Elite HealthCare
KBC Hayes Exchange: Union House
23 Clayton Road, Hayes, Middlesex, UB3 1AN
Tel: 0208 817 1169 Mobile07534097707
Fax: 0208 817 1208 Email: info@eliteconsortium.co.uk
JOB APPLICATION FORM
Post Applied For: Location:
TITLE: FIRST NAME(S): SURNAME:
DATE OF BIRTH;
NATIONALITY: NI no. DO YOU REQUIRE A WORK YES/NO
PERMIT?
PIN no. DO YOU HOLD A UK VALID YES/NO
DRIVING LICENCE?
PIN expiry date:
Details of Next of Kin:
Home Address:
Relationship to you:
Postcode:
Home Address:
Home Telephone No:
Postcode:
Mobile Telephone No:
Home Telephone No:
Email Address:
Mobile Telephone No:
Email Address:
Page 1 of 19
QUALIFICATIONS AND EXPERIENCE
Dates Name of School/College/University Details of Qualifications Attained Grades
From To
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EMPLOYMENT RECORD FOR THE LAST 10 YEARS
Dates Employers Full Name and Address Duties and Position Held Reason for Leaving
From To
Page 3 of 19
PERSONAL STATEMENT: (Please tell us why you think you are a suitable candidate)
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REFEREES:
Please give the name, address, and telephone number of your current and most recent employers. If you are a student then one of your referees will
need to be your tutor. Referees must have worked in a senior position to you. Please note that relatives cannot be accepted as personal referees.
Full Name: Full Name:
Job Title of Referee: Job Title of Referee:
Telephone Number: Telephone Number:
Company Name & Address: Company Name & Address:
Email Address: Email Address:
Can we contact your referee before interview Yes/No Can we contact your referee before interview Yes/No
Page 5 of 19
Asylum and Immigration Act 1996
You will be asked to produce one of the documents specified by the Act to establish your eligibility to work. Any offer of
employment will be limited by, and subject to your continued eligibility to work in the UK.
Health Screening
If you are offered a job, you will be asked to fill in a pre- employment health –screening questionnaire, which will be assessed by
Occupational Health.
Any offer of employment will be subject to a satisfactory report from Occupational Health.
Criminal records
Jobs with Elite HealthCare may involve working with frail and vulnerable people; so all posts are exempt from the Rehabilitation of
Offenders Act 1974. If you are successful in your application, we will then seek an Enhanced Disclosure from the Criminal Records
Bureau. If you have a criminal record, it will not necessarily bar you from employment with Elite HealthCare. Our policy on this
matter and the CRB Code of Practice is available upon request.
Any offer of employment will be subject to a satisfactory criminal records check.
Criminal Convictions Declaration
Have you ever been convicted of a criminal offence which is not spent under the Rehabilitation of Offenders Act 1974? Yes / No
If yes, please give details:
Have you ever been convicted of a criminal offence which is classed as spent under the Rehabilitation of Offenders Act 1974?
(Please note this question is asked not to discriminate against those who have previous convictions. When applying for a role
which requires a Criminal Records Bureau check, any convictions which appear that you have not disclosed may jeopardise your
placement into an assignment).
Signature.........................................................
Print Name......................................................
Date.................................................................
Declaration by Applicant
I confirm that the information in this application is true and accurate to the best of my knowledge and belief. I understand that any
false information may result in the rejection of my application or in the event of employment, dismissal of disciplinary action by Elite
HealthCare.
Signed ..........................................................................................Date.............................................................
Page 6 of 19
CONFIDENTIALITY AGREEMENT
I confirm that during every assignment and afterwards where:
To hold information relating to the client in the strictest confidence, ensure it is kept safely and securely when not in use. I
acknowledge that no information is to be removed from the client‟s premises without the permission of the Client
To use such information only for the purpose of the work for which it was given
Not to disclose to any third party or copy the information except as is required in the course of my duties
Any breach, either by me or a third party, may result in legal proceedings being bought by the Client against me to recover
any losses that have occurred as a result of a breach.
Signature..............................................
Print Name...........................................
Date.....................................................
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New Employee Details:
This form must be completed and signed by the Employee and should be forwarded to the payroll along with a P45 or completed
P46 form as soon as the employee has started employment.
