Medical Questionnaire

Your Title

Mr Mrs Miss Ms

Surname

Forename (s)

Date Of Birth

Address

Your Postcode

Phone Number

Email Address

NI Number

NMC Pin

Do you have your own transport ?

Yes No

Do you have immigration permission to work in the UK?

Yes No

In line with Home Office guidance on the prevention of illegal working we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by React Healthcare professionals for temporary work. Are you subject to any conditions relating to your permission to work in the UK? :

Yes No

If ‘yes’ please give details:

Criminal Convictions:

Do you have any unspent* criminal convictions?

Yes No

If ‘Yes’ please state convictions and dates

*Certain types of employment and professions are exempt from the Rehabilitation of Offenders Act 1974 and in those cases particularly where the employment is sought in relation to positions involving working with children or vulnerable adults, details for all criminal convictions must be given. The information given will be treated in the strictest of confidence and only taken into account where, in the reasonable opinion of React Healthcare Professionals, the offence is relevant to the post to which you are applying. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment if the offence is not declared but later comes to light.

Disclosure and Barring Service:

To ensure the safety of our clients, a DBS check must be completed for all positions. A criminal record will not necessarily be a bar to obtaining a position . If a check is returned and reveals any information, this will be discussed with the applicant and the manager will make a decision as to whether the offer of employment should be withdrawn. There is a £50 charge for carying out the DBS check and a further £13 annually to keep it up to date online should you wish to do so. Please tick yes if you are willing to undergo a full enhanceced DBS and accept these charges.

Yes No

Relevant Qualification / Authorisation:

Qualification

Name of Institution

Date Obtained

Professional Body

Membership Details

Name of Employer:

Address:

Postcode:

Position held:

Period from:

Reason for leaving:

Brief description of duties and responsibilities:

Position:

Name:

Relationship:

Organisation:

Address:

Postcode:

Telephone:

E-mail:

Are you willing for this referee to be approached?

Yes

Are you willing for this referee to be approached?

Yes

Signed by Temporary Worker

Date

Current DBS (this should be less than 6 months old). If you need a new DBS we can arrange this for you, however, this will be at a cost. Please bring this fee with you, when visiting our office, should you need to apply for a new DBS, Or if you have an online DBS put in your online reference number here:

Identity Acceptable photo identification documents include: • Passport • UK or EU National Identity Card • Full or provisional UK Photocard Driver's License (must include paper counterpart)

Photographs 2 Passport Photographs not older than 3 months.

We are able to accept a number of items of address-related evidence, including the following (please note that the document must bear your full name): • A utility bill which is less than 3-months old • A benefit statement which is less than 3-months old • A mortgage statement which is less than 12-months old • A UK Council Tax statement which is less than 12-months old • HM Revenue & Customs tax notification which is less than 12-months old • A credit card/bank/building society statement (we cannot accept statements printed on the internet) which is less than 3-months old

Right to Work British citizens must provide either a passport, or a full UK birth or adoption certificate in combination with an official document issued by a previous employer or government agency bearing the individual's full name and permanent national insurance number (such as a P45, P60, payslip or letter from the HMRC - please note that a National Insurance (NI) number card is not in itself acceptable for this purpose). For non-British citizens, the requirements are dependent on your nationality and current immigration status. For further guidance, please visit the UK Border Agency Web Site. The majority of non-British Citizens will be required to provide their Work Visa and details of any restrictions imposed.