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020 3489 3363- 24/7 Booking
020 8004 3561- 24/7 Booking
020 3747 4717‬ (Office hours)
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Application Form

HomeApplication Form

Application Form

Step 1 of 20

5%
  • Candidate document checklist

  • Completed application form

  • Right to work

    • UK passport

    • Visa

    • Student letter

    • Letter from home office

    • Residence permit

    National Insurance

    • NI card or Letter from DWP

    • P45/ P60

    Proof of Address in UK (x2) (within 3 months)

    • Bank/credit card statement, Utility bills, Council tax, Driving licence or P45/P60

    Evidence of Current Indemnity Insurance

    Current CV (Word document)

    Certificate of incorporation and Business Bank Account (For Limited Companies only)

    Immunisation History

    • MMR – Measles, Mumps and Rubella

    • Hepatitis B

    • HIV & Hepatitis C for EPP (Exposure Prone Procedures) environment

    • Varicella

    • Proof of BCG scar check

    Passport photograph (x2)

    Annual Mandatory Training (Training should be Aligned with the “skills for Health”

    • Basic life support (BLS) & Moving and Handling (Must be Practical)

    • Complaints Handling, Conflict Resolution, Health & Safety, Fire safety, Food hygiene, Infection and control (including COSHH & RIDDOR), Preventing Radicalisation, Safeguarding of Vulnerable adults & Children (SOCA & SOVA), Information Governance & Data Protection

    • ITP, TCG & Paediatric Resuscitation Trainings(Midwives)

    • Immediate Life Support (ILS) – for Nurses

    • Prevention Management of violence & Aggression (PMVA) or Management of Actual or Potential Aggression (MAPA) (Mental Health Only)

    Evidence of Current Professional Registration (NMC/HCPC/GDC/GMC)

    NMC Statement of Entry (For nurses)

    Qualification

    • Degree/ Diploma

    • NVQ/Care Certificate

    Clinical Reference (2x)

    Current DBS (Must be on the update service)

  • Personal Information

    I have read and understood the OPT OUT 48 HOURS working agreement (Which is available upon request) and I hereby consent that the week limit shall not apply to my assignment. I understand that I can end this agreement by giving Optima Staffing Solutions LTD 14 day’s notice in writing.
  • Next of Kin Details

  • Employment History

  • Curriculum Vitae (CV)

    Please submit and up-to-date CV detailing your full employment history with no unexplained gaps of two weeks or more
  • Accepted file types: pdf, word, docx.
  • Appraisal Confirmation

    Please confirm the date of your last Appraisal and the employer who conducted this appraisal
  • Rehabilitation of Offenders Act 1974

    If Yes, please provide outline on a separate sheet the criminal offence, order binding you over, a caution, including approximate date, the offence and the authority and country which dealt the offence.
  • Security Clearance

    If yes, give details below.
  • Fitness to Practice

    If Yes, please provide information on a separate sheet detailing the nature of the proceedings undertaken, or contemplated, including approximate date of proceedings, Country where proceedings were undertaken and the name and address of the licensing or regulatory body concerned.
  • Payment Information

  • Limited Company Payment information - Please ensure this is completed correctly

  • Declaration

    I confirm the details I have provided regarding my bank details are correct and I accept that all my payments should be made into the above account unless otherwise stated in writing to Optima Staffing Solutions LTD.
  • PAYER Payment information for PAYE workers only – Please ensure this is completed correctly

  • Declaration

    I confirm the details I have provided regarding my bank details are correct and I accept that all my payments should be made into the above account unless otherwise stated in writing to Optima Staffing Solutions LTD.
  • To be completed in the absence of a P45

  • Home Address

  • Employee Statement (please tick only one of the following)

  • Clinical references

    Optima Staffing Solutions LTD requires professional references covering at least the last 3 years (without gaps). The named referees should be of a senior position to you and business addresses are essential. By submitting this information, you hereby consent to Optima Staffing Solutions LTD making contact with these persons to obtain references. One reference covering the last 5 years (without gaps) may also be acceptable.
  • Reference 1

  • Reference 2

  • Medical Assessment 1

  • Medical History

    All staff groups complete this section
    Continued

    Have you suffered from any of the following?

  • 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.
  • Medical Assessment 2

    BBV (Blood Borne Virus)
  • If you answered NO to the above, please list all of 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.
  • Tuberculosis

    Do you have any of the following;
  • Ebola Virus Disease (EVD)

    Any person who has been in West Africa in the previous 21 days or those wishing to visit the affected areas must ensure that those deemed the employer are made aware prior to travel and return.

    You will be provided with a separate Ebola Screening Questionnaire to complete as applicable.

    If you answered YES to the above, please list all of the countries that you have lived in/visited in the last 21 days. This MUST include duration of stay and dates or this form will be rejected.
  • Additional Information

    (If you have answered yes to any questions above please provide additional information below)
  • Medical Assessment 3

    Immunisation History
  • Hepatitis B (if yes ticked please give dates below)
  • Proof of Immunity (Please send the following)

  • 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)
  • Hepatitis B

    You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above
  • 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
  • Rubella, Measles & Mumps

    Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles
  • Proof of immunity (Please send the following) EPP Candidates Only

    Hepatitis C- Surface Antigen Evidence of a negative antibody test Report must be an identified validated sample. (IVS)

    HIV- Surface Antigen Evidence of a negative antibody test Report must be an identified validated sample. (IVS)

    Hepatitis B- Surface Antigen Evidence of a negative Surface Antigen Test Report must be an identified Validated sample (IVS)

  • Exposure Prone Procedures

  • Medical Assessment 4

    I understand that if any recommendations to my employer/agency are necessary as a result of this employment assessment, it will be discussed with me before informing my employer
  • DECLARATION AND CONSENT

    Have you had any of the following immunisations as part of Your employment with Optima Staffing Solutions LTD, we may need to contact you before health clearance is given for employment by an occupational Health Nurse (OHN) or occupational Health Physician (OHP).

    I consent to Optima Staffing Solutions LTD processing my personal data with third parties including clients for the purposes of internal and external audits and investigations carried out on the Optima Staffing Solutions LTD to ensure that Optima Staffing Solutions LTD is complying with all relevant legislations and obligations.

    I consent to Optima Staffing Solutions LTD maintaining contact with me via telephone, SMS messaging (including WhatsApp), Email for the purposes of keeping me informed of

    job opportunities, company update and market updates and any information deem necessary by Optima Staffing Solutions LTD for me to know.

    The consent I give to Optima Staffing Solutions LTD will last until I finally request the withdrawal of consent or for a minimum of 6 years post I give my consent in accordance to the General Data Protection Regulation (GDPR) 2018. You have the right to withdraw your consent at anytime by informing Optima Staffing solutions LTD that you wish to do so if I have willingly withheld any relevant medical details I realise I may be subject to disciplinary action. I give my consent to Optima Staffing Solutions LTD and its Occupational Health Department to assess my file.

  • DECLARATION

    I declare that the information given in this application form is true and complete to the best of my knowledge and belief. I have read and understood the Terms of Engagement booklet. I agree to comply with the current Health & Safety at Work Act. I understand that my appointment is subject to the receipt of a minimum of 2 satisfactory references and is subject to Disclosure. I Optima Staffing Solutions LTD to make any further enquiries they may feel necessary to support my application. I agree to respect the confidentiality of patients and clients and any other information I may have access to at all times.
  • Agency worker staff handbook declaration

    I confirm that I have read a copy of the Agency Worker Handbook and have familiarised myself with its contents.

    I understand that the Handbook is not a contract of employment and should not be deemed as such.

  • I consent to Optima Staffing Solutions LTD processing my personal data with third parties including clients for the purposes of internal and external audits and investigations carried out on the Optima Staffing Solutions LTD to ensure that Optima Staffing Solutions LTD is complying with all relevant legislations and obligations.

    I consent to Optima Staffing Solutions LTD maintaining contact with me via telephone, SMS messaging (including WhatsApp), Email for the purposes of keeping me informed of job opportunities, company update and market updates and any information deem necessary by Optima Staffing Solutions LTD for me to know. The consent I give to Optima Staffing Solutions LTD will last until I finally request the withdrawal of consent or for a minimum of 6 years post I give my consent in accordance to the General Data Protection Regulation (GDPR) 2018.

  • Declaration from an individual working through an intermediary for a public authority (Inside 1R35)

  • 1) I do not operate as a sole trader;

    2) I also confirm that any limited or umbrella company that I provide or will be providing my services through is;

    an associated company of the client’s company (i.e. one company controls the other or both companies are under the control of myself alone, or myself and other people); and/or that

    neither myself or any of my associates*, alone or together with other associates have:

    (a) the beneficial ownership of, or the ability to control, directly or through the medium of other companies or by any other indirect means, more than 5% of the ordinary share capital of the limited/umbrella company; and/ or

    (b) possession of, or entitlement to acquire, rights entitling myself or my associate(s) to receive more than 5% of any distributions that may be made by the limited/umbrella company; or

    (c) In the case of a close company, possession of, or entitlement to acquire, rights that would in the event of the winding up of the limited/umbrella company, or in any other circumstances, entitle myself or my associate(s) to receive more than 5% of the assets that would then be available for distribution among any person who has a share or interest in the income or capital of the limited/umbrella company (e.g. a loan creditor or person entitled to acquire share capital or voting rights).

    *An associate in this section includes any relative or partner of yours (including a spouse or civil partner, parent, grandparent or great grandparent, child, grandchild or great grandchild, or a brother or sister). It also includes the trustees of any settlement in relation to which you or any of your relatives (living or dead) is a settlor; or if you have an interest in any shares or obligations of a company which are subject to any trust, the trustees of any settlement concerned.

    3) Where I will be providing services as a member of a partnership, I also confirm that:

    • I am not entitled to 60% or more of the profits of the partnership, either alone or with one or more relatives (i.e. a spouse or civil partner, anyone I live with as a spouse or civil partner, brother or sister, parent or child or remoter relation in the direct line e.g. grandparent, great grandparent, grandchild, great grandchild and so on.); and/or that

    • Most of the profits of the partnership are not derived from the provision of services to a single client, or a single client and its associates, under engagements which fall inside IR35**; and/or that

    • Under the profit sharing arrangements, the income of any of the partners is not based on the amount of income generated by that partner by the provision of services under engagements which fall inside IR35**.

    ** An engagement will fall “inside IR35” where you, or a partner personally performs services for a client, or are under an obligation to do so, as an employee or office holder under the client, or under circumstances where you/the partner would be regarded as an employee or office holder under the client for income tax purposes if the services were provided under a contract between you/the partner and the client directly, instead of through the partnership.

    4) I confirm that the information above is true and accurate and understand that Optima Staffing Solutions LTD may require proof that the above conditions have been met. I agree to notify Optima Staffing Solutions LTD immediately and in any event within 24 hours or other timescale as you require if any of the conditions set out at above change.

    • I understand that I may be removed from an assignment if the information above is not truthful or accurate and/or if I fail to notify Optima Staffing Solutions LTD of any changes within the timescale set out above.

    • I also understand that a failure to provide truthful and accurate information and/or to notify Optima Staffing Solutions LTD of any changes within the timescale set out above may cause Optima Staffing Solutions LTD to suffer loss and that Optima Staffing Solutions LTD reserves the right to recover such losses from me directly.

  • Terms of engagement with a limited company contractor who has opted out of the conducted regulation (Outside IR35)

    The parties
  • Optima Staffing Solutions (registered company no. 10271062) of 23 Whitestone way, Croydon, London, CR0 4WF. (“the Employment Business”).
  • RECITALS

    (A) The Intermediary carries on the business of the provision of contractor services and has agreed to provide the services (“the Intermediary Services”) specified in the relevant Assignment Details Form.

    (B) The Employment Business has requested the Intermediary and the Intermediary has agreed with the Employment Business, to supply the Intermediary Services to the Hirer on the terms and subject to the conditions of this Agreement.

  • DEFINITIONS AND INTERPRETATION

    In this Agreement the following definitions apply:
  • Agency Worker

    Means such of the Intermediary’s employees, workers, officers or representatives supplied to provide the Intermediary Services;
  • AWR

    Means the Agency Workers Regulations 2010;
  • Assignment

    Means the Intermediary Services to be performed by the Agency Worker for a period of time during which the Intermediary is supplied by the Employment Business to provide the Intermediary Services to the Hirer;
  • Assignment Details Form

    Means written confirmation of the Assignment details set out in clause 6.2;
  • Calendar Week

    means any period of seven days starting with the same day as the first day of the First Assignment;
  • Companies Acts

    means the Companies Acts 1985, 1989 and 2006;
  • CONFIDENTIALITY

    In order to protect the confidentiality and trade secrets of any Hirer and the Employment Business and without prejudice to every other duty to keep secret all information given to it or gained in confidence the candidate agrees as follows:

    13.1.1. not at any time, whether during or after an Assignment (unless expressly so authorised by the Hirer or the Employment Business as a necessary part of the performance of its duties) to disclose to any person or to make use of any of the trade secrets or the Confidential Information of the Hirer or the Employment Business with the exception of information already in the public domain;

    13.1.2. to deliver up to the Hirer or the Employment Business (as directed) at the end of each Assignment all documents and other materials belonging to the Hirer (and all copies) which are in its possession including documents and other materials created by him/her during the course of the Assignment; and

    13.1.3. not at any time to make any copy, abstract, summary or précis of the whole or any part of any document or other material belonging to the Hirer except when required to do so in the course of its duties under an Assignment in which event of any such item shall belong to the Hirer or the Employment Business as appropriate.

  • DATA PROTECTION

    The Nurse warrants that in relation to these Terms, s/he shall comply strictly with all provisions applicable to him/her under the Data Protection Laws and shall not do or permit to be done anything which might cause the Employment Business or the Hirer to breach any Data Protection Laws.

    15.2 The Nurse consents to the Employment Business, any other intermediary involved in supplying the services of the Nurse to the Hirer (now or in the future), and the Hirer:

    14.2.1. processing his/her personal data for purposes connected with the performance of the Assignment and pursuant to these Terms; and

    14.2.2 exporting and/or processing his/her personal data in jurisdictions outside the European Economic Area for purposes connected with the performance of these Terms.

  • SEVERABILITY

    If any of the provisions of this Agreement shall be determined by any competent authority to be unenforceable to any extent, such provision shall, to that extent, be severed from the remaining terms, which shall continue to be valid to the fullest extent permitted by applicable laws.
  • NOTICES

    All notices which are required to be given in accordance with this Agreement shall be in writing and may be delivered personally or by first class prepaid post to the registered office of the party upon whom the notice is to be served or any other address that the party has notified the other party in writing, by email or facsimile transmission. Any such notice shall be deemed to have been served: if by hand when delivered, if by first class post 48 hours following posting and if by email or facsimile transmission, when that email or facsimile is sent.
  • THIRD PARTY RIGHTS

    Save as set out in clause, none of the provisions of this Agreement is intended to be for the benefit of or enforceable by third parties (other than permitted assignees who shall be entitled to enforce the provisions of this Agreement as if original parties to it) and the operation of the Contracts (Rights of Third Parties) Act 1999 is excluded.

    The Hirer shall be entitled to rely on and enforce the indemnities in clause 3.7 given by the Intermediary in favour of the Hirer, notwithstanding that the Hirer is not a party to this Agreement.

  • GOVERNING LAW AND JURISDICTION

    This Agreement is governed by the law of England & Wales and is subject to the exclusive jurisdiction of the Courts of England & Wales.

    Signed for and on behalf of the Employment Business

    Manfred Gwunireama

  • I am authorised to sign these Terms for and on behalf of the Intermediary.
  • New Starter Induction Checklist

  • Equal Opportunity

    Optima Staffing Solutions is an equal opportunities employer.

    (EO policy available upon request).

    For the purpose of promoting a corporate commitment to equality and diversity, we kindly ask that you complete the following optional questionnaire:

    Your Age & Gender

  • Optima Staffing Solutions is an equal opportunities employer.

    (EO policy available upon request).
  • Your Ethnic Origin

  • Consent form for GDPR

  • Company Name :

    Optima Staffing Solutions Limited
  • Document :

    Consent Declaration
  • Topic :

    GDPR
  • Date :

    21/05/2018
  • Version :

    1
  • Personal data:

    • Your name

    • Your address

    • Your email address

    • Your contact number

    • Your CV/work history

    • Your job preferences including job role, salary, hourly/rate,geographical areas

    • Any other work-related information such as education, training, qualifications

  • Sensitive personal information:

    • Disability/health condition relevant to the role

    • Criminal conviction

    • Passport/permits/visas

    • Date of birth

    • National Insurance Number

    • Full details of offers and placements

    • Outcome of Criminal record checks and security clearance for certain roles

    • Medical information including immunisation records (if required)

    • References

    • Financial information (including but not limited to payroll details and terms, HMRC data, pension scheme details, court orders, statutory payments

    • A log of our communications with you by email and telephone

  • I consent to the Optima Staffing Solutions processing the above personal data for the following purposes:

    • For Optima Staffing Solutions LTD to provide me with work-finding services

    • For Optima Staffing Solutions LTD to process or transfer my personal data to their NHS and Private Healthcare providers/clients in order to provide me with work-finding services

    • For Optima Staffing Solutions LTD to process my data on a computerised database provided by Insightly or influence or any other appropriate CRM in order to provide me with work-finding services

    • For Optima Staffing Solutions LTD to process my data using automated decisions making processes

    I also consent to Optima Staffing Solutions LTD processing my personal data with third parties including clients for the purposes of internal and external audits and investigations carried out on Optima Staffing

    Solutions LTD to ensure that Optima Staffing Solutions LTD is complying with all relevant legislations and obligations.

    I finally consent to Optima Staffing Solutions LTD maintaining contact with me via telephone, SMS messaging (including WhatsApp), Email for the purposes of keeping me informed of job opportunities, company updates, market updates and any information deem necessary by Optima Staffing Solutions LTD for me to know.

    The consent I give to Optima Staffing Solutions LTD will last until I formally request the withdrawal of consent or for a minimum of 6 years post giving consent.

    I am aware that I have the right to withdraw my consent at any time by informing Optima Staffing Solutions LTD that I wish to do so.

  • Candidate Uniform and Working Time Declaration

  • At CSH Surrey, we are committed to providing the highest clinical and working environment where all co-owners, employees, workers, patients, visitors and contractors are employed, cared for, welcomed, respected and treated in a consistent and non-discriminatory manner. This approach will be applied irrespective of race, gender, disability, age, sexual orientation, religion or faith, transgender and status. We will underpin this by ensuring our current and future clinical services and their outcomes, are reflective of our commitments. We will also ensure that our appropriate policies, procedures, recruitment and development programmes, are fairly and consistently applied, assessed, monitored regularly and treated seriously.

  • Agency worker must arrive wearing the uniform provided by the Agency along with the Agency ID badge. The following rules also apply:

    • Belts must not be worn with dresses or tunic tops due to Health & Safety reasons.

    • Smart trousers must be worn not jeans, leggings or tracksuit bottoms

    • Tights or stockings need not be worn in the summer.

    • Identity badges must be worn at all times and professional badges should be limited to only one. This is of importance as wearing badges can cause injury to patients or clients.

    • It must be noted that wearing of false or acrylic nails is strictly forbidden as they pose an infection control risk. All finger nails should be kept short and clean. Uniformed co-owners must not wear nail polish whilst on duty.

    • Hair should be clean, tidy and if below shoulder length in clinical areas tied back.

    • The “bare below the elbows‟ policy applies when visiting clinical areas or where patient contact is involved. All staff should dress and wear clothing that makes hand hygiene both easy and satisfactory. Shirts or tops must therefore be either short sleeved or have sleeves that are rolled up to the elbow. PPE – Protective should be used and adhered to. It must not cause a risk either from tearing or for infection prevention & control purposes.

    • Footwear must be suitable for the work task. Uniformed Co-owners must wear either black or brown shoes with a rubber non-slip sole and low heel, or clean presentable trainers where clinically appropriate. Shoes should give adequate support and be strong enough to prevent damage to toes should anything be dropped on the feet. Backless or open shoes must not be worn as these constitute a hazard (Manual Handling Operations Regulations, 1992).

    • Jewellery must be kept to a minimum. All Co-owners in direct contact with patients or clients must only wear plain band rings without stones, stud earrings or small sleepers. Wrist watches and neck chains must not be worn in clinical areas.

  • Working Time Rules

    • All workers must have 11 hours rest between shifts

    • 24 hours rest must be taken every 7 days or 48 hours rest every 14 days

    • Any agency worker found not to be adhering to this legislation, will face exclusion from working at Central Surrey Health

  • English Test (ALL WORKERS)

  • Vocabulary

    Section 1 (Select the best answer)
  • Grammar

    Section 2 (Select the Underlined word or phrase that is incorrect)
  • 1. The doctor him visited the Patient’s parents.
  • 2. Each day after work, Rionne run five miles<.b>
  • 3. Do you know the Nurse who id badge was stolen?
  • 4. I told the salesman that I was not interesting in buying the latest model
  • Section3

    (Please select the best answer)
  • Reading Comprehension Section4

    Section 4 (Select the best answer)

    Directions to Joseph’s house

    Leave Junction 25 at exit 7A. Follow that road (Elm Street) for two miles. After one mile, you will pass a small shopping centre on your left. At the next set of traffic lights, turn right onto Maple Drive. Joseph’s house is the third house on your left. It’s number 33, and it’s white with green trim.

    The B&B Tour- Spend ten romantic days enjoying the lush countryside of southern England. The counties of Devon, Dorset, Hampshire, and Essex invite you to enjoy their castles and coastline, their charming bed and breakfast inns, their museums and their cathedrals. Spend lazy days watching the clouds drift by or spend active days hiking the glorious hills. These fields were home to Thomas Hardy, and the ports launched ships that shaped world history. Bed and breakfasts abound, ranging from quiet farmhouses to lofty castles. Our tour begins August 15. Call or fax us today for more information 1-800-222XXXX. Enrolment is limited, so please call soon.
  • Math Test (HCA/SW ONLY)- Please show your workings for each answer (Pass mark 100%)

    I confirm that I am competent in relation to this math test and I have the necessary skill and knowledge to undertake this procedure.
  • Drug calculation (NURSES ONLY)- Please show your workings for each answer (Pass mark 100%)

  • I confirm that I am competent in relation to the Administration of Medicines. I have the necessary skill and knowledge to undertake this procedure.
  • Declaration:

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Optima Staffing Solutions
Weatherill House,
23 Whitestone Way
Croydon, United Kingdom
CR0 4WF

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Phone:
02034893363 - 24/7 Booking
02080043561 - 24/7 Booking
‭02037474717‬ (Office hrs)

Email:
[email protected]
[email protected]
[email protected]
 

Optima Staffing Solutions is a Limited Company registered in England and Wales, registration number 10271062 and head office at Weatherill House, 23 Whitestone Way, Croydon CR0 4WF

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