FULL NAME:

QUALIFICATIONS:
CONTACT NUMBER:
EMAIL ADDRESS:
PAYROLL NUMBER:
OFFICE USE ONLY
BRANCH:
TICKBOX
OFFICE USE ONLY
CRB Paid
All ID Docs Received
3 Refs Given
Tunic Paid
JL Signature
Date
tel: 01244404080
email: info@janelewis.co.uk
web: www.janelewis.co.uk
p
a
s
s
p
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r
t

p
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TWO PASSPORT SIZED PHOTOGRAPHS
NAME AND ADDRESSES OF THREE
PROFESSIONAL REFEREES
YOUR NATIONAL INSURANCE NUMBER AND BANK
DETAILS
PROOF OF IMMUNISATIONS
FOREIGN NATIONALS MUST BRING PROOF OF THEIR
ENTITLEMENT TO WORK
PAYMENT FOR CRIMINAL RECORD CHECK

AN UP TO DATE COPY OF YOUR CV
ORIGINAL CERTIFICATE SHOWING ANY
RELEVANT QUALIFICATIONS
PROOF OF YOUR PROFESSIONAL
REGISTRATION IF APPLICABLE
YOUR PASSPORT, BIRTH CERTIFICATE,
PHOTO DRIVING LICENCE AND TWO ITEMS
SHOWING YOUR CURRENT ADDRESS
E.G. A RECENT UTILITY BILL, COUNCIL TAX BILL
AND / OR BANK / CREDIT CARD STATEMENT
A COPY OF YOUR LAST CRIMINAL RECORD CHECK
(Only If Received Within The Last 12 Months)
1
For Permanent Recruitment, Please Refer To Your Cover Letter For Interview Requirements

PERSONAL DETAILS
TITLE: MR MRS MISS MS
SURNAME:
FORENAMES:
MAIDEN NAME:
FORMER NAME:
DATE OF BIRTH:
HOME ADDRESS:
POSTCODE:
TELEPHONE NUMBER:
OTHER CONTACT NUMBER:
EMAIL ADDRESS:
PROFESSION:
QUALIFICATION:
N.I. NUMBER:
LANGUAGES SPOKEN / SIGN LANGUAGE:
UK DRIVING LICENCE YES NO USE OF CAR: YES NO
DETAILS OF ANY ENDORSEMENTS:
DO YOU REQUIRE ANY SPECIAL ADJUSTMENTS FOR INTERVIEW? (If yes please specify): YES NO
2

lawrence
sharron
edwards
collins
22/04/1967
flat 2, llwyn, gloddaeth avenue,
llandudno, conwy.
ll332ah
07917331270
01492330093
sharronlawrence1@hotmail.co.uk
support worker/ HCA
nm896473b
english/welsh
none

3
PERSONAL DETAILS AND PROOF OF ENTITLEMENT TO WORK
DO YOU HAVE A VISA? YES NO
PASSPORT NUMBER:
PASSPORT NATIONALITY:
PASSPORT PLACE OF ISSUE:
PASSPORT DATE OF ISSUE:
PASSPORT EXPIRY DATE:
KNOWN RESTRICTIONS:
UNDER THE REQUIREMENTS OF THE ASYLUM AND IMMIGRATION ACT, ARE YOU ELIGIBLE TO WORK IN THE UK? YES NO
TO BE COMPLETED BY NON BRITISH AND NON EC NATIONALS ONLY
DATE OF ENTRY INTO THE UK:
DO YOU HAVE A CURRENT VISA? YES NO IF YES, WHAT TYPE AND EXPIRY DATE:
FROM TO NAME OF UNIVERSITY / COLLEGE QUALIFICATIONS OBTAINED
WHERE DID YOU HEAR ABOUT US?
RECRUITMENT EVENT LOCAL PRESS NURSING TIMES RCN BULLETIN NURSING STANDARD
INTERNET OTHER PLEASE SPECIFY

507751027
british
united kingdom
13/02/2012
13/02/2022
none
QUALIFIED NURSES ONLY
UKCC PIN NUMBER:
EXPIRY DATE:
PROFESSIONAL DETAILS
PLEASE TICK ALL THE NURSING SPECIALITIES OF WHICH YOU HAVE SIGNIFICANT EXPERIENCE
MEMBERSHIP OF PROFESSIONAL BODIES
ARE YOU A MEMBER OF A PROFESSIONAL BODY? (If yes please specify)
REGISTERED BODY REGISTRATION NUMBER EXPIRY DATE
DECLARATION
Each registered nurse shall act, at all times in such a manner as to justify public trust and confdence, to uphold and enhance the
good standing and reputation of the profession, to serve the interest of society and above all safeguard the interests of individual
patients and clients.
SIGNED: DATE:
4
A & E
AIDS / HIV
ANAESTHETICS
BURNS & PLASTICS
CARDIOLOGY
CARDIO THORACIC
CCU
COMMUNITY
DERMATOLOGY
ELDERLY CARE
ENT
GYNAECOLOGY
HAEMATOLOGY
ICU
INFECTIOUS DISEASES
ITU
LIVER UNIT
MARIE CURIE
MEDICAL
MENTAL HEALTH
MIDWIFERY
NEUROLOGY
NNU
OCCUPATIONAL HEALTH
ODA
ONCOLOGY
OPTHALMICS
ORTHOPAEDIC
OUTPATIENTS
PAEDIATRICS
PHLEBOTOMY
PSYCHIATRY
RADIOTHERAPY
RECOVERY
RENAL ANALYSIS
SCBU
SURGICAL
PALLIATIVE CARE
THEATRE
TROPICAL
VENEPUNCTURE
X-RAY
LEARNING DISABILITY
CHALLENGING
BEHAVIOUR
HOME CARE

DETAILS OF EMPLOYMENT
Please include all previous employment over the last 10 years. Please account for any time taken out from employment in the
space provided on the opposite page. If you are registered with another agency please give details below.
FROM TO NAME AND ADDRESS OF
EMPLOYER (Most Current First)
JOB DESCRIPTION
(please include reason for leaving)
GRADE &
SALARY
5
2012 2013
Kim Mason Manager
Advantage Health Care Grp
Suite 22, Durham Tees Valley
Business Centre, Orde Way.
Stockton on Tees.
hca on all units of general
hospital, complex care
specialist area of spinal
injury,bp,bm,sats,dip
test,bowel regime,trachy
care,respiratory care,suction
10/14
per hour
2012 2013 Samantha Chapman HR
The Priory Hospital, Middleton
St George, Darlington, County
Durham.
Bank Hca, on all mental
health male and female
units, challenging behavior,
personality disorder, forensic
unit, drug and alcohol rehab.
Relocated to wales
9/12
per
hour
2008 20012 Pin Point Care Agency,
93-105 St James Boulevard,
Newcastle upon Tyne
Hca in learning disabilities
Centre,chaperoning,activities
, maths, English, swimming,
gym, personal care. Working
in elderly nursing homes
8
per
hour
2006 2008 Haven Care
Ground Floor, lyster court, the
millfields, Plymouth
Hca working in clients
homes on 1 on 1 basis, with
challenging
behaviour,learning
disabilities, schizophrenia.
relocation to plymouth
16995
per ann
2004 2008 Nhs Dental practice
appleby
westmoorland
Cumbria
Head Receptionist, filing,
faxing,e-mailing,answering
calls, making appointments,
scanning,diary
management,minutes
meeting, cash management
15000
per
annum
2004 2008 Esport Country Club
Humberston
Grimsby
Clethorpes
Receptionist, cash handling,
making appointment,
memberships, filing,
faxing,ledger
management,e-mailing,
dealing with enquiries,
14995
per ann
GAPS IN EMPLOYMENT
Please indicate any gaps in employment or time taken out for training below:
6
DETAILS OF EMPLOYMENT
Please include all previous employment over the last 10 years. Please account for any time taken out from employment in the
space provided on the opposite page. If you are registered with another agency please give details below.
FROM TO NAME AND ADDRESS OF
EMPLOYER
JOB DESCRIPTION
(please include reason for leaving)
GRADE &
SALARY
Hair Company
35 Verwood close
Stockton on Tees
manager of hairdressing
business.
relocation
16000
per ann
cut above the rest Hair salon
llandudno Junction
apprentice hairdresser,
moving onto senior stylist
9000
per ann
1994 2004
1984 1994
SUPPORTING STATEMENT
Please explain how you see your experience, skills and knowledge meeting the requirements of the type of work you are
applying for.
7
I have great experience in all areas of the care sector, working in general hospitals, mental
health hospitals and learning disabilities centers and also working with spinal injury patients on
a 1 on 1 basis. my key skills are that I am able to deliver high standards of 1 on 1 care to meet
the individual needs, I have an understanding of and able to demonstrate commitment to equal
opportunities and diversity, able to deal with aggressive people in a calm and professional
manner, Mva trained in control and restraint. I possess excellent written and verbal
communication skills. Experience in the implementation of care plans and risk assessments.
Helping patients to develop and maintain social self help. occupational and personal skills.
Patient money and confidentiality management. Awareness of patients right as well as their
cultural beliefs. The ability to record patients observations accurately and report all issues.
Encouraging patients to achieve highest possible quality of life. Responding well to emergency
situations. Being responsive and flexible to change. Experienced in complex care packages for
spinal and respiratory patients, trained in passive movements and physio to upper and lower
limbs, use of nebuliser, sutioning, yanker,tracheostomy care, fully trained in bowel regime, nippy
3 machines,omitting medications via peg feed or orally and preparing medications. Specialing
in hospitals, working in rehab and palliative care units. Ensuring patients dignity and
independence is always respected. Providing emotional support to patients and the team I work
with. Safeguarding patients property and belongings, building relationships and getting to know
patients needs and interests.
CURRENT VACCINATION STATUS
Record of immunity full written all can be obtained by blood test from gp / occupational health department.
CONFIRMATION OF CURRENT VACCINATION STATUS DATE OF ORIGINAL DATE OF BOOSTER
BCG SCAR IF SCAR IS NOT PRESENT EVIDENCE OF HEAF TEST
HEPATITIS B (Titre level > 100)
TITRE LEVEL
TESTED NEGATIVE TO HEPATITIS C
RUBELLA
VARICELLA
CHICKEN POX
MEASLES
MUMPS
TETANUS
POLIO
ANY ADDITIONAL VACCINATIONS
ADDITIONAL NOTES
VACCINATION STATUS DECLARATION
I UNDERSTAND THAT IS IT MY RESPONSIBILITY TO ENSURE ALL OF MY VACCINATIONS ARE KEPT UP TO DATE AND
APPROPRIATE FOR ANY PLACEMENTS I MAY UNDERTAKE.
CANDIDATE SIGNATURE: DATE:
EVIDENCE OF VACCINATIONS SEEN, CHECKED AND COPY FILED BY JANE LEWIS OCCUPATIONAL HEALTH REPRESENTATIVE.
SIGNED ON BEHALF OF JANE LEWIS: DATE
PLEASE STATE YOUR DOCTORS NAME, ADDRESS AND TELEPHONE NUMBER:
DOCTORS NAME
ADDRESS
TELEPHONE NUMBER
8
dr zahid cohen
westshore surgery,9 bryiau road, llandudno, conwy , ll30 2bl
01492 872915
1980 1981
REFERENCES
Please supply names, company addresses and telephone numbers of professional referees and state their job title. You must
include your most recent employer.
1
NAME
TITLE / QUAL
ADDRESS
POSTCODE
TELEPHONE NUMBER
EMAIL ADDRESS
2
NAME
TITLE / QUAL
ADDRESS
POSTCODE
TELEPHONE NUMBER
EMAIL ADDRESS
3
NAME
TITLE / QUAL
ADDRESS
POSTCODE
TELEPHONE NUMBER
EMAIL ADDRESS
ADDITIONAL REFEREE DETAILS:
9
kim mason
office manager
advantage health care group, suite 22,
durham tees valley business centre, orde
way.stockton on tees. teeside
ts19 0ga
01642 606805
kimmason@advantagehealthcare.co.uk
Samantha Chapman
H R department
The Priory Hospital
Middleton st George
Darlington
County Durham
DL2 1 TS
01325 333883
Jenny Jackson
Head Teacher
14 Hazel slade
Eaglescliffe
Stockton on Tees
TS16 9HS
07969246610
jenniajackson@hotmail.co.uk
10
HAVE YOU RECEIVED A POLICE CAUTION? YES NO
IF YES PLEASE GIVE DETAILS:
DATE:
NATURE OF INCIDENT:
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE? YES NO
IF YES PLEASE GIVE DETAILS:
DATE:
NATURE OF CONVICTION:
Please note that care standards regulations require Jane Lewis Health and Social Care to complete criminal record checks on all
applicants prior to placement.
DATA PROTECTIONS ACTS 1984 AND 1998
I am aware that personal data including where relevant, sensitive personal data relating to myself or from any other sources, will
be retained by Jane Lewis Health and Social Care indefnitely for purposes of providing me with temporary work and / or training. I
acknowledge that this may require my personal data to be forwarded to third parties or other departments within Jane Lewis Health
and Social Care.
DECLARATION
I declare that all the information I have given 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 the conditions of service as laid down in Jane Lewis
Health and Social Cares terms and conditions for temporary workers which I have been given at interview. I understand that my
registration is subject to three satisfactory references and a satisfactory result after checking with the criminal records bureau. I
undertake to inform you immediately I am engaged through your induction, including the offer of permanent employment following
temporary assignment.
I hereby confrm that my personal details may be held and disclosed by Jane Lewis Health and Social Care in the manner
contained herein.
APPLICANT SIGNATURE DATE
REHABILITATION OF OFFENDERS ACT 1974
Any work undertaken through Jane Lewis Health & Social Care is exempt from the Rehabilitation of Offenders Act 1974. This
means that you are not entitled to withhold information about convictions, prosecutions pending, cautions, or bindovers which for
other purposes may have expired under the Act. Your failure to declare any such information may result in instant dismissal from the
agency register.

All applicants that are offered assignments will be subject to an enhanced criminal record check by the Criminal Records Bureau
(CRB) before commencing assignments. This will include cautions, reprimands or fnal warnings as well as convictions.
The Protection of Children Act (PoCA) and Protection of Vulnerable Adults (PoVA) lists will also be checked for all applicants.
The outcome of these checks may or may not affect your application. For further details see the Company Policy on Offering
Assignments to Applicants with a Criminal Record.

48 HOUR OPT OUT AGREEMENT

1 DEFINITIONS
1.1 In this agreement the following defnitions apply: the company means Jane Lewis Health And Social Care.
Worker means
1. 2 References to the singular include the plural and references to the masculine include the feminine and vice versa.
1. 3 The headings contained in this agreement are for convenience only and do not affect their interpretation.
2 RESTRICTIONS
2.1 The working time regulations 1998 provide that the worker shall not work in excess of the working week unless he / she
agrees in writing that this limit should not apply.
3 CONSENT
3.1 The Worker hereby agrees that the working week limit shall not apply.
4 WITHDRAWAL OF CONSENT
4.1 The Worker may end this agreement by giving 14 days notice in writing.
4.2 For the avoidance of doubt, any notice bringing this agreement to an end shall not be construed as notice of termination by
the Worker.
4.3 Upon the expiry of the notice period set out in clause 4.1 The working week limit shall apply with immediate effect.
5 THE LAW
5.1 These terms are governed by the law of England and Wales and are subject to the jurisdiction of the courts of England
and Wales.

SIGNED DATE
11
INTERVIEW NOTES OFFICE USE ONLY
DRIVER NON DRIVER WILLING TO TRAVEL
PREVIOUS RELEVANT EXPERIENCE
LOOKING FOR
HAVE YOU OR ARE YOU CURRENTLY SUBJECT TO ANY DISCIPLINARIES (If yes please specify)
PERM RECRUITMENT ONLY
SALARY EXPECTATIONS
HAVE YOU ANY HOLIDAYS BOOKED?
WHAT IS YOUR NOTICE PERIOD?
12
HCA work in mental health, general hospitals, complex care packages, learning disabilities
centers, 1 to 1 work with supported living. Spinal injury/ respiratory .
None
No less than 7 per hour
none
none
INTERVIEW NOTES OFFICE USE ONLY
13
NEXT OF KIN
INFORMATION DOCUMENTS STATING THE NEXT OF KIN DETAILS, AS STIPULATED BY CQC AND CARE STANDARDS
INSPECTORATE FOR WALES.
FOR USE IN THE UNFORTUNATE EVENT OR ACCIDENT OR INJURY TO AID POLICE OR EMERGENCY SERVICES.
(Please note 2 x next of kin required)
1.
NAME OF NEXT OF KIN
RELATIONSHIP
CONTACT NUMBER
ADDRESS
2.
NAME OF NEXT OF KIN
RELATIONSHIP
CONTACT NUMBER
ADDRESS
SIGNATURE DATE
PAY DETAILS
YOU WILL BE PAID WEEKLY BY BACS AUTOMATIC TRANSFER DIRECTLY INTO YOUR BANK ACCOUNT AND RECEIVE A
DETAILED PAYSLIP ON A WEEKLY BASIS.
BANK / BUILDING SOCIETY SORT CODE:
ACCOUNT NUMBER:
BUILDING SOCIETY REFERENCE NUMBER:
ACCOUNT HOLDER NAME / S:
N.I. NUMBER:
BANK / BUILDING SOCIETY NAME:
BANK / BUILDING SOCIETY ADDRESS:
14
77/56/02
15724660
Mrs Sharron Lawrence
NM896473B
LLoyds TSB
5-6 King Street,
Penrith
Cumbria CA11 7AP
Eric Lawrence
Husband
07527176528
flat 2, LLwyn,
Gloddaeth Avenue, Llandudno, conwy.