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Forms

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Job Application form

Curriculum Vitae

DBS Application form

Occupational health medical questionnaire (New non-clinical form)

Occupational health medical questionnaire (new starter clinical form)

COVID-19/General Health Risk Assessment

Reference request form

Authorization Form - Reference Request Consent)

Working Time Regulations 1998 Opt-Out Consent Form

Upload Documents

Upload timesheet

Job Application form

Suite A, First Floor, 7-13, High Street, Romford. RM1 1JU. Tel: 01708201524

Email: info@www.systematiccare.co.uk. www.systematiccare.co.uk

Job Application form

Position apply for:

Prefix

First Name

Middle Name

Last Name

Sex:

Date of Birth

Nationality

National Insurance No

Home Telephone No.

Mobile Phone No.

Email address:

Current Address:

From:

To:

2. Residence History:

Please provide your full address details for the last five years (if the previous one is less than 5 years)

Previous address (1)

Previous address (2)

From:

To:

3. Education/Qualifications

School

Study dates

Qualification & Grade

Date obtained

4. Employment history Please include any previous experience (paid or unpaid), starting with the most recent first.

Current or most recent employer

Name of employer:

Previous address (1)

Position held:

Date started:

Leaving date:

Reason for leaving:

Brief description of duties:

Previous employer

Name of employer:

Address:

Position held:

Date started:

Leaving date:

Reason for leaving:

Brief description of duties:

5. Declaration

Statement to be signed by the applicant

Please complete the following declaration and sign it in the appropriate place below. If this declaration is not completed and signed, your application will not be considered.

I agree that Systematic Care can create and maintain computer and paper records of my personal data and that this will be processed and stored in accordance with the General Data Protection Regulation 25th May 2018.

I confirm that all the information given by me on this form is correct and accurate and I understand that if any of the information I have provided is later found to be false or misleading, any offer of training may be withdrawn or terminated.

Date:

Curriculum Vitae

Upload your Cv or Make a CV

Upload Your CV if it contain more details

No file chosen

Carrier statement

Personal statement

Personal profile

Name

Telephone number

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Personal profile

Date

Institution

Qualification obtained

Employment history

Organisation name

From

Position

Duties

Organisation name

From

Position

Duties

Reference

Available upon request.

DBS Application form

1. Personal information

Select *

First Name *

Middle Name 1

Middle Name 2

Middle Name 3

Last Name *

Date of birth *

Birth Nationality

Country of birth

County of birth

Town of birth

Gender

Applicant Email address:

Mothers Maiden Name:

National Insurance Number:

2. Personal History

Has your Nationality changed since birth?YesNo

If yes, New nationality:

Unspent Convictions: Do you have any convictions, cautions, reprimands or final warnings which would not be filtered in line with current guidance?YesNo

Has your surname changed since birth?YesNo

Have you ever been known by any other names?YesNo

3. Address information

Current Address

Current Address From:

If less than 5 years

Previous address

Previous Address From

4. ID

Please attach a copy

National Identity Card Available?YesNo

NIC Number:

NIC Country of Issue:

Passport Available?YesNo

Passport Number:

Passport Country of Issue:

Driving Licence Available?YesNo

Driving Licence Number:

Driving Licence Country of Issue:

5. DECLARATION

Name

Date

Occupational health medical questionnaire (New non-clinical form)

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

**(NEW STARTER NON-CLINICAL FORM)**

CONFIDENTIAL

Due to the nature of the role you have applied for we need to carry out an assessment of a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.

Before health clearance is given for employment you may be contacted by telephone from a clinician at Healthier Business UK Ltd, however you may also need to be seen by an occupational health advisor/specialist or physician, arrangements for face to face consultations will be arranged by your employer or agency. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Our aim is to promote and maintain the health of all individuals in the workplace: staff, service users and third parties. Your records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.

Personal Information

Title

Surname

First names

DOB

Home Tel:

Work Tel:

Mobile:

Home Address:

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

GP Address:

Job Role or Perspective Job Role:

Medical History

All staff groups complete this section

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?YesNo

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?YesNo

Are you having, or waiting for treatment (including medication) or investigations at present?YesNo

Do you think you may need any adjustments or assistance to help you to do the job?YesNo

Medical History (continued)

Have you suffered from any of the following?

methicillin resistant staphylococcus aureus (MRSA)YesNo

Date

clostridium difficile (C-Diff)YesNo

Date

If you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected.

Additional Information (If you have answered yes to any questions above please provide additional information below, including dates, treatment and details of condition)

Tuberculosis

Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2016)YesNo

If you answered YES to the above, please list all the countries that you have lived in/visited over the last year, including holidays and vacations. This MUST include duration of stay and dates or this form will be rejected

Have you had a BCG vaccination in relation to Tuberculosis?YesNo

If you answered yes, please state when;

Tuberculosis Continued

Do you have any of the following?

A cough which has lasted for more than 3 weeksYesNo

Unexplained weight lossYesNo

Unexplained feverYesNo

Have you had tuberculosis (TB) or been in recent contact with open TBYesNo

(If you have answered yes to any questions above please provide additional information below)

UK General Data Protection Regulation (UK GDPR)

All information supplied by you will be held in confidence by Healthier Business UK Ltd. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone – including Managers, Human Resources Advisors, GP’s, Specialists or third party’s – without your explicit consent. You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation. Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/ If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.uk

Consent

Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing. Further information regarding consent is available on the ‘Candidate Screening Leaflet’.

All staff groups complete this section

Do you consent to this questionnaire and your immunisation reports being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate?YesNo

Do you consent to our Occupational Health Advisors speaking with you regarding any declaration you may have made relating to your medical history?YesNo

Do you consent to our Occupational Health Advisors making recommendations to your employer/agency to assist with your ability to carry out your prospective role?YesNo

Declaration

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Name

Date

Save as Draft

Occupational health medical questionnaire (new starter clinical form)

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

(NEW STARTER CLINICAL FORM)

CONFIDENTIAL

Personal Information

Title

Surname

First names

DOB

Home Tel:

Work Tel:

Mobile:

Home Address:

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

GP Address:

Medical History

All staff groups complete this section

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?YesNo

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?YesNo

Are you having, or waiting for treatment (including medication) or investigations at present?YesNo

Do you think you may need any adjustments or assistance to help you to do the job?YesNo

Medical History (continued)

Have you suffered from any of the following?

methicillin resistant staphylococcus aureus (MRSA)YesNo

Date

clostridium difficile (C-Diff)YesNo

Date

If you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected.

Additional Information (If you have answered yes to any questions above please provide additional information below, including dates, treatment and details of condition)

Chicken Pox or Shingles </h3

Have you ever had chicken pox or shinglesYesNo

If Yes, Date

BBV (Blood Borne Virus)

Have you ever come into contact with any BBV’s? Including Needle Stick Injuries?YesNo

Tuberculosis

Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2016)

Have you lived outside the UK or had an extended holiday outside the UK in the last year?YesNo

Have you had a BCG vaccination in relation to Tuberculosis?YesNo

If you answered yes, please state when

Tuberculosis Continued

Do you have any of the following

A cough which has lasted for more than 3 weeksYesNo

Unexplained weight lossYesNo

Unexplained feverYesNo

Have you had tuberculosis (TB) or been in recent contact with open TBYesNo

Additional Information

(If you have answered yes to any questions above please provide additional information below)

