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Care Crew Limited is committed to Equal Opportunities in all areas and welcomes all applicants irrespective of Sex, Sexual Orientation, Race, Age, Marital Status and Disability.
Care Crew Limited request that you fill in this form honestly and accurately, as it is then used in the recruitment process to assess your suitability for temporary assignments.

By completing and signing the form, you should understand that any offer of a temporary assignment, made on the basis of any omissions or untrue, inaccurate or misleading information, either deliberate or accidental, may be withdrawn or could result in your assignment being terminated. (Candidates may choose not to complete the Equality and Diversity section of this application form, if they prefer).

Along with the completed Application Pack, we will need to sight the originals of the following documents:

  • NMC Statement of Entry / HCPC Certificate and Card / GMC Certificate (not applicable if HCA)
  • Mandatory Training Certificates (Skills for Health Aligned)
  • Passport and Visa (if app) Drivers Licence (if app)
  • Proof of Address x 2
  • National Insurance Proof
  • CRB/DBS Disclosure Certificate
  • Immunisations – Hep B, Rubella, Measles, Varicella and TB(HIV, Hep B Antigen and Hep C if EPP)
  • Photo

Should you have any queries regarding the completion of the form or have any concerns about providing the information requested in this form, please contact the company on

Please ensure the application form is completed fully and that you demonstrate your skills/experience clearly against the job description for the role



Position applied for *
Date of Completion *

PERSONAL DETAILS

Title *
Forename(s) *
Surname *
Have you ever been known by any other name – if so please specify
Date Of Birth *
Permanent Address *
Post Code *
Home Telephone Number *
Mobile Telephone Number *
Email Address *
Do you hold a full current driving licence? *
Driving License Expiry Date(if yes *)
Driving License Issue Date(if yes *)
How did you hear about Care Crew Limited?
Are you registered with the Disclosure and Barring Scheme Update Service, or the Protecting *
Yes
No
DBS/PVG Certificate or Membership Number(if yes *)
Date of Issue (if yes *)

EQUAL OPPORTUNITIES QUESTIONNAIRE

Care Crew Limited will ensure that no employee or prospective employee is subject to any form of discrimination on the grounds of sex, marital status, age, disability, sexual orientation, ethnic origin, language, religion, belief or race.

Care Crew Limited is committed to the principle of Equal Opportunity in employment and pre-selects applicants only on the basis of their qualifications and experience. We would be grateful if you would complete and return this questionnaire to enable us to monitor our policy and assess our performance. This information will be detached from your application form and will be treated in the strictest of confidence.



Please tick the box that is appropriate to you
Please describe your Marital Status: *
Single
Married
Separated
Divorced
Civil Partnership
Prefer not to say

Sex: *
Male
Female
if you are undergoing gender reassignment, please select the box which applies to your future gender.
Sexual Orientation *
Gay
Lesbian
Bisexual
Heterosexual
other
Prefer not to say
Age : *
16 – 24
25 – 34
35 – 44
45 – 54
55 – 67
67 +

Do you consider that you have a Disability? *
Yes
No
Please state your ethnic group *
Prefer Not to say
Black African
Black Caribbean
Black Other
Asian Bangladeshi
Asian Indian
Asian Pakistani
Asian Other
White English
White Irish
WhiteNorthern Irish
White Scottish
White Welsh
White Other
White&Black Africa
White&Black Caribbean
White&Asian
Other EthnicGroup

Religion or Faith *
Prefer Not to say
Atheist
Agnostic
Buddhist
Baha'i
Catholic
Christian
Hindu
Muslim/Islam
Sikh
Jewish
Church of England/Protestant
Jehovah‟s Witness
Other




RIGHT TO WORK IN THE UNITED KINGDOM

Nationality *
Passport Number *
Passport Issue Date *
Passport Expiry Date *
For non-British/EU nationals – Type of Visa held(if yes *)
Visa Expiry Date(if yes *)
National Insurance Number *
Do you have the right to work in the United Kingdom? *

EDUCATION, TRAINING & QUALIFICATIONS

Please provide details of examination passes, qualifications obtained etc. You will be required to provide proof of relevant professional qualifications. Please provide details in sequence with the most recent first. Where you have had a break in your educational history, please give details.

Start Date *
End Date *
Institution/Awarding Body *
Course Details *
Grade/Qualification *

EMPLOYMENT HISTORY

Please give us details of every job or voluntary position you have held since leaving school, including the names, addresses and dates for leaving (continue on additionally sheet if necessary). Please indicate which of these positions of these involved direct work with children and young people, and explain any significant gaps in your employment history.

NB: We are required by the Fostering Services Regulations 2011: "Where a person has previously worked in a position whose duties involved work with children or vulnerable adults, so far as reasonably practicable verification of the reason why the employment or position ended" is required. We reserve the right to contact any employer where you have worked with children or vulnerable adults.

Name of Employer *
Full Address of Employer *
Telephone Number *
Email Address
Position Held *
Start Date (Month & Year) *
Duties *
Reason for Leaving *
Did this position involve work with children or vulnerable adults? *
Yes
No


REFEREES

Please provide the names and addresses of two referees, one of whom should be your present or most recent employer. Please note that references are not accepted from close personal friends or relatives.If you do not wish your employer to be contacted at this stage, please tick the box .


Name of Referee *
Position *
Full Address of Referee *
Telephone Number *
Email Address *
Period Known From(Month & Year) *


Name of Second Referee *
Position *
Full Address of Referee *
Telephone Number *
Email Address *
Period Known From(Month & Year) *

DISCIPLINARY & CRIMINAL ISSUES

Have you ever been subject to a Disciplinary/Suspension or Dismissal? *
Yes
No
If yes, please give details below

The position for which you have applied is exempt from the Rehabilitation of Offenders Act 1974 (In Scotland this is by virtue of the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Order 2003) (as amended in 2013). This means that you must declare all criminal convictions, including those which would otherwise be considered “spent”.

With the exception of question 7, answering yes to any of the questions below will not necessarily bar you from appointment. This will depend on the nature of the position for which you are applying and the particular circumstances. The information given will be treated in confidence and only taken into account where, in the reasonable opinion of Swiis, the offence is relevant to the post for which you are applying. Failure to declare a conviction may require us to terminate your employment and if any offence is not declared, but later comes to light. This also includes any offences gained after your date of employment with Swiis.

1. Have you ever received a police caution, public order offence, reprimand, fine or final warning? *
Yes
No

2. Have you ever been charged with any offence in the UK or, in any other country that has not yet been disposed of? You must inform us immediately if you are charged with an offence after you complete this form, and before taking up any position offered to you. *

Yes
No
3. Are you aware of any current police investigation in the UK or in any other country following allegations made against you? *
Yes
No
4. Have you ever been dismissed for misconduct from any employment, office or other position held by you? *
Yes
No
5. Have you ever been disqualified from the practice of a profession or required to practice subject to specified limitations following fitness to practice proceedings by a regulatory or licensing body in the UK or in any other *
Yes
No
6. Are you currently the subject of any investigation or fitness to practice proceedings by a licensing or regulatory body in the UK or in any other country? *
Yes
No

7. Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the position for which you are applying? This question relates to a position which involves regular contact with children and vulnerable adults. *

Yes
No

If you have answered yes to any of the questions above please give full details on a separate sheet and attach it in a sealed envelope marked "Confidential Disclosure".

DECLARATION & CONFIDENTIALITY AGREEMENT

I declare that the details which I have given on this form are true and accurate and that I am not banned or disqualified from working with children or vulnerable adults, nor subject to any sanctions or conditions on my employment imposed by The Independent Safeguarding Authority, the Secretary of State or a regulatory body.
I understand that providing any misleading or false information to support my application could mean that any job offer is withdrawn or that I will be dismissed for gross misconduct.
I hereby declare that I have understood and complied with the requirements laid down in the previous paragraph. For the purposes of the Data Protection Act 1998, I consent to the information contained in this form and any information received by or on behalf of Care Crew Limited relating to the subject matter of this form being processed by them in administering the recruitment process.
I will notify Care Crew Limited immediately should any circumstances change as detailed above. I agree to Care Crew Limited requesting DBS/PVG Disclosure Scotland checks as appropriate.
I understand that due to the nature of the role I will be undertaking, I may come into contact with information of a sensitive, personal or confidential nature.
I agree that: a: I will not disclose any such information except where this is necessary in carrying out my duties or where this is required by law. b: I will return any such information to the workplace when it is no longer needed c: I will not use any information gained through my dealings with Care Crew Limited other than for the benefit of Care Crew Limited or its customers.


Full Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

TRAINING AND QUALIFICATIONS

HCPC / NMC / GMC Registration Number
Date of Expiry
Where did you study and qualify?
What year did you qualify?
Please tick if you have completed/renewed any if the following training modules within the last 10 months:

C.O.S.H.H

Completion Date

EPILEPSY

Completion Date

EQUALITY,DIVERSITY&INCLUSION

Completion Date


FIRE & SAFETY

Completion Date

FOOD HYGIENE

Completion Date

HANDLING MEDICATION

Completion Date


VIOLENCE,AGGRESSION&COMPLAINT HANDLING

Completion Date

HEALTH and SAFETY

Completion Date

INFECTION CONTROL

Completion Date


INFORMATION GOVERNANCE

Completion Date

LONE WORKER

Completion Date

MENTALCAPACITY ACT2005

Completion Date


RIDDOR

Completion Date

SOVA&SOCA Level3

Completion Date

RESTRAINT TRAINING

Completion Date


BREAKAWAY TRAINING

Completion Date

DBS

Completion Date

DEMETIA AWARENESS

Completion Date


FIRST AID

Completion Date

MANUAL HANDLING THEORY

Completion Date

MANUAL HANDLING THERAPY

Completion Date

Any Other Training

PAYMENT DETAILS

Account Type *
Name of PAYE/Limited Company *
Bank Address *
Registered Address *
Sort Code *
Account Number *
In relation to the above and signing the below, you are agreeing that you personally have made the decision to be either a PAYE employee or a Limited Company Contractor with no guidance from Care Crew Limited
Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

HEALTH AND DISABILITY

The following questions on health and disability are asked in order to find out your needs in terms of reasonable adjustments to access our recruitment service and to find out your needs in order to perform the job/position sought.



Do you have any health issues or a disability which may make it difficult for you to carry out functions which are essential for the role you seek? *
Yes
No
If you have a disability, what are your needs in terms of adjustments? (if yes *)

RECORDS

Is there any aspect of your health that may affect your ability to work? *
Yes
No
Have you any reason to believe you may be infected by any communicable disease? *
Yes
No
Do you suffer from blackouts, fits or attacks of giddiness? *
Yes
No
Any type of allergy? *
Yes
No
Frequent diarrhea, vomiting or constipation? *
Yes
No
Heart, circulation and blood disorders? *
Yes
No
Disorders of eyes/ears/nose? *
Yes
No
TB or any infectious disease? *
Yes
No
Drug or alcohol related condition/dependency? *
Yes
No
Diabetes? *
Yes
No
Jaundice or Anaemia? *
Yes
No
Are you taking any regular prescribed medication? *
Yes
No
Can you carry out all aspects of the job without any special adaptation? *
Yes
No

Should you feel that any section of the following Medical Questionnaire is not applicable to you, please tick here and opt out of completing this page

