DNA Nursing Services & DNA Care Services - Electronic Application

The information disclosed within this application form may be used in conjunction with a
Criminal Records Bureau Enhanced Disclosure Application.

Electronic Application

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Position Applied For
How/where did you hear about D’N’A?

Personal Details

Title
Surname
Previous Surnames (if applicable)
Forename(s)
Home Address
Town
County
Postcode
Home Tel.
Mobile tel.
Work/Others Tel.
Email
Nationality
Country of Birth
Date of Birth
Are you eligible to work in the U.K.?
Visa Number
National Insurance No
Do you hold a UK driving license?
Are you eligible to drive in the U.K.?
Do you have the use of a car?
Passport Number

Next of Kin

Name
Relationship
Home Address
Postcode
Contact No(s)

Employment History

Please give a full and continuous employment history since leaving full time education explaining any gaps or breaks.
Most Recent First.

Start Date	Finish Date	Position Held and Grade	Employer Name and Address	Reason for Leaving

References

Please supply the details of at least two referees of which, one must be your current or most recent employer. References will be sought upon receipt of this application.

Name
Address
Post Code
Telephone No.
Profession/Position
Relationship to applicant

Name
Address
Post Code
Telephone No.
Profession/Position
Relationship to applicant

Name
Address
Post Code
Telephone No.
Profession/Position
Relationship to applicant

If your application were successful, when would you be able to commence work?
NB. If applying for this position as a secondary income, responsibility is placed upon you the applicant to seek authorisation where necessary

Qualifications

Please be sure to include any qualifications relevant to the position for which you are applying.

NMC PIN No	Part of Register	Expiry Date

Qualifications	Date obtained	Place of training

Do you have any formal training in any of the below? (leave blank if not)

Training received	Date obtained	Training Company	Expiry Date
Management of Violence and Agression
Food and Hand Hygiene
Moving and Handling
Fire Awareness
First Aid
Infectious Disease Control
Maybo
Health and Safety
Safe Handling of Medication
Safeguarding of Vunerable Adults

Declaration of Health

Have you suffered any of the following

	Yes/No	Details
Back Trouble
Heart Disease / Blood Pressure
Epilepsy
Diabetes
Asthma / Chest Complaints
Dermatitis / Skin Problems
Any Major Operations
Do You Have Any Notifiable Diseases
Do You Smoke
Are You Taking Any Long Term Medication
Do You Suffer Any Allergic Reactions
Eye Sight Problems
Hearing Problems
Mental Health Problems
Infectious Diseases

IMMUNISATIONS:
D’N’A strongly advises you to have up to date immunisations for at least the following. Immunisations are available from your local GP/ Health clinic who will advise you of current recommendations for adequate protection when working in healthcare environments. Please supply written confirmation of any immunisations you may have. Certain institutions may insist on proof of immunisation before allowing staff to work. It is YOUR responsibility to ensure that immunisations are kept up to date.

	Yes/No
Rubella
Hepatitis B
Typhoid
Tuberculosis
Tetanus
Polio

Name & address of your General Practitioner:

Declaration of Health

I declare that to the best of my knowledge I have no infections or contagious or debilitating medical conditions and that I know of no reason relating to my health which could in any way restrict my ability to carry out the functions and duties required in Health Profession. I am aware that it is my responsibility to maintain up to date immunisation against infectious disease. I do not know of any reason which, on medical grounds, would prevent me from giving care or assistance to a member of the public. I hereby confirm that I am not currently in receipt of sickness benefit from any employer or from the state.

Please note that in certain circumstances you may have to provide a Health Reference from your GP.

Rehabilitation of Offenders Act 1974

DNA will use the CRB Disclosure service to assess applicants' suitability for positions of trust. It complies fully with the CRB Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a Disclosure on the basis of conviction or other information revealed.

• DNA is committed to the fair treatment of its staff, potential staff or users of its services, regardless of race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental disability or offending background.

• DNA promotes equality of opportunity for all with the right mix of talent, skills, and potential and welcomes applications from a wide range of candidates, including those with criminal records. Candidates are selected for interview based on their skills, qualifications and experience.
• A Disclosure is requested thorough risk assessment indication that one is both proportionate and relevant to the position concerned, this is due to the types of environments our company works within. For those positions where a Disclosure is required, all application forms, job adverts and further details will contain a statement that a Disclosure will be requested in the event of the individual being offered the position.

• Where a Disclosure is to form part of the recruitment process, DNA encourages all applicants called for interview to provide details of their criminal record at an early stage in the application process. This information is sent under separate, confidential cover, to a designated person within the Company, which guarantees that this information is only seen by those who need to see it as part of the recruitment process.

• As the nature of the position involves working with vulnerable adults this allows DNA to ask questions about the entire criminal record rather than only asking about 'unspent' convictions as defined in the 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 provisions of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of his normal duties. DNA ensures that all staff who are involved in the recruitment process have been suitably trained to identify and assess the relevance and circumstances of offences. It will also ensure that they have received appropriate guidance and training in the relevant legislation relating to the employment of ex-offenders, e.g. the Rehabilitation of Offenders Act 1974. At interview, DNA aims to ensure that an open and measured discussion takes place on the subject of any offences or other matter that might be relevant to the position sought and could lead to withdrawal of an offer of employment.

• DNA will make every subject of a CRB Disclosure aware of the existence of the CRB Code of Practice and make a copy available on request.

• DNA undertakes to discuss any matter revealed in a Disclosure with the person seeking the position. Any person seeking employment who have a positive disclosure will be asked for a written explanation before withdrawing a conditional offer of Employment.

Have you ever been convicted of a criminal offence?
(If yes please give details including dates)

Declaration

I declare that I have answered the above questions honestly and fully and that I am not aware of any physical or mental disability, which may affect my working capacity. I realise that any false or incomplete statement on my part will render me liable to disciplinary action or dismissal. I also understand that my details will be submitted for a check by the criminal records bureau.

I agree to comply with the current health & safety at work act.

It is a condition of employment that you work flexibly in accordance with the requirements of the company. Accordingly if accepted and employed you acknowledge that there may be periods when no work is available and the company has no obligation to provide an employee with any work or to provide any minimum number of hours in any day or week.

I hereby give permission for DNA to contact the UK Border Agency to seek verification of my documents.

I also confirm that I give permission for my documentation to be viewed as appropriate by official bodies for the purposes of internal and external audits.

Please attach a photograph
(max 1MB):

Personal Statement

Please Use the box to the right to add any additional comments or attach your CV.
Upload your CV (max 1MB):

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