Application Form Step 1 of 15 6% Candidate document checklistBelow are the compliance requirements for registration with Optima Completed application formStaffing 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) Personal InformationName* First Last Current AddressCityPostal codeNationalityPassport NumberDate of Birth NI NumberBandPermanent Address (If different from current)SpecialityRole and indicate : HCA RGN RMN Support worker Social Worker Others....... NMC/HCPC/GDC/GMC NumberExpiryHome Tel NumberWork Tel NumberMobile NumberEmail Enter Email Confirm Email Do you hold a full UK Driver’s License ?YesNoAre you a car owner?YesNoHow did you hear about us?I confirm that I am entitled to work in the UK and I will provide Optima Staffing Solutions LTD with the relevant original documents in accordance to the Asylum and Immigration act. Please tick Date Print NameSignature*Next of Kin DetailsFull Name* First Last AddressEmail Enter Email Confirm Email Mobile NumberRelationshipEmployment HistoryCurriculum Vitae (CV)Please submit and up-to-date CV detailing your full employment history with no unexplained gaps of two weeks or moreCV UploadAccepted file types: pdf, word, docx.Rehabilitation of Offenders Act 1974Because of the nature of work for which you are applying, this post is exempt from the provisions of Section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption order 1975). You are required to declare prosecutions or convictions, including those considered ‘spent’ under this Act. Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations, which might lead to a conviction, an order binding you over or a caution in the UK or any other country?YesNoIf 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.DBS ClearanceDo you hold any form of current DBS Clearance?YesNoIf yes, give details below.Date Issued Level of ClearanceExpiry Date Issue BodyFitness to PracticeHave you been or are you currently subject to any fitness to practice proceedings by an appropriate licensing or regulatory body in the UK or any other Country?YesNoIf 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. Email information to [email protected] Payment InformationUmbrella Company Payment information - Please ensure this is completed correctlyFull Name First Last Date of Birth Umbrella Company NameRegistered Address (including Postcode)Bank Account NameBank/Building Society NameAccount NumberSort CodeBuilding Society Roll Number (if applicable)DeclarationI 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 correctlyFull Name First Last NI NumberDate of Birth Bank Account NameSort CodeAccount NumberBank/Building Society NameBuilding Society Roll Number (if applicable)DeclarationI 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*NameDate To be completed in the absence of a P45Full Name Surname First Date of Birth GenderMFHome AddressAddress Line 1Address Line 2Address Line 3PostcodeNational Insurance NumberEmployment 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.YesNoClinical referencesOptima 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 1Name*PositionPlace of workAddressContact numberEmail Address Dates Employed FromDates Employed TOReference 2Name*PositionPlace of workAddressContact numberEmail AddressDates Employed FromDates Employed ToAdditional comments Agency worker staff handbook declarationI 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. NameSignature*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 LimitedRegistered company noTrading 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 INTERPRETATIONIn this Agreement the following definitions apply:Agency WorkerMeans such of the Intermediary’s employees, workers, officers or representatives supplied to provide the Intermediary Services; AWRMeans the Agency Workers Regulations 2010; AssignmentMeans 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 FormMeans written confirmation of the Assignment details set out in clause 6.2; Calendar Weekmeans any period of seven days starting with the same day as the first day of the First Assignment; Companies Actsmeans the Companies Acts 1985, 1989 and 2006; CONFIDENTIALITYIn 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 PROTECTIONThe 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.SEVERABILITYIf 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. NOTICESAll 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 RIGHTSSave 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 JURISDICTIONThis 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 GwunireamaSignature*(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 NameI am authorised to sign these Terms for and on behalf of the Intermediary. Date New Starter Induction ChecklistI 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 NameSignature* Equal OpportunityOptima 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 & GenderOptima Staffing Solutions is an equal opportunities employer.(EO policy available upon request).Age16-2425-3435-4445-5455-6465-7475+GenderMaleFemaleGender Identity:TranssexualTransgenderIntersexYour Ethnic OriginWhiteBritishIrishOtherBlackAfricanCaribbeanOtherAsianBangladeshiIndianPakistaniOtherMixedWhite & Black CaribbeanWhite and Black AfricanWhite and AsianOther MixedDo you consider yourself to have a disability within the meaning of the Equality Act 2010?YesNoPrefer not to sayYour Sexual OrientationBisexualHomosexual womanHomosexual manHeterosexualYour Religion and BeliefAgnosticBahaiBuddhistCatholicChristianHinduJainJewishNo ReligionMuslimProtestantSikhOther... Consent form for UK GDPRCompany Name :Optima Staffing Solutions LimitedDocument :Consent DeclarationTopic :GDPRDate :21/05/2018Version :1 I____________________ hereby give my consent to Optima Staffing Solutions LTD to process the following informationPersonal 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 telephoneI 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 standardsCandidate Signature*Date English Test (ALL WORKERS)NameSpecialityDate