Immunisation History

Have you had any of the following immunisations

Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)YesNo

PolioYesNo

Hepatitis B (If Yes is ticked please give dates below)YesNo

Course:	1		2		3
Boosters:	1		2		3

Proof of Immunity (Please send the following)
Varicella	You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity
Tuberculosis	We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)
Rubella, Measles & Mumps	Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles
Hepatitis B	You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above
Proof of Immunity (Please send the following) EPP Candidates Only
Hepatitis B Surface Antigen	Evidence of Hepatitis B Surface Antigen Test (Inc. ‘e’ antigen and DNA viral loads if applicable Report must be an identified validated sample. (IVS)
Hepatitis C	Evidence of a Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR if applicable) Reports must be an identified validated sample. (IVS)
HIV	Evidence of a HIV I and II antibody test (Inc. DNA viral loads if applicable) Reports must be an identified validated sample. (IVS)

Exposure Prone Procedures

Will your role involve Exposure Prone ProceduresYesNo

UK General Data Protection Regulation (UK GDPR)

Consent

All staff groups complete this section

Do you consent to this questionnaire and your immunisation reports being assessed by an Occupational Health Advisor for the purpose of providing a Fitness to Work Certificate?YesNo

Do you consent to our Occupational Health Advisors speaking with you regarding any declaration you may have made relating to your medical history?YesNo

Do you consent to our Occupational Health Advisors making recommendations to your employer/agency to assist with your ability to carry out your prospective role?YesNo

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

Name

Date

Save as Draft

COVID-19/General Health Risk Assessment

Candidate name

Personal Profile

GenderMaleFemaleOther (please state)

EthnicityWhiteMixedAsianBlack/AfricanCaribbeanBlack BritishOther ethnic groups

General health question

How would you rate your general Health?ExcellentGoodFairPoor

Are you feeling that you might be sick or have feelings of any medical concern?YesNo

If yes (please state)

Have you experienced any pain or discomfort within the last 7 daysYesNo

If yes, how would you describe itNoneMildSevere

Have you exercised in the last 7 daysYesNo

Do you have any conditions that require regular attentionYesNo

Are you taking any blood thinning medication?YesNo

COVID19 Vulnerability risk assessment

Do you have or suffer from any of the following

Chronic kidney diseaseYesNo

Liver diseaseYesNo

Severe Liver diseaseYesNo

HIV or AIDSYesNo

A condition affecting your immune systemYesNo

A weakened immune system due to a medical treatmentYesNo

Cancer (such as blood cancer like leukaemia or lymphoma)YesNo

Rheumatoid / Lupus / PsoriasisYesNo

If you have said yes to any of the above, a letter of suitability will be required from your GP.

Pregnancy

Are you pregnant?YesNo

If yes (estimated due date)

Covid19 assessment

Are you showing any of the following symptoms

Flulike symptoms/or sore throatYesNo

High temperatureYesNo

Continuous or dry coughYesNo

Shortness of BreathYesNo

HeadacheYesNo

Feeling tired or exhaustedYesNo

Loss of taste or smellYesNo

Have you visited any Civid-19 red list in the last 7 days?YesNo

Have you had contact with someone with a confirmed Covid19 within the last 7 daysYesNo

Do you have any confirmed underlying health conditions that might affect your work?YesNo

If yes, please discloseYesNo

HTML

Note

There is the possibility that you may be working with suspected or confirmed cases of Covid-19 patients within the NHS Hospital Trusts during your placement.

Declaration

I confirm that to the best of my knowledge, the above information is true and I thereby authorise Systematic Care to process my information based on the information I have provided.

I also confirm and take responsibility to notify the agency immediately if I develop any symptoms of Covid-19 and take action to Self-Isolate according to the government guidelines.

In any case of Covid19 symptom, I authorise Systematic care to cancel all my pre-booked shifts.

Date

Reference request form

Suite A, First Floor, 7-13, High Street, Romford. RM1 1JU. Tel: 01708201524

Email: info@www.systematiccare.co.uk. www.systematiccare.co.uk

Reference request form

Position apply for:

1. Personal details

Title:

Sex:

First Name

Middle Name

Last Name

2. Reference

Reference 1

Organisation name

Contact person

Position

Email Address

Telephone No:

Relationship

Reference 1

Organisation name

Contact person

Position

Email Address

Telephone No:

Relationship

3. Declaration

I hereby agree that Systematic Care Solutions Ltd. can contact the above people for reference.

