be automatically deducted or added to the member’s following payment.
Payment
Completed timesheets must be handed into the office weekly by 12 midday on Monday
for payroll processing, to be paid 9days later.
Timesheets handed in after this time will mean your pay will be delayed by a week.
Bank holiday weekly pay varies, please check with the office regarding this
Payment regulations are very strict. In order to protect MNRA Healthcare Agency, you
and the client, MNRA Healthcare is appointed by its members to collect and recover all
fees, charges expenses and any other extras in its name.
MNRA Healthcare pays its members in advance for fees earned by them
Pay rates will be notified as per assignment basis according to the pay rates. These will
be subject to deductions in respect of National Insurance contributions and (PAYE)
income tax and any other deductions which MNRA Healthcare may be required to make
by law.
Training and Development
It is mandatory that MNRA Healthcare temporary and permanent staff undertake the
following training as appropriate:
i.
Moving and Handling
ii.
First aid
iii.
Care course
iv.
CPR (qualified staff)
v.
Prep updates
Conduct of Assignment
There is no obligation for the member to accept the offered assignment, but where this
is so
Members must be under the direction, supervision and control of the client or person in
charge at all times
Members must not at any time divulge to any person, client or patient personal
information. Client information must be kept in the strictest confidence.
A clean neatly pressed MNRA Healthcare uniform must be worn
Hair should be neatly tied back
Appropriate footwear must be worn
Always wear a MNRA Healthcare identification badge
Trained nurses must wear NMC pin cards
Where a work assignment is not completed and a member wishes to leave before time,
please notify the client and MNRA Healthcare office.
Rest Periods
In homecare, hospitals, sleepovers, residential homes, etc where flexibility may be required,
a compensatory rest period should be agreed upon between members and clients. For night
duty health assessment, contact your GP prior to commencement of night shifts.
Sickness
Contracts between members and MNRA Healthcare exist only for the length of the shift.
Please notify the manager on the first day of sickness. Self certification will cover 3 days of
illness and for longer periods a Doctor’s Certificate is required.
Health and Safety of Work
Safe working practice, assessing risks and maintaining a safe environment policy for yourself,
patients, colleagues and clients is imperative. In home care services, more knowledge and
adherence to the Health and Safety legislation will be needed as some patients/clients may
not have up to date knowledge.
Keeping Records
Please ensure up to date record keeping is maintained as required by the client and MNRA
Healthcare. Changes in patient’s physical and mental condition must be reported to the
appropriate person.
Negligence
Our human resources are of great value to us. Should a member have a bad experience or
any other work related problems, please let the manager know. Likewise, complaints about a
member’s attitude, work, misconduct or negligence are taken seriously. MNRA Healthcare
reserves the right to withhold payment of a member’s wages until investigations are
completed.
Data Protection
MNRA Healthcare may use member’s form/data to keep you informed of developments,
policy and legislation changes. We may also use it for market research. MNRA Healthcare
acknowledges the Data Protection Act 1998, when using the application form to inform
members of potential work opportunities by mail, telephone or e-mail.
Termination
Please give MNRA Healthcare notice to terminate membership if an assignment is in
progress. Members are required to provide 4 weeks notice of intention to terminate a
contract by informing NRA. MNRA Healthcare may without prior notice or liability instruct
members to end an assignment at any time.
Equal Opportunities
Discriminatory requests from either the member or the client will not be accepted. MNRA
Healthcare aims to provide equal opportunities in employment regardless of sex, race, age,
ethnic orientation or disability.
Convictions
I. Members must provide MNRA Healthcare with information that he or she has not been
convicted or cautioned in relation to a criminal offence before commencing any assignment.
II. Where the member has been charged or cautioned in relation to any criminal offence,
he/she must inform MNRA Healthcare immediately and provide reports regarding
proceedings.
III. Members must inform MNRA Healthcare about any complaints made against them which
are relevant to professional conduct. MNRA Healthcare will in turn inform members about
any complaints made against them referring to their professional competence.
Statutory Leave
The leave year commences on the 1st January for the purposes of calculating entitlement for
leave. Members (PAYE Candidates ONLY) are entitled to 5.6 weeks paid leave pro-rata
annually under the Working Time Regulations 1998. No leave may be carried forward to the
next year. Please give MNRA Healthcare four weeks notice in writing of intention to take
leave. Members are not able to work whilst on annual leave.
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.
Signature of Member:
Date:
Signed on behalf of
MNRA :
Date:
MNRA HEALHCARE Ltd . ABBOTSBURY HOUSE . 156 UPPER NEW WALK . LEICESTER . LE1 7QA
Tel: 0116 210 4987 . Fax: 0116 212 6703 . Email: [email protected] . Website: www.mnrahealthcare.co.uk
MNRA Healthcare Ltd: Registered in England and Wales: 8999188