Careers - Care Worker Application Form 2022

Register Here

Please answer all questions to the best of your ability - any difficulties should be discussed with a member of the TAC Healthcare Staff. Your application form may be subject to scrutiny by Local Authority Accreditation Bodies and the Care & Social Services Inspectorate. If you require further support completing the registration form drop us an email at info@tachealthcareservices.com

Registration Form

Personal Details

Title:

Maiden Name (if applicable):

Full Driving Licence:

National Insurance Number (UK):

First Name:

Date of Birth:

Car Owner:

Mobile:

Last Name:

Gender:

Nearest Station:

Work Tel:

Marital Status:

Email:

Nationality:

Home Tel:

If non british or eea national, please give details below of your right to work in the uk:

Type of Visa:

Languages:

Issue Date:

Band:

Expiry Date:

Speciality:

Other Permission:

List all higher education, professional & postgraduate qualifications:

Institution:

Qualification:

Dates:

Professional registrations & memberships:

Professional Body:

Membership Number:

Date of Expiry:

Employment History

Please give details of continuous employment history during the past 10 years (most recent first) including any training posts. Any gaps in employment must be accounted for. (Please continue on blank paper in the same format as below If necessary).

From:

Grade:

To:

Duties:

Job Title:

Reported To:

Employer:

Reason for Leaving:

From:

Grade:

To:

Duties:

Job Title:

Reported To:

Employer:

Reason for Leaving:

From:

Grade:

To:

Duties:

Job Title:

Reported To:

Employer:

Reason for Leaving:

From:

Grade:

To:

Duties:

Job Title:

Reported To:

Employer:

Reason for Leaving:

From:

Grade:

To:

Duties:

Job Title:

Reported To:

Employer:

Reason for Leaving:

Please attach an up-to-date CV. Gaps in employment must be accounted for.

In case of emergency, please provide two next of kin

1st - Next of Kin:

Title:

Home Tel:

First Name:

Work Tel:

Last Name:

Mobile:

Email:

Relationship to you:

Address:

Postcode:

2nd - Next of Kin:

Title:

Home Tel:

First Name:

Work Tel:

Last Name:

Mobile:

Email:

Relationship to you:

Address:

Postcode:

How did you hear about tac health care services ltd

Please select any applicable options below:

Advert

Google / Internet Search

Referral

Other

If Referral please detail:

If Other please detail:

Mandatory training

Do you possess any of the following training certificates (enter YES or NO and Date completed)

	Practical	Online	Date
Fire Safety	Fire Safety, Practical:	Fire Safety, Online:	Fire Safety, Date:
Health & Safety	Health & Safety, Practical:	Health & Safety, Online:	Health & Safety, Date:
RIDDOR	RIDDOR, Practical:	RIDDOR, Online:	RIDDOR, Date:
COSHH	COSHH, Practical:	COSHH, Online:	COSHH, Date:
Lone Worker	Lone Worker, Practical:	Lone Worker, Online:	Lone Worker, Date:
Information Governance / Caldicott Procedures	Information Governance / Caldicott Procedures, Practical:	Information Governance / Caldicott Procedures, Online:	Information Governance / Caldicott Procedures, Date:
Safeguarding of Children & Vulnerable Adults (SOVA / SOCA)	Safeguarding of Children & Vulnerable Adults (SOVA / SOCA), Practical:	Safeguarding of Children & Vulnerable Adults (SOVA / SOCA), Online:	Safeguarding of Children & Vulnerable Adults (SOVA / SOCA), Date:
“Complaints Handling	“Complaints Handling, Practical:	“Complaints Handling, Online:	“Complaints Handling, Date:
Infection Prevention & Control	Infection Prevention & Control, Practical:	Infection Prevention & Control, Online:	Infection Prevention & Control, Date:
Handling of Violence & Aggression	Handling of Violence & Aggression, Practical:	Handling of Violence & Aggression, Online:	Handling of Violence & Aggression, Date:
Basic Life Support Training	Basic Life Support Training, Practical:	Basic Life Support Training, Online:	Basic Life Support Training, Date:
Advanced Life Support Training	Advanced Life Support Training, Practical:	Advanced Life Support Training, Online:	Advanced Life Support Training, Date:

