Candidate
Application Form
Personal Details
Surname:
Forenames:
Title: (Please Tick) Mr Mrs Miss Ms
Address:
Eircode:
PPS Number:
Occupation Nurse Health Care Assistant Social Care Worker Midwife
Email address:
Tel Mobile:
Home:
Date of Birth:
Sex: Male Female
Bank Details
IBAN:
BIC:
Emergency Contact
Name:
Relationship:
Tel Number:
Eligibility Of Employment
EU Passport or GNIB Card:
Nationality (as per passport):
Please send a scanned copy of passport and visa where applicable with this application form and bring originals to your interview.
Source
Where did you hear about us? (Please Tick)
Referral Please specify name: 
Professional Healthcare References
At least two references are required.
Organisation:
Department:
Name:
Title:
Address:
Contact Tel:
Email:
Period of employment:
Start date:
End date:
Organisation:
Department:
Name:
Title:
Address:
Contact Tel:
Email:
Period of employment:
Start date:
End date:
Organisation:
Department:
Name:
Title:
Address:
Contact Tel:
Email:
Period of employment:
Start date:
End date:
Mandatory Safety Checklist
Please state whether you have up to date certification of the following: (Please Tick)
CPR/Basic Life Support
Yes No
Patient moving & handling
Yes No
Infection prevention & control
Yes No
Elder abuse training
Yes No
Personal Protective Equipment
Yes No
Hand Hygiene
Yes No
Fire & Safety
Yes No
Safeguarding Vulnerable Adults
Yes No
Children First Training
Yes No
Fundamentals of GDPR
Yes No
Management of Violence & Aggression TCI/PMVA
Yes No
Mental Health Act 2001
Yes No

Professional qualification (Please Tick)

NMBI Retention Certificale (Nurses only)
Yes No
Fetac Level 5 or equivalent (HCA only)
Yes No
Student Nurse ID
Yes No
Social Care Degree/Certification
Yes No

Proof of Occupational Health (Please Tick)

Immunity to MMR
Yes No
Immunity to Varicell
Yes No
HEP B
Yes No
Record Of Experience

(For Nurses Only)

Course
(Please Tick)
Experience
(Number of Years)
Duration/Comments
(Months/Years/Additional Information
1. A & E
2. Burns/Plastic
3. Cardio Thoracic
4. CCI
5. ENT
6. Geriatrics
7. ICU (Adults)
8. ICU (Paeds)
9. IV Policy
10. Medical
11. Midwifery
12. Neonates
13. Nephrology
14. Neurosurgery
15. Obstetrics/Gynae
16. Occ Health
17. Oncology
18. Orthopaedics
19. Paediatrics
20. Phlebotomy
21. Psychiatry
22. Renal
23. Special Care (Babies)
24. Surgical
25. Theatre/OR
26. Non-violente Crisis Intervention (Psychiatric Nurses only)
27. OTHER
Additional Comments:
Medical History

Confidential

This section of our application form seeks to establish whether you have any health issues that could affect your ability to perform your duties at work or that would result in risk to you at work. On completing our assessment of your responses we may recommend a course of action to enable you to work safely. You may be contacted in this regard and we may recommend that you see an occupational health advisor or medical practitioner prior to providing any engagements to you. These records will be held on file as part of our application form.

Medical History (Please Tick)

Do you have any illness/impairment/disability which may affect your employment?
Yes No
Have you ever had any illness/impairment/disability which may have been caused or made worse by your employment?
Yes No
Do you think you may need any adjustments or assistance to help you to carry out your work?
Yes No
Are you having, or waiting for treatment (including medication) or investigations at present? If your answer is yes, please provide further details of the condition,treatment and dates.
Yes No
If you have answered ‘yes’ to any of the above questions please provide further details.We cannot proceed with your application without this detail.

Tuberculosis (TB) (Please Tick)

Have you had a BCG vaccination in relation to Tuberculosis?
If yes, please provide date:
Yes No
Have you ever had TB or any symptoms of TB i.e. unexplained weight loss,unexplained fever, a cough which has lasted for more than 3 weeks?
Yes No
If you have answered ‘yes’ to any of the above questions please provide further details.We cannot proceed with your application without this detail.
The information above is true and I agree to inform Access Healthcare Limited and any employer at which I am placed of any health problems so that my health and safety and that of my patients can be protected whilst at work.
Print name:
Date:
Sign Here:

Declarations and Authorisations
Please Read Each Point Below Carefully:
I, Name:
Date of Birth:
Address:
HEREBY DECLARE that:
1.
I have never been arrested for, or convicted of, any offence or crime (other than an offence under road traffic legislation), either in Ireland or in any other state;
2.
I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform  Access Healthcare Limited.
3.
I have never been the subject of a pardon or amnesty or other similar legal action in respect of any offence or crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable);
4.
I have never unlawfully distributed or sold a controlled substance (drug);
5.
I am not currently nor have I ever been to my knowledge under investigation by the Garda Siochana/Police force of any state in relation to the commiting of a crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable);
6.
I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform Access Healthcare Limited if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Access Healthcare Limited.
7.
I acknowledge that my personal details will be stored and handled correctly by Access Healthcare Limited in accordance with the General Data Protection Regulation, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents – Garda Vetting, Occupational Health, References).
8.
I give permission to Access Healthcare Limited to confirm reference letters with the referees and to validate passport and GNIB Cards with the passport office and immigration.
9.
I agree that Access Healthcare Limited can send me texts and emails regarding jobs and relevant information.
10.
I give permission to Access Healthcare Limited to give copies of relevant documents to the relevant appraisal bodies including the HSE for Auditing purposes.
11.
I give permission to Access Healthcare Limited to give my timesheets to Clients for auditing purposes and for the purpose of verification of signatures and to authorize payment.
12.
I give Access Healthcare Limited permission to use my date of birth when verifying my registration by email with the Healthcare and Midwifery Board of Ireland (NMBI).
13.
I acknowledge that I have been given a copy of the terms and conditions of service issued by Access Healthcare Limited, which is mine to keep, and furthermore that I have read those terms and conditions and agree to abide by them.
14.
I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my occupational Medical History on this form.
15.
I acknowledge and confirm that Access Healthcare Limited is authorised to apply for and obtain a Garda Vetting check and references from any previous employers and educational establishments.
16.
I agree that the maximum weekly working time specified in Regulation 4(1) of the Organisation of Working Time Act 1997 shall not apply to working with Access Healthcare Limited.
17.
I understand that if I am on a student visa I can only work 20 hours per week during term time. I understand that I have a responsibility to monitor this, in addition, if my position as a student changes, I must inform  Access Healthcare Limited.
18.
I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for Access Healthcare Limited, I must inform Access Healthcare Limited.
19.
I confirm that when asked about my working history (primarily, but not exclusively, for the purpose of the Agency Workers Directive) I will provide accurate information.
20.
I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have, Access Healthcare Limited may cease to offer me further agency placements  without notice, as well as claim for recovery of any payments I have received, together with a claim for loss of profit to Access Healthcare Limited.
Print name:
Date:
Sign Here: