Registration Pack Checklist
This checklist states all the documentation and supporting evidence that you must supply before working with MediPro Recruitment – if you have any problems obtaining any of the information listed below, please call the office and we will be happy to help.
Up to date CV
Eligible to work in the UK (Passport and Work Permit)
Serological evidence of Hepatitis B Status
Serological evidence of Mumps, Measles & Rubella Immunity
Serological evidence of Tuberculosis (BCG Scar)
Self declaration or serological evidence of Varicella
EPP (SCRUB) APPLICANT ONLY – IVS Sample of HIV & Hepatitis C
Passport size photograph in colour for your identification badge
Photographic ID – Driving Licence Card/Passport
National Insurance Card or Wage Slip
Proof of current address – Bank statement/Council Tax Bill/Utility Bill
Professional Qualifications
Copy of your NMC/HCPC Registration (if RGN or ODP)
Mandatory Training – please see overleaf for details
Details for 2 professional references (1 of these must be your current/last employer)
Important Notice
It is a legal requirement for MediPro Recruitment to obtain all relevant documentation prior to providing healthcare professionals into NHS or Private Hospitals.
It is acceptable to send photocopies of documents through the post, however, original documents must be seen and should be brought along to your interview;
CRB – ID ACCEPTED
3 documents must be seen.
One document from Group 1 plus any two from Group 1 or 2
If you cannot produce any documents from Group1, 5 documents from Group 2 must be seen.
Group 1
Passport - check that the passport has not expired
UK Birth Certificate – issued within 12 months of birth
UK issued driving licence – both photo card and the counterpart must be seen
HM Forces ID card - UK
EU National Identity Card
Adoption Certificate – UK
Group 2
Marriage/Civil Partnership agreement
Financial Statement (e.g. pension, endowment, ISA)
P45/P60 Statement – UK
Bank/Building Society Statement - less than 3 months old
Utility Bill – electricity, gas, water, telephone, mobile phone - less than 3 months old
TV Licence - less than 12 months old
Addressed payslip - less than 3 months old
Credit card Statement - less than 3 months old
National Insurance Card
Store Card Statement - less than 3 months old
Mortgage Statement - less than 12 months old
Insurance Certificates - less than 12 months old
Certificate of British Nationality – UK
Council Tax Statement – UK, less than 12 months old
Work Permit/Visa – UK, less than 12 months old
Mandatory Training Requirements
We need to have details of each of the subjects below, all of which is to be updated annually
Basic/Advanced/Intimidate Life Support
Manual Handling
Health & Safety including RIDDOR & COSHH
Infection Control
Fire Safety
Complaints Handling
Conflict Resolution
Information Governance and Data Protection
Lone Worker Training
Level 2 Safeguarding Children and Vulnerable Adults
REGISTRATION FORM
Please complete all sections using black pen and block capitals
PLEASE COMPLETE IN BLOCK CAPITALS
Personal Details
Surname: Forenames: Title:
Name you wish to be known by:
Address:
Country: Post Code:
Mobile Phone: Telephone:
Email:
Date of Birth: / / National Insurance Number:
Employment Eligibility
Qualification:
Registration / Pin Number: Exp date:
Nationality:
What is your work status (if not UK Citizen):
Work Permit Held: Yes No Type of Work Permit: Exp / /
Transport
Do you hold a current driving licence: Yes No Do you have your own transport Yes No
Professional Indemnity
Do you have private indemnity insurance: Yes No
Do you belong to a Union Yes No Name of Union:
Membership Number: Expiry Date: / /
Professional References
Please provide the details of 2 people that you wish to use as referees (one of these most be you current/or most recent employer, the other must be a senior member of staff). Please complete all sections of this form
Name of referee: Position:
Mailing Address:
Country: Post Code:
Telephone Number: Fax:
Email Mobile Phone:
Name of referee: Position:
Mailing Address:
Country: Post Code:
Telephone Number: Fax:
Email Mobile Phone:
Bank Details
Name of Bank:
Address:
Account Holder:
Account Number:
Sort Code:
Please tick the box that applies below regarding method of payment:
Limited Company – A copy of your Certificate of Incorporation is required
PAYE – I have enclosed a P45 / this is my second job so I need a P46*
Next of Kin
Name: Relationship:
Telephone Number: Mobile Number:
Mailing Address:
Country: Post Code:
Data Protection Consent Form
I hereby consent to privileged information concerning myself being ‘processed’ by Medipro Recruitment Ltd. I accept that Medipro Recruitment Ltd as my agent, are required to process this information in order to perform their duties, rights and obligations. The information gathered will principally be for personnel, administration and payroll purposes.
It is my understanding that the details about me shall include information of sensitive personal nature regarding:
· racial or ethnic origin
· membership or non-membership of a Trade Union
· physical or mental health or condition
· any commission or alleged commission by me of any offence
· any proceedings or the sentence of any court in such proceedings
The term ‘processing’ includes the obtaining, recording or holding of information or data carrying out any operation or set of operations on the information or data, including organising, altering, retrieving, consulting, using, disclosing, combing, or destroying the information of data.
I have read and understood the above explanation of the processing data relating to myself by Medipro Recruitment Ltd and give my consent to the processing of such data.
Print Name: Signed: Date: / /
Skills Evaluation Sheet
Evaluation of your skills and level of competency in key areas will help us place you appropriately. Please provide as much detail as possible when telling us about your past experience
Scrub
Speciality / Procedure / Comments / Dates of experienceBurns
Cardiac
Dentals
Endoscopy
ENT
EPI/Spinal Blocks
General Major
General Minor
Gynaecology
Laparoscopic
Maxillo Facial
Neurology
Obstetrics
Ophthalmic
Orthopaedics Major
Orthopaedics Minor
Orthopaedic Trauma
Paediatrics
Plastics
Spinal Surgery
Thoracic
Transplant
Emergency / Acutes
Urology
Vascular
Skills Evaluation Sheet continued
Evaluation of your skills and level of competency in key areas will help us place you appropriately. Please provide as much detail as possible when telling us about your past experience.
Anaesthetics
Speciality / Procedure / Comments / Dates of experienceAnaesthetics
Bariatric
Neurology
Obstetrics
Paediatrics
Cardiac
Other
Speciality / Procedure / Comments / Dates of experience
Theatre HCA
Ward HCA
Other
Healthcare Assistant
Recovery
Speciality / Procedure / Comments / Dates of experienceRecovery
ITU/HDU
Neurology
Paediatrics
Rehabilitation of Offenders Act
Because of the nature of the work for which you are applying, this work is exempt from the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are therefore, not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to the application for positions in which the Order applies, and should be entered at the end of any particulars you give in support of your application.
A copy of our policies is available upon request. A criminal record will not necessarily be a bar to obtaining a position. Further guidance can be obtained by reference to the CRB’s code of practice, a copy of which is available from our office or on the CRB website www.crb.gov.uk
Have you ever been convicted of a criminal offence? Yes No
Have you completed an enhanced CRB? Yes No
With an Enhanced Disclosure, under Section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption Order), all previous cautions, warnings and convictions will always be detailed regardless of how long ago they occurred.
Do you have any spent or unspent criminal convictions? Yes No
Any Conviction, caution, reprimand will require a written statement of each and every event and how it does not affect your ability for the role you are applying for.
Have you provided an original Enhanced CRB Disclosure Yes No
Disclosure Number:
Have you supplied additional information with this Registration form for any spent/unspent convictions, cautions or reprimands?
Have you ever been involved in court proceedings? Yes No
PLEASE GIVE ANY ADDITIONAL INFORMATION WHICH YOU THINK MAY BE RELEVANT TO SUPPORT YOUR APPLICATION ON A SEPARATE PAGE.
I confirm that the information I have provided in support of this application is complete and true and understand that knowingly to make a false statement could be a criminal offence.
Print Name: Signed: Date: / /
I consent to Medipro Recruitment Ltd checking the details I have provided in support of this Registration form against the various data sources in order to verify my identity and process this Registration. These details may be recorded and used to assist other organisations for identity verification purposes such as the CRB, regulatory bodies such as NMC or GSCC.
Print Name: Signed: Date: / /
Medipro Recruitment Ltd reserves the right to hold this registration form and any other data required to process your registration (whether in the UK, European Union or elsewhere) and keep for as long as necessary in line with the Data Protection Act.
Equal Opportunities
Medipro Ltd adheres to a policy that promotes equal opportunity. To ensure that the policy works effectively please complete the following.
Age Range: 16-24 25-34 35-44 45-54 55+
Gender: Male Female
Gender Identity (Optional): If you identify as a transsexual or transgender or as intersex please indicate which
group you identify with. Transsexual Transgender Intersex
Ethnic Origin:
White: British Irish Other White
Asian: Bangladeshi Indian Pakistani Other Asian
Black: African Caribbean Other Black
Mixed: White and Black Caribbean White and Black African White and Asian
Other Mixed
Other: Chinese Other Ethnic Groups Prefer not to say
Nationality:
British Chinese Hungarian Indian
Irish Jamaican Nigerian Pakistani
Filipino Polish Romanian South African
Spanish Zambian Zimbabwean Other
Prefer not to say
Do you consider yourself to have a disability?
Yes No Prefer not to say
Religion: Bahia Buddhist Christian Hindu Jain
Jewish Muslim Sikh Other Prefer not to say
No Religion
Marital Status:
Single Married Divorced
Widowed Separated Other Prefer not to say
Sexual Orientation:
Heterosexual Homosexual Bisexual
Other Prefer not to say