Personnel Registration form

Hidden

Department

Place of Interview(Required)

Name of Interviewer

First Last

Interviewer Email Address

Date

Personal Details

Applicant Name(Required)

First Middle Last

Applicant Maiden Name

First Middle Last

Date of Birth(Required)

Marital Status(Required)

Single

Married

Divorced

Widowed

Do you hold a driving license valid for use within the UK?(Required)

Yes

National Insurance Number(Required)

I confirm that I have received and read the Key Information Document(Required)

Yes

I confirm that Total Assist Group have my permission to request and obtain copies of payslips from my employer/ umbrella company/ personal service company and have my permission to make this available to third parties(Required)

I Agree

I understand that any personal data held by Total Assist is liable to be inspected by the Care Standards Commission and/or any other authorised 3rd party including for any audits. Please select below if you do/do not agree for your personal data to be made available to any 3rd party without direct supervision from a member of staff from Total Assist or myself being present.(Required)

I Agree

I agree to give Total Assist Recruitment permission carry out online DBS checks both annually or as required.(Required)

I Agree

I have received, read and understood, and agree to abide by the contents of the Total Assist Recruitment Locums Handbook. I have received, read and understood the terms and conditions of engagement of Total Assist. I understand that my ID Badge must be visible at all times during a Total Assist Group Recruitment assignment and that if I leave Total Assist that I must Hand back my identity badge. All patient records should be kept confidential in line with the Data Protection Act 2018/GDPR. I also agree not to disclose to any confidential information to any 3rd Party without prior written consent(Required)

I confirm

I confirm that Total Assist Group have my permission to generate and complete my share code check for my right to work(Required)

I confirm

If you take on a role through Total Assist, will you be working another role within the NHS at the same time?(Required)

Yes

Are you currently claiming any of the below statutory leave in another role?(Required)

Maternity/Paternity/Adoption/Shared parental Leave

Sick Leave (Either long or short term)

Extended leave for caring/childcare

Study Leave

Other

None of the above

Next of Kin

Name(Required)

First Last

Relationship(Required)

Contact Number(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Nationality

Do you hold a British Passport?(Required)

Yes

Evidence of all passports and visas are required. Please enclose photocopies with this application form and make sure you bring the originals to your interview. To work in the NHS you will be expected to communicate proficiently in English and this will be assessed at your interview.

Passport Number(Required)

Passport Expiry Date(Required)

Working Holiday Visa

Yes

Working Holiday Visa Expiry Date(Required)

UK Residency Visa

Yes

UK Residency Visa Expiry Date(Required)

Student Visa

Yes

Student Visa Expiry Date(Required)

Working Permit

Yes

Working Permit Expiry Date(Required)

Should you hold any other Visa or residency permit, please provide the information below:

Current Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Mobile Phone(Required)

Home Phone

Work Phone

Applicant Email Address(Required)

Availability for Work

Availability to start work(Required)

Availability over the next 12 months(Required)

Which part of the UK do you prefer to work in?

Declarations

In line with the Government legislation under the terms of the “Working Time Regulations” we recommend that your working hours should not exceed 48 hours per week (averaged over a 17 week period.)

Should you wish to waive this right, please confirm my ticking below:(Required)

I confirm that I wish to work more than 48 hours per week

I understand that information give on this form will be stored and handled by Total Assist Healthcare Group in accordance with the Data Protection Act 1988, however, I agree that this information may be made available for audit by the relevant Government organisations e.g. CCS / CPP Framework.
Data Protection Act 1998 / The General Data Protection Regulations 2018
In relation to the Data Protection Act 1998 / The General Data Protection Regulations 2018, you agree to the processing of personal data for the purposes of the recruitment process as well as for future potential employment arrangements for the purposes of calculating your remuneration and maintaining records on attendance, health, discipline and grievances such as are necessary for the performance of your contract. Our full GDPR Privacy Notice can be found on our website www.totalassist.co.uk/gdpr. For further information, please see the Information Commissioner's website ww.dataprotection.gov.uk, from which the above guidance is reproduced.
I acknowledge that I have been given a copy of the terms and conditions of service issued by Total Assist Healthcare Group, which is mine to keep and further more that I have read those terms and conditions and agree to abide by them. I am not aware of any condition, medical or otherwise which would affect or limit my employment or performance, other than those declared in my Pre-employment Health Questionnaire From and I am fit for work.
I authorise Total Assist Healthcare Group to disclose any convictions to any potential employers in accordance with the DBS Code of Practice and the Rehabilitation of Offenders. I declare that the details given by me on this application form are correct to the best of my knowledge and belief. I understand that if I have given any information which is false, or I withhold any relevant information, this may lead to my application being rejected, or if already appointed, to my dismissal, as well as a claim for recovery of any payments I have received, together with a claim for loss of profit to Total Assist Healthcare Group.
I also give Total Assist Group Permission to apply and to check my DBS certificate on the UK DBS update service annually.
I give Total Assist Group Permission if required to conduct any relevant right to work checks Via the Government websites.

Signature(Required)

Influenza Vaccine History

Have you received the influenza vaccine?(Required)

Yes

Date of influenza vaccine(Required)

Would you consider having the influenza vaccine, if offered to you?(Required)

Yes

Have you received both doses of either a Pfizer BioNTech or Oxford/AstraZeneca COVID vaccine?

Yes

If Yes please attach your COVID vaccine passport(Required)

Drop files here or

Max. file size: 48 MB.

Employment History

Can you please provide details in the boxes below of your last 3 years employment (most recent first). If there are any gaps of 3 month or more it is important that you explain the reason why in the box below.

Employer name (1)

Position Held (Employer 1)

Location (Employer 1)

Tel Number (Employer 1)

Date From (Employer 1)

Date To (Employer 1)

Employer name (2)

Position Held (Employer 2)

Location (Employer 2)

Tel Number (Employer 2)

Date From (Employer 2)

Date To (Employer 2)

Employer name (3)

Position Held (Employer 3)

Location (Employer 3)

Tel Number (Employer 3)

Date From (Employer 3)

Date To (Employer 3)

Professional Referees

You are required to supply at least two work related professional referees. The 2 referees provided must be within the last 12 months and be concurrent. If you have worked at the same Hospital for the last 12 months then we require 2 referees from that Hospital. Both referees must be a Consultant or Clinical Director. (We have allocated space for additional referees to be included, should you wish to provide more than two referees you must follow the above same principle.)

Name of First Referee

First Last

Email of First Referee

Address of First Referee

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone of First Referee

Known Capacity of First Referee

Name of Second Referee

First Last

Email of Second Referee

Address of Second Referee

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone of Second Referee

Known Capacity of Second Referee

Signature to apply for references(Required)

Please sign to allow us to contact your referees immediately.

I give Total Assist Recruitment permission to forward my CV to agreed clients for the purpose of obtaining employment.(Required)

I agree

Equal Opportunities Policy

As an Equal Opportunities employer the organisation welcomes applications from suitably qualified persons from all sections of the community. The organisation is committed to achieving a working environment which provides equality of opportunity and freedom from discrimination on the grounds of race, nationality, religion, gender, class, family responsibilities, marital status, sexual orientation, age, disability or special need. The Directors believe in best practice in Equal Opportunities on the grounds of morality, good business practice and awareness that certain kinds of discrimination are unlawful. This is a key employment value to which all employees and candidates are expected to give their support. To ensure that the policy is effective it is essential that detailed monitoring is carried out, which necessitates the collection of information. The information on this form will be kept confidential and will not be used by those involved in the selection procedure and is for statistical purposes only and will not form part of any job application. *

Please Select(Required)

Please Specify

Criminal Record Declaration(Required)

Yes

Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, applicants for locum medical posts are not entitled to withhold information about convictions which for other purpose are ‘spent’. Therefore you are to inform Total Assist Healthcare Group in writing of any convictions for criminal offences past in the future.

Please Provide Details(Required)

Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?(Required)

Yes

If you haven’t completed a DBS (previously DBS) check through Total Assist Recruitment Ltd, or if the last one was completed over 12 months ago, you are required to complete the attached DBS form provided so that we may undertake an Enhanced DBS check on your behalf. You will not be place in employment without having completed a current DBS check. Please ensure you enclose all original documentation (e.g. passport) as photocopies will not be accepted and your form will be returned to you.

Disclosure Number

Date of Disclosure

Applicants Name(Required)

First Middle Last

Applicant's Signature(Required)

Interviewer's Name

First Last

Interviewer's Signature

For Office Purposes Only

THE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.

Did the candidate have a good command of the English language?

Yes

Was the candidate pleasant and polite?

Yes

Was the candidate courteous and helpful?

Yes

Are you happy to offer this candidate work on the basis of this interview?

Yes