Application form

All of the data collected in this form is necessary to process your application, for the position that you are applying for. Hive Healthcare shall treat all personal information with the utmost confidentiality in line with the standards of data protection required by the EU General Data Protection Regulation (GDPR). A copy of our Privacy Policy can be found on our webiste and in our staff handbook.

I give Hive Healthcare permission to use, process and store my personal information in relation to the position I am applying for *

Yes

No

Personal Information

First Name *

Last Name *

Address *

Address

City *

County *

Post Code *

Phone *

Email Address *

Date of Birth *

National Insurance Number *

Are you authorised to work in the UK? *

Yes

No

Visa Expiry date

Position Applying For *

NMC Pin

Union/ Indemnity insurance number *

Expiry date

Next of Kin name *

Relationship *

Contact number *

Employment History

Please complete your full employment history since leaving school, explaining any gaps.

Employer 1 - Current or most recent

Company Name *

Address

Start Date * +

End Date +

Position

Reason for Leaving

Employer 2

Company Name

Address

Start Date +

End Date +

Position

Reason for leaving

Employer 3

Company Name

Address

Start Date +

End Date +

Position

Reason for Leaving

Additional employment history

Please explain any gaps in employment

Interview Questions

What is the importance of proper record keeping and documentation? *

If you discovered a safeguarding concern, what process would you take? *

If you realise you made a medication error, what steps would you take? *

References

Please note we cannot accept family members as referees.

Reference 1- Current or most recent employer

Name *

Position *

Company

Email Address *

Phone

How long have they worked with you?

Reference 2

Name *

Position *

Company

Email Address *

Phone

How long have they worked with you?

Working Time Regulations - 48 hour opt out

Regulation 5 of the Working Time Regulations 1998 require that a worker’s average time must not exceed 48 hours per week unless the worker agrees in writing to exceed this limit. If you are prepared to work more than 48 hours per week, please acknowledge this by ticking below to enable us to pay you for any hours worked over the limit. This agreement shall apply from today’s date and can be terminated by giving 7 day’s notice.

I agree that the limit of working 48 hours as Specified in Regulation 4 (1) of the Working Time Regulations 1998 shall not apply to me-

Yes

No

I will, however, ensure that I will work no more than 6 days in a 7 day period, or 12 days in a 14 day period, and take at least 11 consecutive hours break in each 24 hour period

Yes

No

Disability Declaration

Do you have any disability?

Yes

No

If yes, please describe

Criminal Records and Investigations

Due to the nature of Hive Healthcare, this position is exempt from the provisions of Section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption Order 1975). You are therefore, not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act. Failure to disclose any convictions or investigation will result in immediate termination of registration.
Any information given will be completely confidential and will be considered only in relation to the position in which the application applies. A copy of our written policies is available upon request. A criminal record will not necessarily be a bar to obtaining a position.

Have you ever been convicted, cautioned or received a reprimand for a criminal offence? *

Yes

No

If yes , please provide us with further details. Every conviction, caution or reprimand will require a written statement and how it does not affect your suitability for the position you are applying for.

Do you have any spent or unspent criminal convictions? *

Yes

No

If yes , please provide us with further details. Every conviction, caution or reprimand will require a written statement and how it does not affect your suitability for the position you are applying for.

Are you aware of, or are you currently involved in any proceedings that may lead to a criminal conviction? *

Yes

No

If yes , please provide us with further details.

Are you currently under any disciplinary action or investigation due to alleged misconduct? *

Yes

No

If yes , please provide us with further details.

Failure to disclose any convictions or investigations will result in immediate termination of registration. Any information given will be completely confidential and will be considered only in relation to position in which the application applies.

Fitness to Practice Declaration

Have you ever been/are you currently subject to a professional conduct/competence enquiry? *

Yes

No

If yes, please provide further details

Declarations

I declare that the information provided within this form is true, correct and not presented to mislead. I will inform Hive Healthcare immediately if there are any changes to the details contained within the application form *

Yes

No

I declare that I am in good physical and mental health and accept responsibility for maintaining my fitness to practice. *

Yes

No

I declare that I will inform you immediately if I am- convicted of a criminal offence, cautioned, placed under investigation, the subject of any ‘Fitness to practice’ proceedings or suspended from duty by any other employer/agency. *

Yes

No

I understand and agree for Hive Healthcare to obtain verification of the information provided through an Access NI check and references as part of my registration. *

Yes

No

I agree for the details contained in this application form and associated documents to be shared with and confidentially retained by Hive Healthcare and any other approved companies such as the RQIA and Government departments. *

Yes

No

Is there any reason why you cannot work in regulated activity? *

Yes

No

If yes, please provide more details.

I will comply with the latest department of Health guidelines, NHS regulations and Hive Healthcare policies. *

Yes

No

Signature *

clear

Date +