Please select the Nursing Specialities of which you have significant
post training experience. (Medical, Learning Disability, ITU
Intensive Care Unit, In charge Duties, Hospitals, Hospices, Home Care,
dependency Unit, Health Visitors, Haematology, Gynaecology, GU Med,
District Nursing, Family planning, Urology, Mental Health, Stoma Care,
Theatre, Renal, Residential Homes, Paediatric, Oncology, Midwifery,
Homes, Out patients, CSSD, Neonatal, Care of the elderly, Practice
Nurse, Recovery, Prisons,
Surgical, Occupational Health, Mental health, Orthopaedics, PICU, SCBU,
A & E,
Cardiac, ODP /ODA, Neurology, Radiology, Scrub, Theatre, Day Surgery,
Care Unit, Day Care Centre, School Nurse, Ante Natal, Cardiothoracic,
Chemotherapy, Anaesthetic Trained, Medical Assess unit)
Please remember you will be held accountable
for any missing information
Please give details of your past 5 years of continuos work history giving
reason(s) for any breaks in employment
Have you been vaccinated or tested against the following? (Hepatitis
B, HIV, Tetanus, Poliomyelitis, Typhoid, Rubella (German Measles),
Tuberculosis and BCG, Hepatitis B Antibodies, Mantoux - tine or Heaf,
Varicella, Last X-ray, Others (Specify) If yes, fill below).
Do you or have you at anytime suffered from any of the following?
(Skin complaints- dermatitis, Psoriasis, Eczema Diabetes or glandular
complaints, Headaches or Migraine, Hypertension/ heart problems/ similar
illness, Back pains / Back injury or problems, Jaundice / Hepatitis,
Epilepsy or fainting attacks, Pleurisy /Bronchitis / Pneumonia, Asthma,
Infections - ear / sore throat, Psychiatric illness – Mental disorder/
depression etc )
If you do not have vaccination information, please provide details
of where we can request them below
I certify the above information is correct and hereby give permission to
Solutions Healthcare Services to request a further report
from my GP/ Occupational Health/ Hospital for clarifaction if required and
for my health report.
What kind of Nursing Work are you
interested in? (Fill yes, in all that apply)
Please indicate when you would like to
Because of the nature of the work for which you are applying, this post is
from the provisions of section 4.2 Rehabilitation of Offenders Act 1974
(Exemption Order 1975). Applicants are therefore, entitled to withhold
information about convictions, which for other purposes are 'spent' under
provision of the Act in the event of employment, any failure to disclose
convictions could result in dismissal or disciplinary action. Information
provided will be kept confidential and use in relationship to the post
Have you ever been convicted of a criminal offence?
Do you have any spent or unspent convictions?
Have you instigated an enhanced disclosure within the last six years?
I CONSENT TO MY NURSING AGENCY CHECKING THE DETAILS I HAVE PROVIDED AGAINST
VARIOUS DATA SOURCES IN ORDER TO VERIFY MY IDENTITY AND PROCESS THIS
APPLICATION.. THESE DETAILS MAYBE USE TO ASSIST OTHER ORGANISATION SUCH AS
NMC IN IDENTITY PURPOSES.
Please give the names and addresses of two of most recent employers with
work addresses who is able to
comment on your work ability and experience. starting with your present to
most recent employer if possible.
I authorise Solutions Healthcare to pay my weekly wages into
the above bank account and I will notify My Nursing Agency if changes occur
to my details
I have read and understood the Working Time Regulations and I hereby consent
the working time limit shall not apply to my assignments
I declare that the information provided on this application is true to the
best of my knowledge.
I have read the terms and condition of engagement and agree to comply with
the current Health and Safety at Work Act.
I understand that my appointment is subject to the receipt of two
satisfactory references and it subject to Enhanced CRB Disclosure.
My Nursing Agency is free to make any other enquiries thy may find necessary
relating to my application.
I agree to respect the confidentiality of patients and clients and any other
information I may have access to.