VocabularySection 1 (Select the best answer)1. The bus __________ arrives late during bad weatherA – laterB - willC - alwaysD - every week2. The rate of ___________ has been fluctuating wildly this weekA – moneyB - exchangeC - billsD - coin3. Do you __________ where the nearest pharmacy is?A – knowB - noC - notD - now GrammarSection 2 (Select the Underlined word or phrase that is incorrect) 1. The doctor him visited the Patient’s parents. A – TheB - himC - visitedD - Patient’s2. Each day after work, Rionne run five miles<.b>A – EachB - afterC - runD - miles3. Do you know the Nurse who id badge was stolen?A – DoB - knowC - whoD - was4. I told the salesman that I was not interesting in buying the latest modelA – toldB - thatC - interestingD - latest Section3(Please select the best answer)1. Daniel ___________ in the library this morningA – Is studyingB - Is studyC - be studyingD - are studying2. Tania’s Hobbies include Reading, cooking, and ___________A – climb mountainsB - to climb mountainsC - to climbD - climbing mountains3. The Drug round will begin ___________ fifteen minutesA – atB - inC - onD - climbing mountains4. I have only a ___________ notes left to writeA – lessB - fewC - fewerD - little Reading Comprehension Section4Section 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. 1. Which is closest to Joseph’s house?A – The shopping centreB - Exit 7AC - a greenhouseD - The Traffic lights2. What is Joseph’s Address?A – 33 maple driveB - Junction 25C - 33 elm streetD - exit 7AThe 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. 3. What can we infer about the area of Southern England?A – The land is flatB - The coast has harsh weatherC - The region has lots of vegetationD - The sun is hot and the air is dry4. Which of the following counties is not included in the tour?A – DevonB - HampshireC - EssexD - Cornwall5. How many people can go on this tour?A – 2 – 8B - An unlimited numberC - 10D - A limited numberCandidates Signature* Math Test (HCA/SW ONLY)- Please show your workings for each answer (Pass mark 100%)NameDate 1) If it costs £13.50 for 3 people to go to the cinema, how much will it cost for 5 people?A. £23.50B. £27.00C. £22.50D. £17.002) The bus is scheduled to leave at 16:24pm. It doesn’t actually leave until 7 minutes later. You get off the bus at 17:17pm. How long was the journey?A. 53 MinutesB. 46 MinutesC. 47 MinutesD. 54 Minutes3) How do you write 0.75 as a fraction?4) Last year a TV cost £390. This year it costs 10% more. How much is it now?A. £399B. £429C. £400D. £3515) If Rob earns £6.51 per hour. How much does he earn in 4 hours?A. £26.94B. £25.09C. £26.04D. £18.566) You have 30 people and 6 dogs in a room. How many legs will they have in total?A. 58B. 36C. 72D. 847) A bag contains 6 blue balls, 4 green and 2 red. If you put your hand in and picked a ball at random what are the chances it is blue?A. 45%B. 60%C. 50%D. 33.3%8) A shirt normally costs £42. If you receive a 15% discount, how much change will you get from £50?A. £35.70B. £23.00C. £8.00D. £14.309) If a loaf of bread costs £1.52 how much change would you get from £10 if you buy 4 loaves?10) Today the temperature is minus 4 degrees Celsius. It is expected to get 15 degrees Celsius warmer by tomorrow. What will the temperature be tomorrow?A. -11 degrees CelsiusB. -19 degrees CelsiusC. 19 degrees CelsiusD. 11 degrees CelsiusI confirm that I am competent in relation to this math test and I have the necessary skill and knowledge to undertake this procedure. SignatureDate Drug calculation (NURSES ONLY)- Please show your workings for each answer (Pass mark 100%)NameSpecialityDate 1. A patient is prescribed fentanyl 287 microgram transdermal patch. State how many of the following patches you would use: I00 microgram, 75 microgram and 12 micrograms (use as few as possible).2. Your patient requires Oxynorm 7.5mg. You have 62.5ml of Oxynorm liquid 5mg/5ml in the bottle. a) How many mls will you administer to the patient? b) How many mls will be left in the bottle?3. Morphine sulphate 15mg subcutaneously has been prescribed for breakthrough pain. The drug comes in 30mg/ml. How many mls will you give?4. A patient is prescribed alfentanil 300micrograms subcutaneously. The vial comes in 1mg/2mls a) How many mls would be used? b) How many mls would be discarded?5. Hyoscine hydrobromide 600 micrograms is prescribed by subcutaneous bolus injection. The drug comes in 400 microgram/1ml. How many mls will you administer?6. Gliclazide 120mg is prescribed with breakfast. Drug comes in 80mg scored tablets, how many would you administer7. A dose of midazolam 2mg is required by subcutaneous injection. How many mls would you give if using 10mg/2ml strength ampoules?8. Levomepromazine 5mg is prescribed subcutaneously for nausea. The drug comes in 25mg/ml ampoule doses. How many mls do you need to draw up?9. Your patient requires Oramorph 80mg. You have Oramorph Concentrate 20mgs/1ml in the bottle. There is 32.5ml left in the bottle. a)How many ml will you administer to the patient? b) How many ml will be left in the bottle?10. Amoxycillin trihydrate oral suspension 0.25grams is prescribed every 8 hours. The drug comes in 125mg/5 ml. How many mls will you administer per dose?I confirm that I am competent in relation to the Administration of Medicines. I have the necessary skill and knowledge to undertake this procedure.NameDate SignatureDeclaration:I ................................ confirm that I have completed this form to register with Optima Staffing Solutions Limited and I authorise the company to use information provided for the purpose of finding suitable work for me. I confirm that all information provided are correct to the best of my knowledge and should be relied upon; and I agree to be held liable for any false information provided on this form. As this form was digitally signed I will send my specimen signature to the company for record purposesName*Signature*Date This iframe contains the logic required to handle Ajax powered Gravity Forms.