Skills List

Please tick the appropriate

Clinical Experience

Please tick the appropriate

	Under 6 months	Over 6 months	1-2 years	2+ years
A&E	A&E, Under 6 months:	A&E, Over 6 months:	A&E, 1-2 years:	A&E, 2+ years:
ICU	ICU, Under 6 months:	ICU, Over 6 months:	ICU, 1-2 years:	ICU, 2+ years:
Medical	Medical, Under 6 months:	Medical, Over 6 months:	Medical, 1-2 years:	Medical, 2+ years:
Surgical	Surgical, Under 6 months:	Surgical, Over 6 months:	Surgical, 1-2 years:	Surgical, 2+ years:
Orthopaedics	Orthopaedics, Under 6 months:	Orthopaedics, Over 6 months:	Orthopaedics, 1-2 years:	Orthopaedics, 2+ years:
EAU	EAU, Under 6 months:	EAU, Over 6 months:	EAU, 1-2 years:	EAU, 2+ years:
Psychiatry	Psychiatry, Under 6 months:	Psychiatry, Over 6 months:	Psychiatry, 1-2 years:	Psychiatry, 2+ years:
Learning Disabilities	Learning Disabilities, Under 6 months:	Learning Disabilities, Over 6 months:	Learning Disabilities, 1-2 years:	Learning Disabilities, 2+ years:
Paediatrics	Paediatrics, Under 6 months:	Paediatrics, Over 6 months:	Paediatrics, 1-2 years:	Paediatrics, 2+ years:
Theatres	Theatres, Under 6 months:	Theatres, Over 6 months:	Theatres, 1-2 years:	Theatres, 2+ years:
Cardiac	Cardiac, Under 6 months:	Cardiac, Over 6 months:	Cardiac, 1-2 years:	Cardiac, 2+ years:
Urology	Urology, Under 6 months:	Urology, Over 6 months:	Urology, 1-2 years:	Urology, 2+ years:
Anaesthetics	Anaesthetics, Under 6 months:	Anaesthetics, Over 6 months:	Anaesthetics, 1-2 years:	Anaesthetics, 2+ years:
Hospices	Hospices, Under 6 months:	Hospices, Over 6 months:	Hospices, 1-2 years:	Hospices, 2+ years:
Nursing/Residential Homes	Nursing/Residential Homes, Under 6 months:	Nursing/Residential Homes, Over 6 months:	Nursing/Residential Homes, 1-2 years:	Nursing/Residential Homes, 2+ years:
Prisons	Prisons, Under 6 months:	Prisons, Over 6 months:	Prisons, 1-2 years:	Prisons, 2+ years:

Print Name:

Date:

Documents received

Tick box to confirm receipt

Document Names:

Tac Healthcare services Registration Form

Medical Questionnaire

DBS Application

48 Hour Opt Out - Working Time Directive (WTD) Form

Health & Safety Policy

Information on DGPR

Terms of Engagement

Company Handbook

Candidate Consent Declarations:

I agree that TAC ltd retains the right to hold this application and any other data required to process and pass on to any authorised third party the details held within. I also agree for TAC Healthcare Services Ltd to retain these details for as long as reasonably necessary in accordance and within the DGPR legislation. I also authorise that TAC Healthcare Services Ltd may share my data will all group and associated companies for the purpose of finding me work.

I give consent for Tac Healthcare Services Ltd to contact the UKBA (UK Borders Agency) if deemed appropriate.

I give consent for Tac Healthcare Services Ltd to forward my details (CV, References, Qualifications, Occupational Health and other information held on file) to prospective clients/employers for the purpose of locum assignments.

I give consent for Tac Healthcare Services Ltd to apply for references from previous employers.

I give consent for Tac Healthcare Services Ltd to provide prospective clients/employers with information concerning my skills, experience, incidents, investigations, cautions, undertakings and any other information deemed necessary.

I confirm that I shall inform Tac Healthcare Services, Ltd immediately of any changes to my professional registration, fitness to practice or health that would affect my ability to perform duties as required.

I give consent for my file and its contents to be used for the purpose of internal and external audits.

Confirm:

I confirm that I received the above documents at the Interview / Registration stage. I confirm that all the information provided on this registration form is true to the best of my knowledge.