I agree that Systematic Care can create and maintain computer and paper records of the references and that this will be processed and stored in accordance with the General Data Protection Regulation 25^th May 2018.

Date

Authorization Form - Reference Request Consent)

Authorization Form – Reference Request Consent)

Applicants Name:

Position Applied for:

Dear applicant,

In line with the compliance check, we will be requesting references from the details you have provided.

Please note your personal detail is protected under the new General Data Protection Regulation 2018 (GDPR).

We hereby request your consent to obtain a reference from the lists you have provided

Kindly sign this letter to signify consent.

Signature

Date

Kind regards

Ryan Dawkins

Compliance Manager

Working Time Regulations 1998 Opt-Out Consent Form

Working Time Regulations 1998

Out Consent Form

Employee’s Name:

The Working Time Regulations govern aspects of employment in relation to hours worked, break entitlements and days off. The provisions vary for Adult and Young (under 18 years old) workers. The law states that a legal maximum of 48 hours a week (on average) must not be exceeded without the consent of the adult worker. The purpose of this form is to allow you to give your consent to work in excess of 48 hours per week (on average) if you so wish.

Please read the form carefully and make sure you fully understand its purpose, do not hesitate to ask a member of the management team if you are unsure of anything.

The completion of this form is voluntary – the Company will not condone any management action amounting to pressure or compulsion.

Declaration

I confirm that I am aware of my entitlement to work a maximum 48-hour working week as specified in the Working Time Regulations 1998.

I do not wish to be restricted to working a maximum of 48 hours on average each week, until:

I confirm that I have made this decision independently and have not had any pressure put on me by my manager and/or the Company. I am aware that this form will be kept on my Employee File and reviewed on an annual basis.

Date

Upload Documents

Please upload your document

Proof of IDPassportBirth or adoption certificateBiometric cards/residence permitEU ID cards/Share codePlease choose 3

Upload file

Drag and Drop (or) Choose Files

Proof of addressDriving licenseUtility billsBank statementTelephone billsOthersPlease choose 3

Upload Proof of address

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Proof of NINI letterNi cardPayslip/P45/P60 etc.

Upload Payslip/P45/P60 etc.

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Deed poll (For name change)
Certificate of name change (For name change)
Others
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Selfie

Auto response email from email after the submission of the form.
All the forms to be connected and submitted at completion.

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Upload timesheet

Upload Timesheet

Name

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About Us

Address:

Suite A, First Floor 7-13, High Street
Romford, RM1 1JU

Email:

info@www.systematiccare.co.uk

Call:

+44 (0) 77 7500 0780

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Forms

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Job Application form

Curriculum Vitae

Personal profile

DBS Application form

1. Personal information

2. Personal History

3. Address information

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

(NEW STARTER NON-CLINICAL FORM)

OCCUPATIONAL HEALTH MEDICAL QUESTIONNAIRE

Personal Information

Medical History

Medical History (continued)

If you have indicated yes to any of the above questions you must provide further details in additional information section, failure to do so will result in the form being returned/rejected.

Chicken Pox or Shingles </h3

BBV (Blood Borne Virus)

Tuberculosis

Tuberculosis Continued

Immunisation History

Proof of Immunity (Please send the following)

Proof of Immunity (Please send the following) EPP Candidates Only

Exposure Prone Procedures

UK General Data Protection Regulation (UK GDPR)

Consent

All staff groups complete this section

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.

COVID-19/General Health Risk Assessment

Personal Profile

General health question

Reference request form

1. Personal details

Authorization Form – Reference Request Consent)

Working Time Regulations 1998

Out Consent Form

Declaration

Please upload your document

Upload Timesheet

About Us

Address:

Email:

Call:

Follow us on

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Our Services

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**(NEW STARTER NON-CLINICAL FORM)**