Title and Surname:
Forenames:
National Insurance number:
Date of birth:
Current Home Address and Postcode:
Ethnic Origin:
Disability:
Date of commencement
Job Title:
Sort Code:
Account Number:
Account Name:
Bank Name and Branch:
Building Society Roll Number:
Building Society Name and Branch:
AUTHORISATION
Managers Authorisation: Date:
Employee Signature: Date:
Action by Payroll: Date:
Page 8 of 19
Health Questionnaire:
This questionnaire asks for information of a personal nature. It is necessary to establish your health status as there are aspects of
the work which requires us to make risk assessments in order to protect our employees and clients.
All information given will be held in strict confidence.
Position Applied for: Location:
Title (Mr, Mrs, Ms, Miss): First name:
Surname: Date of Birth:
Full Address:
Postcode:
Please indicate whether you have suffered from any of the following by answering Yes or No:
Provide details where the answer is Yes
Epilepsy Yes No
Fits, Fainting attacks or dizziness Yes No
Stomach problems Yes No
Frequent vomiting Yes No
Chronic or recurrent cough Yes No
Varicose veins Yes No
Rupture /Hernia Yes No
Serious Injury Yes No
Rheumatism/Arthritis Yes No
Skin problems ( e.g. Dermatitis, Eczema, Psoriasis Yes No
Back problems Yes No
Hearing problems/ ear problems Yes No
Chest problems Yes No
Diabetes Yes No
Eye/ sight problem not corrected by glasses Yes No
Kidney problems Yes No
Mental illness Yes No
Heart problems Yes No
Abnormal blood pressure Yes No
Persistent head aches Yes No
Jaundice Yes No
Dysentery or typhoid Yes No
Blood borne virus (i.e. Hepatitis /HIV Yes No
Asthma, Bronchitis, or TB Yes No
Have you been vaccinated against the following, Proof of all immunisations must be provided:
German Measles (Rubella ) Yes Date No Tuberculosis Yes Date No
Hepatitis B Yes Date No Tetanus Yes Date No
Polio Yes Date No Varicella Yes Date No
Mumps Yes Date No BCG Scar Seen Yes No
Note: I certify that the above information is correct and hereby give permission for a further report to be requested from my GP for
clarification if required.
Signed:.............................................................................................Date:................................................................................
Doctor‟sName.........................................................................................................................................................................................
.Address...............................................................................................................................................................
Page 9 of 19
EQUAL OPPORTUNITY STATEMENT
Elite HealthCare is committed to a policy of Equal Opportunity and is keen to actively promote this where possible.
Our objective is to ensure that all applicants receive the same treatment regardless of Race, Ethnic or National origin, Gender, Marital status, Sexual orientation,
Religion, Political belief or Disability.
Job Reference Number: ........................................................................Post Applied for:.........................................................................................
Surname Name:.............................................................................................Forename(s):............................................................................................
Please tick appropriate boxes below:
1. Gender: Male Female
2. Marital Status:
Single Married/Civil Partner Co-habiting
Widowed Separated Not stated
Divorced/Partnership Dissolved
3. Date of Birth: …………………………………………………….. (dd/mm/yyyy)
4. What is your ethnic group?
Please choose from selection (a) to (e), and then tick the appropriate box to indicate your cultural background.
a) White d) Mixed
[W1] British [M1] White and Black Caribbean
[W2] Irish [M2] White and Black African
[W9] Any other white background [M3] White and Asian
[M9] Any other mixed background
b) Black or Black British e) Asian or Asian British
[B1] Caribbean [A1] Indian
[B2] African [A2] Pakistani
[B9] Any other black background [A3] Bangladeshi
[A9] Any other Asian background
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c) Chinese or other Ethnic Group Not stated
[01] Chinese
[09] Any Other
5. Sexual Orientation
Bisexual
Gay/Lesbian
Heterosexual
Transsexual
Not stated
Prefer not to say
6. Religious Belief/Faith
Agnostic Church of England
Atheist Church of Ireland
Baptist Church of Scotland
Buddhist Hindu
Christian Jehovah‟s Witness
Christian - Apostolic Judaism
Christian – Dutch Reformed Methodist
Christian – Evangelical Muslim
Christian – Lutheran Pagan
Christian – Mormon Roman Catholic
Christian – Orthodox (Greek) Sikh
Christian – Orthodox (Russian) None
Christian – Pentecostal Not Disclosed
Christian – Presbyterian Prefer not to say
Christian – Quaker
Christian – Spiritualist
Christian – United Reformed
7. Do you consider yourself to have a disability? Yes No
If „Yes‟, please give details (it may help you to read the information below first)
Definition of the term ‘Disability’
The Disability Discrimination Act defines disability as a physical or mental impairment with long term, substantial effects on a person‟s ability to perform day to
day activities.