Print Name:

Date:

Rehabilitation of offenders act

Because of the nature of the work for which you are applying, this post 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 in which the Order applies and should be entered at the end of any particulars you give in support of your application. A copy of our written policy is available upon request. A criminal record will not necessarily be a bar to obtaining a position.

You may be offered an opportunity to work in an environment or establishment where you come into contact with children or other vulnerable adult groups; or your professional occupation may fall within certain expected categories. Where this is likely to apply, the Rehabilitation of Offenders Act 1974 (Exemption order 1975) requires us to ask you for additional information. A criminal check from the CRB (Criminal Records Bureau) will be required when this type of work is sought. Please answer all of the following questions. If you answer ‘YES’ to any of the questions, PLEASE PROVIDE FULL WRITTEN DETAILS AND ATTACH IT TO THIS APPLICATION. Any other information that may have a bearing on your suitability for the position for which you are applying should also be attached. Please note: You do not need to tell us about parking offences.

1. Are you currently bound over or do you have any current ‘unspent’ (recent) convictions that have been issued by a Court or Court-Marshal in the United Kingdom or in any other country?

If YES, please attach details of the order binding you over and/or the nature of the offence, penalty, sentence or order of the Court and the date and place of the Court Hearing.

2. Have you ever received a police caution, reprimand or final warning?

If YES, please attach details of the caution, reprimand or final warning, including the date and the reason administered.

3. Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?

If YES, please attach details of the nature of the offence with which you are charged, date on which you were charged and details of any on-going proceedings by a processing body.

PLEASE NOTE: YOU MUST INFORM US IMMEDIATELY IF YOU ARE CHARGED WITH ANY OFFENCE IN THE UNITED KINGDOM OR IN ANY OTHER COUNTRY AFTER YOU COMPLETE THIS REGISTRATION FORM AND BEFORE TAKING UP ANY POSITION OFFERED TO YOU.

4. Are you aware of any current police investigation in the United Kingdom or in any other country following allegations made against you?

If YES, please attach details of the nature of the allegations made against you, and if known to you, any action to be taken against you by the police.

5. Are you aware of any current NHS Counter Fraud and Security Management Service (NHS CFSMS) investigation following allegations made against you?

If YES, please attach details of the nature of the allegations.

6. Have you been investigated by the Police, NHS CFSMS or any other Investigatory Body resulting in a current conviction or dismissal from your employment? (Investigatory bodies include Local Authorities, Customs and Excise, Immigration, Passport Agency, Inland Revenue, Work and Pensions, Security Agencies, Financial Services Authority, Banks & Building Societies (this list is not exhaustive and you must declare any investigation conducted by an Investigatory Body):

If YES, please attach details of the nature of the allegations made against you and if known to you, any action to be taken against you by the Investigatory Body.

7. Have you ever been dismissed by reason of misconduct from any employment, office or other position previously held by you?

If YES, please attach details of the employment, office or position held, the date you were dismissed and the nature of the allegations of misconduct made against you.

8. Have you ever been disqualified from the practice of a profession, or required to practice subject to special limitations following ‘Fitness to Practice’ proceedings, by a regulatory or licensing body in the United Kingdom or in any other country?

If YES, please attach details of the nature of the disqualification, limitation or restriction, the date and the name and address of the licensing or regulatory body concerned.

9. Are you currently the subject of any investigation or fitness to practice proceedings by any licensing or regulatory body in the United Kingdom or in any other country?

If YES, please attach details of the reason given for the investigation and/or proceedings undertaken, the date, details of any limitation or restriction to which you are current subject, and the name and address of the licensing or regulatory body concerned.

10. Are you subject to any other prohibition, limitation or restriction that means we are unable to consider you for the post in which you are applying?

If YES, please attach details of the nature of the prohibition, limitation or restriction, when and by whom it was made.

11. Do you hold a Criminal Record Bureau (CRB) Disclosure or overseas police check, carried out within the last 3 years?

If YES, please attach a copy.

12. Do you have any form of current Security Clearance?

If YES, please attach a copy or provide full details below:

Date Granted:

Expiry Date:

Level of Clearance:

Place of Work when granted:

Print Name:

Date: