Kerry Collins Application Form – Capital Outsourcing Group UK

Personal Details

Preferred Title, if any

First Name

Last Name

Address

Address Line 1

Town

Post Code

Email

Phone/Mobile

National Insurance Number:

Bank Details

Bank/Building Society Name

Branch Location

Account Holder’s Name

Roll Number

Account Number

Sort Code

Right to Work Information Request

Are you a British or Irish national? (You will be required to submit a passport or Birth Certificate & National Insurance Number)

Yes

No

if ‘No’ – You must complete a Right To Work check on the provision that you supply a Share Code via the following website https://www.gov.uk/prove-right-to-work/get-a-share-code-online. Alternatively we can do this on your behalf but we must have a your consent to do so. If you would like us to do this complete below:

I consent to ‘Kerry Collins Recruitment’ to obtain or support in gaining my ‘share code’ information at the start and if I have a break in my ‘assignment work’ using either my ‘Biometric Residence Permit’ or ‘Passport Number’.

Yes

No

MY ‘Biometric Residence Permit’ (BRP Card) – Unique permit number is

OR my ‘Share code’ is

OR my ‘Passport Number’ is

Do you have a student visa?

Yes

No

If ‘Yes’ – You will be required to comply with the following requirements below:

I confirm that I will not accept any work which takes me over 20 hours per week whether that be for Kerry Collins Recruitment or any other employer. I acknowledge that I must bring an enrolment letter from my place of study to include term dates.

Are you a ‘Sponsored Worker’?

Yes

No

If ‘Yes’ – I will not come in excess of 1 additional shift per week & I will inform you if I get any work elsewhere.

Yes

No

Are you currently working?

Yes

No

If ‘Yes’ state noticed period

Do you have your own PPE?

Yes

No

Emergency Details

Emergency contact name:

Relationship

Emergency contact number:

Emergency contact address:

Education or Professional Reference Details

Name of referee:

Capacity known:

Education

Professional

Email

From

To

Phone/Mobile

Course tutor name (If applicable):

In what capacity known to you? (Please note they must not be a relative & preferably be a person of standing in the community):

Employment History & Referencing Request Section

Have you worked for the company before?

Yes

No

If ‘Yes’ please provide details and dates below:

Present/last employer:

Job Title

Agency Work:

Yes

No

From:

To:

Address

Town/City

Post Code

Manager Name:

Email

Phone no:

Pay rate: £

Responsibilities/duties:

Reason for leaving:

Is there a gap of longer than 1 month between positions?

Yes

No

If yes, please give details:

2nd previous employer:

Job Title

Agency Work:

Yes

No

From:

To:

Address

Town/City

Post Code

Manager Name:

Email

Phone no:

Pay rate:

Responsibilities/duties:

Reason for leaving:

Is there a gap of longer than 1 month between positions?

Yes

No

If yes, please give details:

3rd previous employer:

Job Title

Agency Work:

Yes

No

From:

To:

Address

Town/City

Post Code

Manager Name:

Email

Phone no:

Pay rate:

Responsibilities/duties:

Reason for leaving:

Is there a gap of longer than 1 month between positions?

Yes

No

If yes, please give details:

Workers skills checklist

Care assistant

Yes

No

Support Worker

Yes

No

What kind of ‘service user’ have you worked with? (Give the day to day responsibilities)

Which specialist areas? (Mental health/learning disabilities/ autistic disorders/Asperger’s)

Have you worked ‘one to one’/key worked?

What settings have worked in? Please tick appropriate box:

Experience (Please indicate)

Supported living

Yes

No

Assisted living

Yes

No

Care home

Yes

No

Residential home

Yes

No

Hospital/clinical setting

Yes

No

Domiciliary care

Yes

No

Assisting/enabling a patient with medication

Yes

No

Bed making

Yes

No

Care of patients: hair/fingernails /bladder/bowls/eyes/pressure areas

Yes

No

Changing a bed/draw sheet with patient in/on it

Yes

No

Emptying a catheter bag

Yes

No

Experience in hospice/palliative care

Yes

No

Obtaining simple specimens

Yes

No

Preparation of meals

Yes

No

Recording pulse

Yes

No

Recording instructions from gp/district nurse

Yes

No

Weight charts reading/understanding/documenting

Yes

No

Moving & handling patients

Yes

No

Peg feeding

Yes

No

Simple dressing procedures

Yes

No

Use of bed pan/commodes

Yes

No

Reporting to the person in charge of care

Yes

No

Shopping

Yes

No

Temperature: taking/understanding

Yes

No

Use of both acids

Yes

No

Use of hoists

Yes

No

Washing/ironing of personal laundry

Yes

No

Bathing/washing patients

Yes

No

Blood pressure taking/recording understanding

Yes

No

Changing of colostomy bag

Yes

No

Detailing with relatives of ill and terminally ill patients

Yes

No

Experience of dementia

Yes

No

Feeding & assisting a patient who has difficulty or is unable to feed themselves

Yes

No

Recording of fluid balance

Yes

No

Shaving patients

Yes

No

Report writing/giving

Yes

No

Urine testing

Yes

No

Use of walking aid/wheelchairs

Yes

No

4.0 Declarations

If you have a disability do you have any needs in terms of reasonable adjustments in order to access this recruitment progress. e.g. to attend, or to take any aptitude tests etc? Please specify:

Yes

No

If a permanent role or temporary assignment requires an intrinsic function to be completed, we will discuss your ability to undertake this function after you have been successfully registered with the agency.

Working for our group of companies amendment

In order to meet our clients’ requirements and to ensure you have a consistent flow of work, from time to time we may ask you to undertake Assignments for other companies in our Group, not just for Kerry Collins Recruitment.

If you do not wish us to consider you for other work that we get through our Group of companies, then please tick the box.

Disclosure and Barring Service

Do you have a ‘current’ DBS? (Within the last 12 months)

Yes

No

Is your current DBS on the update service?

Yes

No

Do you consent to Kerry Collins completing 3 monthly ‘update service check’?

Yes

No

Do you consent to Kerry Collins retaining your DBS on file?

Yes

No

If no subscription service please give the 12 digit number:

If yes, please give details:

I do not require Kerry Collins to process the DBS on my behalf as I have a full DBS certificate and details are on the update service.

If you have NO DBS please complete the DBS section below 4.4

4.4 Processing an enhanced DBS including children & Adults Barred list

You are required to have an enhanced DBS including a check on the children & Adults Barred List. You are able to provide the information via the Updated service or via a third party. If you wish us to process the DBS on your behalf the cost for this is £87.50 which you are required to pay in advance directly into the Kerry Collins Bank Account:

Please select one of the boxes below:

I do require KC to process the DBS on my behalf and agree to pay £87.50 in lieu of my DBS.

I do require KC to process the DBS on my behalf and agree to pay £50 upfront and have a £37.50 wage deduction after my first shirt in lieu of my DBS.

Please confirm we are using your bank details on page 1 of application form – by indicating your sort code

Signature

Choose File

Date

Personal Details

(in full as written on your right to work document)

Mother’s maiden name:

Have you ever been known as another name?

Yes

No

If so please give the name change and dates:

Birth Details

Town of birth:

Registration District:

Passport number:

Country of birth

Driving licence number:

Additional information

Contact Information

(in order to process your DBS we need a minimum of five years complete address history)

Current Address:

Door number or name:

Address Line 2

Town/City

Post Code

Date you moved in:

1. Previous Address:

Door number or name:

Address Line 2

Town/City

Post Code

Date you moved in:

2. Previous Address:

Door number or name:

Address Line 2

Town/City

Post Code

Date you moved in:

Temporary workers signature:

Choose File

Date:

Consultant/account manager signature applying for DBS:

Choose File

Date:

Unspent Criminal Convictions:

Certain types of employment and professions are exempt from the Rehabilitation of Offenders Act 1974 and in those cases, particularly where the work is sought in relation to position involving work 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 Kerry Collins Recruitment, 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 to terminate an assignment if the offence is not declared but later comes to light.

Do you have any unspent * criminal convictions?

Yes

No

Do you have any unspent* conditional cautions or convictions under the rehabilitation of offenders act 1974?

Yes

No

Do you have any adult cautions (simple or conditional) or spent convictions that are not protected as defined by the Rehabilitation of offenders act 1974 (exceptions) order 1975 (amendment) (England and Wales) order 2020?

Yes

No

The amendments to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (2013 and 2020) provides that when applying for certain jobs and activities, certain convictions and cautions are considered ‘protected’. This means that they do not need to be disclosed to employers, and if they are disclosed, employers cannot take them into account.

Guidance about whether a conviction or caution should be disclosed can be found on the Ministry of Justice website. If you have declared any convictions you are welcome to provide us with any additional information about the circumstances of the offence, any work (paid or voluntary) or training that you have undertaken since, change in your circumstances etc.

We will seek to put forward/supply the best possible candidates to our clients. Having criminal conviction will not necessarily exclude you from the process.

4.6 Overseas self-declaration:

Have you spent 6 months or more overseas in the last 5 years? If Yes answer the below (note, we may conduct an overseas police check on you)

Yes

No

Can you supply an Overseas Police Check/Good Character Reference?

Yes

No

Have you been convicted of any crimes overseas? If Yes, answer below.

Yes

No

Conviction Date

Name of Conviction

Police Action Taken

Sentence

Other Informatioin

Conviction Date

Name of Conviction

Police Action Taken

Sentence

Other Informatioin

Conviction Date

Name of Conviction

Police Action Taken

Sentence

Other Informatioin

4.7 APPLICATION FORM DECLARATION:

I confirm that the information disclosed in this application form is correct and the information regarding employment can be verified by previous employers and/or professional bodies or character referees specified. I also undertake the responsibility to inform Kerry Collins Recruitment if any of my personal details change. I confirm that I have been informed about the Worker Handbook, have had access to Branch / site copy and know that I can view this at any time via the company website. It is my responsibility to familiarise myself with the Handbooks contents.

I understand that I must inform Kerry Collins Recruitment of any changes to any of my personal information that may affect my ability/eligibility to undertake assignments. I declare that I have no unspent convictions and there are not prosecutions pending at this time. I also undertake to inform Kerry Collins Recruitment of a prosecution that occurs whilst my details are held by Kerry Collins Recruitment.

Please list any pre-booked holidays:

DATA PROTECTION CONSENT:

Under data protection rules we must obtain your express consent to us processing your personal data (‘Personal data’ means information relating to You as an individual which allows you to be identified from it) for specific purposes which we must inform you of.

We have provided you with our Data Protection Privacy Notice (available via our website on the following link Data Protection Privacy Notice Recruitment and Data Protection Privacy Notice Engagement) which sets out the following for your reference: what information we will collect, how we collect it, why we collect it and how we use it, how we may share the information, where information may be held, how long we retain your information, your rights to access and correct your information, your right to ask for it to be erased and how we keep your information secure.

Having provided you with this information, please confirm by ticking the appropriate box whether you consent to us holding and processing your data:

I consent to you holding my data and processing it for the purposes stated in your Data Protection Privacy Notice which I have read and understood which includes my consent to 3rd Party auditors.
I consent to you sharing ‘special’ category specific data which includes the ‘unspent criminal convictions section’, a conviction, investigatory, regulatory or criminal proceedings, ‘copies of DBS certificates’ etc. I have read and understood the statement which includes my consent to 3rd.
I do not consent to you holding my data and processing it for the purposes stated in your Data Protection Privacy Notice which I have read and understood.
Please note that you may at any time withdraw your consent by emailing hr@headofficeaccounts.com

Signature:

Choose File

Print name:

Date:

Section 2:

to be completed if applicable to job applied for and / or after a job offer has been confirmed

1.0 Temporary workers health and safety declarations:

All employers must have a Health & Safety Policy stating who is responsible for Health & Safety and a Health & Safety arrangement in place. All temporary Workers have a duty under the Health & Safety Act to take reasonable care to safeguard their own safety and anyone who may be affected by their work activities and actions and also to co-operate with the Organisation and others in meeting statutory regulations. It is your responsibility to familiarise yourself with the Organisations policy, particularly the procedures for fire, first aid and accidents upon arrival at the Organisations premises. The Act also requires Temporary Workers not to interfere with or misuse anything provided to protect their health, safety or welfare in compliance with the Act.

In order to safeguard you at work should an emergency happen please answer the following questions:

Do you have any special requirements relating to any medical condition(s) that employers should be made aware in case of emergency?

Yes

No

Do you have any allergies?

Yes

No

Many of the roles that Kerry Collins Recruitment offer include physically demanding activity and/or driving vehicles or operating machinery and can be in a variety of working environments form industrial to medical. If you have been offered one of these roles please complete the questions below:

Are you suffering from or have you ever suffered from:

Any conditions relating to your heart or circulations?

Yes

No

Any respiratory problems?

Yes

No

Any eyesight condition that cannot be corrected by wearing glasses or contact lenses?

Yes

No

Any ongoing bone, muscle or joint problems?

Yes

No

If you have indicated yes to any of the points above, please detail any further information that you feel is relevant:

2.0 Health self-assessment declaration for night workers:

In compliance with the Working Time Regulations, the purpose of this declaration is to assess your fitness to carry our night work whilst on an assignment with Kerry Collins Recruitment Ltd. Whilst, there is no difference in the physical demands of night work compared to daytime work, the human body is naturally programmed to sleep at night. The disruption to this sleep pattern can aggravate certain medical conditions, albeit often temporarily. Additionally the reduced access to services and facilities that may be apparent both inside and outside of the workplace may also have an effect.

PLEASE ANSWER THE QUESTIONS BELOW:

However, should your answers raise concerns about your fitness for night work, then unfortunately you may not be assigned to organisation requiring night working, unless you are able to provide proof that you are indeed physically able to do so having been assess by a qualities healthcare or medical professional.

Do you have any health concerns that you feel may prevent you from working at night?

Yes

No

If yes, are these based on:

A. The requirement to take medication(Tablets, injections etc.) on a strict timetable

Yes

No

B. Heart or circulatory problems that could be aggravated by additional stress/stamina that night work may require.

Yes

No

C. Stomach, intestinal or other disorders where the regularity/timing of meals is important.

Yes

No

D. Chronic chest or respiratory disorders those night time symptoms are significantly worse than in the daytime.

Yes

No

E. Any other health related reason.

Yes

No

F. Are You a New or Expectant Mother

Yes

No

G. Are you under the age of 18

Yes

No

If you have indicated yes to any of the points above, please detail any further information that you feel is relevant:

I confirm that above is correct to the best of my knowledge

Signature:

Choose File

Print Name:

Date:

3.0 Influenza declaration

Please complete section 1 or section 2

1. I confirm that I have had my annual influenza vaccination

Please give the date of the vaccination

2. I confirm that I have not had my annual influenza vaccination

Signature:

Choose File

4.0 Vaccinations

(applicable to health workers only)

Hep b (Full course and blood tests)

Yes

No

Hep b booster

Yes

No

TB

Yes

No

TB scar check

Yes

No

Varicella (2 vaccinations)

Yes

No

MMR (2 vaccinations)

Yes

No

Blood test (to check current immunity)

Yes

No

If you have indicated yes to any of the points above, please detail any further information that you feel is relevant:

I confirm that above is correct to the best of my knowledge

Signature:

Choose File

Print Name:

Date:

Healthcare Application Form

Personal Details

Bank Details

Right to Work Information Request

Emergency Details

Education or Professional Reference Details

Employment History & Referencing Request Section

Workers skills checklist

What settings have worked in? Please tick appropriate box:

Experience (Please indicate)

4.0 Declarations

Working for our group of companies amendment

Disclosure and Barring Service

4.4 Processing an enhanced DBS including children & Adults Barred list

Personal Details

Birth Details

Contact Information

Unspent Criminal Convictions:

4.6 Overseas self-declaration:

4.7 APPLICATION FORM DECLARATION:

DATA PROTECTION CONSENT:

Section 2:

2.0 Health self-assessment declaration for night workers:

3.0 Influenza declaration

4.0 Vaccinations