I confirm that I have read this document fully and that all the information given to Care Crew Limited is correct to the best of my knowledge and belief. I am aware of the need to protect patients and myself and agree to notify Care Crew Limited if my circumstances change.
I give my permission to Care Crew Limited to contact my occupational health department, specialist or GP to seek further information with regard to any aspect of the contents of this Health Statement.
I understand that the information in this form is sensitive personal data within the meaning of the Data Protection Act 1998 and that in signing this form I am agreeing to Care Crew Limited processing my data as detailed in in the form. I confirm that I consent t o a copy of my fitness certificate, declaring my fitness to work and containing information on my immunity status, being sent to any client of Care Crew Limited from whom I may seek assignments from time to time.
I have read and agree to adhere to Care Crew Limited terms of engagement.





Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

INSPECTION AND THE DATA PROTECTION ACT

Part of the inspection process under the Care Standards Act 2000 involves the Local Registration and Inspection Units having access to your personnel file held at Care Crew Limited are maintaining the correct information required under the Care Standards Act. Your permission is required for inspectors to view your file. Please record your consent below:

Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

DATA PROTECTION ACTS 1984 & 1998

I declare that all of the information that I have provided in this application pack and on my CV is correct. I understand that if I knowingly make false statements I could be subject to police investigation and prosecution. I have read, understood and agreed to Care Crew Limited's conditions of service. I understand that my registration is subject to at least two satisfactory references and a satisfactory result after checking with the Criminal Records Bureau. I am engaged through your introduction, including the offer of permanent employment following temporary assignment. I am aware that personal data (including where relevant, sensitive personal data) relating to myself, whether obtained from myself or from any other source, will be retained by Care Crew Limited and/or any of its associated and/or subsidiary companies indefinitely for the purpose of providing me with temporary/permanent employment and/or training. I acknowledge that this may require personal data to be forwarded to third parties or other organizations within Care Crew Limited.
I hereby confirm that my personal details may be held and disclosed in the manner contained herein:


Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

REHABILITATION OF OFFENDERS ACT

Because of the nature of the role for which you are applying, Section 4(2) and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974)(Exception s) Order 1975 apply. Applicants are therefore required to provide information about convictions which for the purposes are “spent” under the provisions of the Act. Any information give n will be completely confidential and will be considered only in relation to positions to which the order applies.

Have you at any time been cautioned of an offence? *
Yes
No
Have you ever had any convictions filed against you or currently pending? *
Yes
No

It is a condition of proceeding with your application that you apply for an „Enhanced‟ CRB Disclosure through Care Crew Limited or produce a disclosure which you have already obtained as long as it is no older than 1 year. Please note for all positions, you will need to complete a new DBS application through us unless you are registered with the DBS Update Service. Convictions and any other information obtained through the DBS will not necessarily be a bar to employment. All circumstances will be taken into account however, any inconsistencies compared with the information given above may invalidate your application. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offence is not declared but later comes to light. It is a condition of engagement that clients will be informed of all details of criminal convictions, Cautions, Reprimands and Final Warnings so that they make an informed decision as to whether or not to engage a candidate on a temporary assignment.

Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

DISCIPLINARY

Have you ever been the subject of a disciplinary action or currently undergoing disciplinary actions? *
Yes
No

CONFIDENTIALITY AGREEMENT

Care Crew Limited requires all locums to comply with the Confidentiality policy of our company, the confidentiality policies and procedures of our clients and the relevant Code of Professional Conduct. This undertaking also encompasses the provisions and principals within the Data Protection Act 1984 and 1988, which concerns the protection of personal information. Care Crew Limited operates a system to ensure security of information to the highest standards. This includes information held concerning Agency Workers, Clients and Service Users.
In summary, you must treat information about service users and clients as confidential and use it only for the purposes for which it was given. You must protect this information from improper disclosure at all times. Written information must be stored in a confidential place.
Agency staff must not disclose to any person (other than a person authorized by Care Crew Limited or the client) any information acquired by them in connection with the work assignments they undertake. This will include:

  • The medical condition of or the treatment received by a service user
  • The identity of any service user at any location or work place setting
  • Confidential information concerning contracts, charges, procedures and other privileged information from Care Crew Limited or its clients

Computer Access within the Clients Establishment:
As an Agency Worker you may be given authorization by the client to gain access to certain computer systems and certain programs and data within those systems. You must not attempt alone or in concert with others, to gain access to data or programs to which authorisation has not been given. In using any Client computer systems, as an agency worker you must:
Observe the computer security instructions in respect of the proper use and protection of any password used in connection with such computer systems and if there is a need to use or insert into any computer and floppy disk, CD ROM disk, removable hard drive or any other device for the storage and transfer of data programs
Not load any program onto any computer via disk, typing, electronic data transfer or any other means;
Not access any other computer or bulletin board or information service (including, without limitation, the internet) except with the specific prior consent from the Client‟s representative; Not download any files or connect any piece of computer equipment to any network or other item of computer equipment except with the prior authority of the client‟s representative.
I have read and understood this confidentiality policy and I agree to comply:


Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

CANDIDATE DECLARATION

I hereby confirm that the information given in this application is, to the best of my knowledge, true and correct. I consent to my personal data and my CV being forwarded to clients and consent to references being passed onto potential clients/hiring managers. I understand that my registration is subject to the receipt of at least two satisfactory references and a satisfactory enhanced disclosure received from the Criminal Records Bureau. I undertake to inform Care Crew should I be convicted of an offence in the future. Also, I understand the fact that Care Crew Limited is not responsible for my professional liability negligence or mistake.
I undertake to inform Care Crew Limited immediately if I am engaged through a Care Crew Limited introduction, including the offer of a permanent employment following a temporary assignment and I acknowledge that Care Crew Limited will be entitled to charge the client an introduction fee/ transfer fee or to agree to an extension of the hiring period with the client (after which I may be employed by the client without further charges being applicable to the client).
I agree to respect the confidentiality of clients and any other information I may have access to at all times.


Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

ISA DECLARATION

Assignments to which you are or may be submitted are regulated or controlled activity under the Vetting & Barring Scheme* and consequently you are required to answer the following question.

Are you a barred person under the terms of the Vetting & Barring Scheme?
Yes
No
NB. It is a criminal offence for a barred person to apply for or work in a regulated activity. For more information please refer to isa.gov.uk. *Safeguarding Vulnerable Groups Act 2006
Were your status to change to a barred person you must notify CARE CREW Limited and ensure that the Hirer‟s management (i.e. where you are placed) is aware of the change.

Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

EMPLOYMENT BUSINESS

The worker has been asked* whether they are a barred person under the terms of the Vetting & Barring scheme and they are aware of their continuing responsibilities under the Scheme

Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

DBS UPDATE SERVICE DECLARATION

As from 17 June 2013, you can access the new Disclosure and Barring Service (DBS) update service to carry out status checks on a DBS certificate. In order for Care Crew Limited to access your certificate, you must go online www.gov.uk/dbs and complete the information where applicable. The DBS will issue DBS Certificates to the applicant only; the charge for using this service is £13.00 and expires annually.

Care Crew Limited requires the applicant‟s permission in order for Care Crew Limited to view the certificate.

Please can you answer the following questions:

Do you give permission for Care Crew Limited to carry out a status check? *
Yes
No
Do you give permission for Care Crew Limited to hold a copy of your status check on file? *
Yes
No
Is the certificate at the same level of an „Enhanced‟ disclosure? *
Yes
No
Does the certificate contain information that we are legally to see? *
Yes
No
What force does your DBS certificate cover? *
Adult
Child
Both
I give permission that Care Crew Limited may have access to my DBS certificate in order to process my application.

Candidate Name *
Signature *
By checking you are electronically signing this form
Date of Signature *

FINAL PHASE

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. I hereby authorize sharing of the information furnished on this form with the Care Crew Limited.

By Submitting your application,you are electronically signing your application form.