Examples of Disabilities
We thought it might help you to answer the question if we provided a list of some medical conditions or impairments that could cause someone to describe
him/herself as `having a disability‟. It is not meant to be an exclusive list and is given for guidance only.
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Hearing, speech or visual impairments. If you wear glasses or contact lenses, this is not normally considered a disability.
Co-ordination, dexterity, or mobility. Examples could include polio, spinal cord injury, severe back problems, repetitive strain injury.
Mental Health. Examples could include schizophrenia, severe depression, severe phobias.
Learning Difficulties. Examples could include Down‟s Syndrome or dyslexia.
Other physical or medical conditions. For examples, diabetes, epilepsy, arthritis, cardiovascular conditions, haemophilia, asthma, cancer, facial
disfigurement, sickle cell.
Are you registered disabled? Yes No
If „Yes’ please provide registration number:..............................................................................
8. How did you find out about this vacancy?
Publication:........................................................................................
Job Centre:.......................................................................................
Other:...............................................................................................
DECLARATION
I declare that the information given, to the best of my knowledge, is accurate, and that, if appointed, any statement made on this form which is found to be false
may result in my employment being terminated.
Signed:.......................................................................................
Date: ........................................................................................
THANK YOU FOR COMPLETING THIS FORM.
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Terms and Conditions of Membership
This is an important document please sign and return one copy to Elite HealthCare.
The terms and conditions set out below (the “Conditions of Membership”) shall govern the relationship between Elite HealthCare and you during any period in
which you are providing your services to Elite HealthCare. There is no contractual relationship between us outside of these periods. It is a condition of
Membership that you read and fully understand these conditions. We will be pleased to clarify any points you do not understand.
1. The role of Elite HealthCare
Elite HealthCare will offer work to its Members where suitable work is available. There is no obligation to offer any level of work to you or any obligation upon
you to accept work.
2. Assignments
Elite HealthCare makes every effort to find Members suitable work but will make no guarantee that we shall always be able to do this. Temporary work
assignments are made in accordance with the terms of this Agreement and the terms of Business (copies of which are available upon request). Members must
keep any appointments or arrangements that are made for them. Members who are unable to report for duty for any reason whatsoever must telephone Elite
HealthCare immediately so that every effort can be made to find a replacement under no circumstances may any person who is not a Member of Elite
HealthCare be introduced to a case.
3. Payment
Elite HealthCare makes payments to Members in advance of fees earned by them, and Members irrevocably appoint Elite HealthCare to collect and recover
fees, expenses, charges and extras in the name of Elite HealthCare. All moneys due to Elite HealthCare will be deducted from the moneys received from the
client. All assignments must be booked through Elite HealthCare.
4. Fees and Expenses
Payment in advance of fees earned by Members is made weekly by Bankers Automated Clearing Services (BACS) accompanied by a full statement. Accounts
prepared by Elite HealthCare on behalf of Members are usually submitted weekly.
5. Timesheets
Fully completed and signed timesheets must be submitted to the payroll branch weekly, to arrive no later than Monday noon, in order for payment to be made
promptly. Failure to submit a completed timesheet may result in payment being delayed. To fulfil our record keeping obligations, hours worked will continue to
be monitored on a timesheet basis.
6. Members Employment Status
Members are self-employed in all cases. Members may be deemed employees for the purpose of PAYE and Class One National Insurance Contributions only in
appropriate cases, PAYE tax deductions will be made from Members‟ fees and National Insurance Contributions will be collected by Elite HealthCare. Because
Members‟ contract exists only for the period of each duty, Elite HealthCare does not usually pay statutory sick pay. Members should make inquires to their local
DSS office with regard to sickness benefit.
7. Standards and conduct
Members of Elite HealthCare must at all times maintain the highest professional standards and comply with Elite HealthCare policies and procedures. Members
are also required to work to the policies, procedures and requirements of the client and workplace and comply with the codes of conduct of any professional
organisation to which they belong.
8. Uniform
Members will be required to purchase and wear an Elite HealthCare uniform at all times. The only exceptions to this condition are (a) where the Client provides
their own uniform, or (b) where the Client does not wish one to be worn.
9. Changes to Personal Details
The Management of Elite HealthCare must be notified immediately in writing of changes of address, telephone number or bank details. Failure to notify such
changes may result in non-receipt of statement of fees and other correspondence loss of assignments, or incorrect or non-payment of fees.
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Incomplete Assignments
The Employment Business expects the Temporary Worker to complete given assignments unless there is a situation that arises which may make it undesirable
for the Temporary Worker to continue with such assignment. Temporary Workers wishing to leave an assignment before completion should inform the
Employment Business immediately and the Client must be given clear reasons for such action only after consultation with the Employment Business. Members
wishing to leave an assignment before its completion must inform the Elite HealthCare office immediately and give at least one weeks‟ notice to the client.
10. Termination of Membership
Members may terminate their Membership of Elite HealthCare at any time and one weeks‟ notice must be given if an assignment is in progress. If a Member
wishes to take up any appointment with a Client introduced by Elite HealthCare within six months of the termination of Membership, the Member must notify
Elite HealthCare in writing, as a fee will be due from the Client. Failure to inform Elite HealthCare will jeopardise future work opportunities or result in termination
of Membership.
11. Client Care/Reports
Changes in patients‟ mental and physical condition should be reported to the appropriate person Detailed records must be kept in accordance with both Client
and agency requirements, as required by the Elite HealthCare Manager.
12. On Call
For the purpose of the Working Time Regulations, time spent “on –call” whilst not working will not count towards a members working time unless and until the
Member is called to work.
13. Time Off
Members who wish to have time off from an assignment other than, as paid holiday must give Elite HealthCare at least one weeks‟ notice to find a suitable
replacement for the period of absence.
14. Paid Holiday
The working Time Regulations provide that Members who work for 13 consecutive weeks ( the qualifying period) will from 2 nd February 2007 begin to accrue a
right to paid holiday on a pro -rata basis equivalent to full time employment of 4 weeks per year. This right is broken should you cease to work continuously.
However, Elite HealthCare has decided to offer greater benefit to you by giving you the entitlement to accrue 1 hour of paid holiday for every 13 hours worked
through Elite HealthCare (following your initial qualifying period) If you have a period of 6months or more without undertaking, any assignments you will need to
re-work the qualifying period to accrue more hours. Elite HealthCare holiday year commences from 2nd February and runs through to 30th March. Members are
obliged to give appropriate notice to their intention to take time off. Leave may not be booked in advance of it being accrued. The purpose of the entitlement to
paid holiday is to ensure that you take time off work. Elite HealthCare therefore recommends that you do not work during your holiday period. Accrued annual
leave not taken within the holiday year will be lost.
15. Working Hours
In compliance with the implementations of the Working Time Regulations, Elite HealthCare recommends that working time (including any time that you
personally provide your services to anyone else) should not exceed 48 hours per week (average over a period of 17 weeks). However, should you wish to waive
this right please indicate this preference by ticking Yes /No in the box provided below. Members can withdraw the option to work in excess of 48 hours per week
at any time by providing 3 months written notice to their local Elite HealthCare. Working Time shall include only the period of attendance at each individual
assignment through Elite HealthCare.
16. Daily Rest Period
All Members should be provided with the opportunity to take 20minutes unpaid break during assignments of 6 hours duration or more. It is the responsibility of
the Member to ensure this is taken in the course of work. Members are entitled to take 11 hours of consecutive rest per day. In circumstances in which flexible
practice is required such as home care, sleepovers, hospitals, residential homes, prisons, etc; and there is no opportunity to take rest breaks, this is permitted
providing an equivalent break or compensatory rest period is agreed at the convenience of the Member and Client. However, where an agreement has been
reached by collective means within the established workforce, Members will be bound by that agreement in relation to working hours. This will not entitle
Members to any other benefits or provisions under such collective agreements. Members are not entitled to receive pay during any rest breaks.
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18. Shift Workers
Members are entitled to 11 hours of daily consecutive rest, but this does not apply in relation to shift workers who cannot take a daily rest period between the
end of one shift and the start of the next. In these circumstances, clause 17 relating to rest period applies and an equivalent break of compensatory agreed
weekly hours must not be exceed.
19. Night Shifts
Members have the opportunity to undergo a health assessment prior to night duty assignments for which they will not be charged. (This can be arranged
through our office). Night duty hours must not exceed 8 hours in 24 hours, and this is averaged over a standard period of 17 weeks. (In certain circumstances in
which flexible practice is required, clause 17 relating to rest periods applies, and individual agreements between the Member and Elite HealthCare must be
reached if night hours are to exceed this limit. In these circumstances, an equivalent break of compensatory rest period is agreed at the convenience of the
member and client.)
20. Members’ Health
Membership of Elite HealthCare is conditional upon true statement of the details of a Member‟s mental physical health as set out in the application form, and
upon the understanding that a Member must be in a state of good health when reporting for each and every duty. Failure to provide all accurate declaration of
health or to update Elite HealthCare of any change could jeopardise Elite HealthCare Membership.
21. Health and Safety
Members, as self-employed persons, determine their working hours through accepting or refusing assignments offered. Members are individually responsible for
ensuring their chosen working hours (including all work other than through Elite HealthCare are compatible with their own health and safety at work and that of
patients, clients and colleagues. As self-employed persons, members have a personal responsibility to regard health and safety policies and fully co-operate
with those in charge of the workplace. Members are required to assess for any risk in the workplace and maintain a safe environment both for themselves, other
staff and clients. Often, this will involve working to establish health and safety practices, but private householders are unlikely to have such a detailed
knowledge, so particular care is required when providing home care services
22. Negligence
If a Member is removed from an assignment or a complaint for misconduct or professional negligence is received, Elite HealthCare reserves the right to withhold
payment in advance of fees earned by the member
23. Professional Negligence Indemnity Insurance
Elite HealthCare does not provide professional indemnity cover. However, the temporary worker is strongly recommended to obtain professional indemnity
insurance cover. The cover offered by the Clinical Negligence Scheme for Trusts is by no means sufficient to cover all situations in which you might find
yourself. Without your own professional indemnity Insurance you could be liable for all costs relating to any claim made against you.
24. Data Protection
Elite HealthCare holds information on Members, racial or ethnic origin, religious beliefs, health and criminal records. This sensitive information is held for
monitoring purposes only. However, Elite HealthCare may use other, non-sensitive information supplied by you to occasionally send, or arrange to send,
information which we believe will be of interest to Members. If you do not wish us to pass on this non-sensitive information about you please mark the relevant
box below.
25. Identification
Members must carry their NMC PIN card and wear an Elite HealthCare ID. Badge at all times whilst on duty, or whilst on duty the Client‟s premises, going to, or
coming off, an assignment
If you have read and understood the terms and conditions please sign and date:-
Signature................................................................................................................................................Date.......................................................................
Page 15 of 19
Please tick 1 box only for each question
Working hours Yes, I may wish to work more than 48 hours per week
No, I do not wish to work More than 48 hours per week
Data Protection Yes, I would like to receive Correspondence from Elite HealthCare
and agree to non-sensitive Information about me being used
for this purpose.
No, I do not wish to receive Correspondence from Elite HealthCare
and do not agree to Non-sensitive Information about me
being used for this purpose.
Member Name...................................................................................
(PRINTED)
Signature............................................................................................
Payroll No..................................................Date..................................
Branch................................................................................................
If you have any queries concerning these conditions, please contact Elite HealthCare for further explanation. No variation or alteration to these conditions shall
be valid unless confirmed in writing by a Director of Elite HealthCare.
Should you have any specific comments, a copy of our comments and complaint procedure is available from Elite HealthCare Registered Office
Company Registration 6899211 Incorporated in England and Wales.
Registration Office KBC Hayes Exchange, Union House 23 Clayton Road, Hayes Middlesex UB3 1AN
Page 16 of 19
QUALITY QUESTIONNAIRE FORM
Elite HealthCare strives to constantly improve its services to clients and staff alike. Taking a few minutes to complete this questionnaire will help us improve our
standard of service to our staff.
The Recruitment Consultant (RC) you dealt with was Excellent Good Average Poor
Was the Recruitment Consultant sufficiently knowledgeable about your needs? Yes No
Was the RC too pushy Yes No
How would you describe the overall recruitment process Excellent Good Average Poor
Did you experience difficulties in calling our phones Yes No
Is this your first dealings with Elite HealthCare Yes No
Why did you choose Elite HealthCare ................................................................................................................................................................................
.............................................................................. ..............................................................................................................................................................
.............................................................................................................................................................................................................................................
Where did you hear of Elite HealthCare..............................................................................................................................................................................
What do you like best about Elite HealthCare....................................................................................................................................................................
.............................................................................. ..............................................................................................................................................................
.............................................................................................................................................................................................................................................
Would you recommend Elite HealthCare to a friend............................................................................................................................................................
What do you like least about Elite HealthCare.....................................................................................................................................................................
............................................................................. ...............................................................................................................................................................
Page 17 of 19
FOR OFFICE USE ONLY
INTERVIEW QUESTIONAIRE
Surname Name:............................................................................................. Forename(s):..........................................................................................
Post Applied for:........................................................................................ Date...........................................................................................................
Why have you applied for this position? :.......................................................................................................................................................................
What makes you suitable for this position:.....................................................................................................................................................................
.............................................................................................................................................................................................................................................
. ...........................................................................................................................................................................................................................................
What Health care trainings have you attended?.............................................................................................................................................................
Describe a time when you made a significant impact on a service user’s life?
.............................................................................................................................................................................................................................................
. ...........................................................................................................................................................................................................................................
Describe a time when your actions towards a service user was less than satisfactory............................................................................................
.............................................................................................................................................................................................................................................
. ...........................................................................................................................................................................................................................................
On a scale of 1-10 with 10 being the highest how important is your work to you?.....................................................................................................
Which do you prefer to work as a team or on your own................................................................................................................................................
What support/training will help you perform your job better?......................................................................................................................................
If you find a service user on the floor what will you do?...............................................................................................................................................
If a service user ask you to prepare a meal what will you do?......................................................................................................................................
Where would you be in the next 3 years.........................................................................................................................................................................
Why do you want to leave your present job?..................................................................................................................................................................
What is your salary expectation? ....................................................................................................................................................................................
Is there anything you need to know about us?...............................................................................................................................................................
OFFICIAL USE ONLY
Name of Interviewer...................................................................................Designation....................................................................................................
Interviewers Remark............................................................................................................................................................................................................
............................................................................................................................................................................................................................................
Signature...................................................................................................Date...................................................................................................................
Page 18 of 19
LIST OF REQUIREMENTS TO VALIDATE YOUR REGISTRATION
Please include the following when handing in your completed application form. Please bring only ORIGINAL
document as copies will be made by us. This is to speed up the application process.
1. Two recent passport photographs.
2. Two proof of address, either a valid UK drivers license or utility bill with your name on it- phone or
electricity bill, bank statement etc.
3. National Insurance Card (NI).
4. Curriculum Vitae (detailed history in month/year format with no gaps)
5. Immunisation history report (where applicable)
6. Educational certificates ( translated into English )
7. Passport and visa / eligibility to work in the UK
8. Birth certificate
9. CRB must be a disclosure from Elite - £50 (where applicable)
10. Health Assessment Questionnaire
11. GSCC Registration / HPC Registration ( where applicable)
12. Non Disclosure Agreement / Confidentiality Agreement
13. Overseas Police Check ( not a legislative requirement )
14. Criminal Convictions Declaration
15. Mandatory training certificates (For positions in the Health and Social Care Sector )
Moving and handling
CPR adult or paediatric
CTG and Resuscitation
Infection control
Health and Safety
Fire awareness
Dementia
Price
PMVA
Mental Health Awareness etc
16. Face to face Interview
17. References – all gaps to be covered in references
Positions subject to CRB checks need 5 years of written references from ex-employers
Positions NOT subject to CRB checks require 2 years referencing
Please note that we are under obligation to conduct a fresh CRB check for every applicant (where the job
requires it) irrespective of whether they have recently done one.
All applications must be submitted in PERSON together with the above listed documents.
Page 19 of 19