Application Form

Candidate document checklist
Below are the compliance requirements for registration with Optima
Completed application form
Staffing Solutions:
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

Two (2) Clinical References to cover a at least the last 3 years of employment
Clinical Reference (2x)
Current DBS (Must be on the update service)

Payment Information
Umbrella Company Payment information - Please ensure this is completed correctly
Full Name
First Last
Date of Birth
Umbrella Company Name
Registered Address (including Postcode)
Bank Account Name
Bank/Building Society Name
Account Number
Sort Code
Building Society Roll Number (if applicable)
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
Full Name
First Last
NI Number
Date of Birth
Bank Account Name
Sort Code
Account Number
Bank/Building Society Name
Building Society Roll Number (if applicable)
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.
Signature*
Name
Date
To be completed in the absence of a P45
Full Name
Surname First
Date of Birth
Gender
- M
- F
Home Address
Address Line 1
Address Line 2
Address Line 3
Postcode
National Insurance Number
Employment Start Date
Employee Statement (please tick only one of the following)
This is my first job since last 6 April and I have not been receiving taxable jobseeker’s allowance, employment and support allowance, taxable incapacity benefit, state or occupational pension
- A
This is now my only job but since last 6 April I have had another job, or received taxable jobseeker’s allowance, employment and support allowance or taxable incapacity benefit. I do not receive a state or occupational pension.
- B
As well as my new job, I have another job or receive a state or occupational pension
- C
I have a student loan which is not fully repaid, and I left a course of UK higher education before last 6 April and I received my first student loan instalment on or after 1 September 1998. (select “no” if you are repaying your student finance loan directly to the student loans company by agreed monthly instalments.
- Yes
- No
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
Name*
Position
Place of work
Address
Contact number
Email Address
Dates Employed From
Dates Employed TO
Reference 2
Name*
Position
Place of work
Address
Contact number
Email Address
Dates Employed From
Dates Employed To
Additional comments

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.
Name
Signature*
Date
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.
Signature*
Date

Terms of engagement with a limited company contractor who has opted out of the conducted regulation (Outside IR35)
The parties
Intermediary’s name Limited
Registered company no
Trading name(if different)
Registered Trading Address (“the Intermediary”). if the Intermediary is a limited liability partnership]
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
Signature*
(Please sign by hand and not electronically) Signed for and on behalf of [insert name of limited company or limited liability partnership Ltd. (the Intermediary)
Candidate Name
I am authorised to sign these Terms for and on behalf of the Intermediary.
Date

New Starter Induction Checklist
I confirm that I have been informed and understand about how the following items are relevant to my employment with Optima Staffing Solutions LTD.
- ID Badge
- Timesheet
- Uniform
- Staff Handbook
- Terms of engagement
Name
Signature*

Consent form for UK GDPR
Company Name :
Optima Staffing Solutions Limited
Document :
Consent Declaration
Topic :
GDPR
Date :
21/05/2018
Version :
1
I____________________ hereby give my consent to Optima Staffing Solutions LTD to process the following information
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.
Signature*
Date

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
I ……………………………………………….. (Candidate name) confirm I have read and understood the above uniform policy for Central Surrey Health and confirm I will agree to these standards
Candidate Signature*
Date

Application Form

Step 1 of 15

Candidate document checklist

Completed application form

Right to work

Personal Information

Next of Kin Details

Employment History

Curriculum Vitae (CV)

Rehabilitation of Offenders Act 1974

DBS Clearance

Fitness to Practice

Payment Information

Umbrella Company Payment information - Please ensure this is completed correctly

Declaration

PAYER Payment information for PAYE workers only – Please ensure this is completed correctly

Declaration

To be completed in the absence of a P45

Home Address

Employee Statement (please tick only one of the following)

Clinical references

Reference 1

Reference 2

Agency worker staff handbook declaration

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

RECITALS

DEFINITIONS AND INTERPRETATION

Agency Worker

AWR

Assignment

Assignment Details Form

Calendar Week

Companies Acts

CONFIDENTIALITY

DATA PROTECTION

SEVERABILITY

NOTICES

THIRD PARTY RIGHTS

GOVERNING LAW AND JURISDICTION

New Starter Induction Checklist

Equal Opportunity

Optima Staffing Solutions is an equal opportunities employer.

Your Age & Gender

Optima Staffing Solutions is an equal opportunities employer.

Your Ethnic Origin

Consent form for UK GDPR

Company Name :

Document :

Topic :

Date :

Version :

Personal data:

Sensitive personal information:

Candidate Uniform and Working Time Declaration

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

Working Time Rules

English Test (ALL WORKERS)

Vocabulary

Grammar

Section3

Reading Comprehension Section4

Math Test (HCA/SW ONLY)- Please show your workings for each answer (Pass mark 100%)

Drug calculation (NURSES ONLY)- Please show your workings for each answer (Pass mark 100%)

Declaration: