Registration Form

Name

Address

Next of Kin

IMPORTANT

ONLY CLICK THE LINK BELOW IF YOU WANT TO SAVE THIS FORM AND COME BACK LATER.

PRESS NEXT TO GO TO THE NEXT PAGE.

Educational Details

Please complete the information below:

Employment History

Please enter details of the past five years work history starting with your current or most recently held position. You must state reasons for any breaks in employment. Please enclose copy of your current CV if you have one.

A full employment history that shows as a minimum the Temporary Worker’s previous 5 years’ continuous employment history (if any and as appropriate) including, but not limited to, any previous or current employment or assignments with other Framework Agencies or recruitment agencies and explanations for any gaps in employment.

Work Preferences

NEXT OF KIN

DISCLOSURE AND BARRING SERVICE (DBS)

REHABILITATION OF OFFENDERS ACT 1974 – Please answer all five questions

Because of the nature of the work for which you are applying , Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies.

I agree for you to contact these references and only once references have been received will my application go any further.

I certify that the information on this form is to the best of my knowledge correct. I understand that any engagement entered into will be subject to satisfactory references being received and a satisfactory DBS Disclosure.

PROFESSIONAL REGISTRATION & REVALIDATION

In order to meet the framework requirements you need to provide with the details of your previous and upcoming revalidation.

REFERENCES

Please provide 2 professional references that are covering at least 3 years, one of which should be from your current or most recent employment.

We will request these references at the next available opportunity, if you haven't asked for their permission please do not fill out this section.

Referee 1

Referee 2

Skills & Experience Checklist

Nurses Only

Skills & Experience Checklist

Individual Training Record

Food & Hygiene

Health & Safety

Fire Awareness

COSHH

Infection Control

First Aid

Deprivation of Liberty

Medication Administration

Epilepsy Awareness

Mental Capacity Act

Control & Restraint

SOVA

SOCA

Mandatory Training

Please state below Mandatory and any other training which is still valid. (E.g. Manual Handling / Food Hygiene, and ENB courses that are relevant to the role applied for. Please note evidence of training is required. Original certificates will need to be presented at interview. It is imperative that mandatory training is undertaken and valid to the areas in which you require work. All training is provided by suitably qualified instructors and is provided to all agency members.

If required, I confirm I am happy to go through Kolloco Medical Services' Training before I can start to work with them.

If we are paying for the training, then it will be deducted from your future Pay Cheque.

Do you have or have you ever had any of the following:

Immunization Information

Proof of immunizations must be provided

DECLARATION:

I declare that all the above is true to the best of my knowledge. I am willing to provide details of my GP should the company require a medical report.

EQUALITY AND DIVERSITY MONITORING PROGRAM

Kolloco Medical Services is committed to Equal Opportunities in employment and welcome applications from all sections of the community. In order to ensure the effectiveness of this policy and for no other purpose you are requested to place a tick in the appropriate boxes below and complete the details as required. The information is exclusively for monitoring purposes and will be kept strictly confidential.

Please tick the appropriate box that indicates your cultural background.

FAILURE TO COMPLETE THIS FORM WILL NOT AFFECT YOUR APPLICATION. If you believe that there has been unfair discrimination in making the appointment, there is a process of investigation available, subject to reasonable grounds for suspicion being identified. If you wish to pursue an unfair discrimination complaint please contact the Director of Kolloco Medical Services.

General Information

Eligibility to work

Before you can work with Kolloco Medical Services, we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK in accordance with Home Office guidance on the prevention of illegal working.

Rehabilitation Offenders Act

Please note that this application will require an enhanced DBS criminal background check, and a POVA first check. Even if you already have a disclosure for other employment, legal requirements are that all agency workers must obtain a new check.

Please complete the enclosed DBS form and return it with your application. It can take approximately up to four weeks for the completion of the process.

Unfortunately, we are not able to facilitate any agency work placements until we have received a certificate from the Criminal Records Bureau.

Association with Kolloco Medical Services, may result in placements involving contact with children and vulnerable adults.

In such cases, a record of all convictions must be given as this is required in accordance with the rehabilitation of Offenders act 1974.

Failure to disclose any convictions which are later discovered could lead to termination of placements and removal from our register.

Equal Opportunities Statement

Equal opportunity for all work seekers is of paramount importance at Kolloco Medical Services. As such, Kolloco Medical Services is committed to a policy of equal opportunities, and shall adhere to non discriminatory practices at all times on all aspects of operation including recruitment and placement, and to unlawful or undesirable discrimination. Every worker will be treated equally regardless of race, ethnic or national origin, colour, sex, sexual orientation, disability, marital status, age, religion, political beliefs, offending history or membership or non-membership of a trade union and we require commitment from all staff and agency workers to respect and act in accordance with the policy.

Assessment of candidates will solely be based upon the candidates’ merits, qualification and ability to perform the relevant duties required by a particular vacancy.

Confidentiality Agreement

I confirm that during every assignment and afterwards:

• To hold information relating to the client in the strictest confidence, ensure it is kept safely and securely when not in use. I acknowledge that no information is to be removed from the client’s premises without the permission of the client.
• To use such information only for the purpose of the work for which it was given.
• Not to disclose to any third party or copy the information except as is required in the course of my duties.
• Any breach, either by me or a third party, may result in legal proceedings being brought by the Client against me to recover any losses that have occurred as a result of a breach.

If you are worried by any information you have obtained and consider that you should talk about it to someone else, MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER.

Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register.

Any conversations that compromise the patient relating to the above statement may jeopardize my position with Kolloco Medical Services.

Working Time Directives

I understand that I am under no obligation to work more than an average of 48 hours in any week - these hours include any hours that I work with other employers as well as Kolloco Medical Services

I further understand that I may work more than 48 hours per week if I wish.

Under the terms of engagement, I realise that I may turn down any assignment at any time, for any reason without detriment.

By signing this declaration, I am signifying that any hours in excess of an average of 48 per week are worked by my choice, but also make it clear that this declaration does not mean that I will work more than an average of 48 hours in any week.

I undertake to inform if the total number of hours I work in a week from all forms of employment exceeds 48, in order that Kolloco Medical Services may take this into consideration before offering work to me.

I understand that it is necessary to inform the agency of my availability for work each week and accept that there are no guaranteed hours of work.

Identification Authority

In line with the requirements of current legislation I give Kolloco Medical Services my permission to hold and transmit my photograph and date of birth, when necessary, to those clients who require identification cards when on assignment for them.

Uniform Deduction Form

I accept that I must wear a uniform together with black trousers and black shoes (no high heels or trainers) on any care assignment with Kolloco Medical Services. Jeans and non-closed shoes are not acceptable.

I am happy to pay the cost price for my uniform.

I understand that I must not wear my uniform when working for anyone other than Kolloco Medical Services.

I also give permission to Kolloco Medical Services, to make deductions from my wages for the cost of my uniform.

I will be required to return the uniform in the event of dismissal/resignation.

Working with Challenging Behaviour

When working in this industry there are hazards associated with the industry. I appreciate and accept that one of these hazards is possible aggressive behaviour from Challenging service users. Service users may present challenging and aggressive behaviour and this is out of the control of Kolloco Medical Services.

I understand and accept that I am under no obligation as an Agency Worker to accept assignments. I accept that there is this risk and accept that this risk is as a result of the industry and not of Kolloco Medical Services.

I understand that if I am unhappy with an assignment I can withdraw my submission at any time with reasonable notice dictated in my contract for service, and as a result will not hold Kolloco Medical Services liable for any injury or loss of earnings as an agency Worker.

I understand that as an Agency Worker I am not employed by Kolloco Medical Services and therefore I am not guaranteed any assignments and have no claim against Kolloco Medical Services at any time and for any reason whatsoever for loss of any earnings as an Agency Worker.

I understand that if I am injured or affected in any other way whilst on an assignment that this is not the fault or liability of Kolloco Medical Services.

Charges

If I need the office staff to provide me with transport for a shift I understand I will have to pay a fee which will be agreed with me on the day.

I also understand that I need to give at least 12 working hours notice if cancelling a shift or I will be charged a fee of up to £50, we understand there are certain situations that cannot be helped and we will always take these into consideration. When cancelling a shift I understand that I should call the on call mobile phone as well as texting.

Terms of Engagement

1. SEVERABILITY:
   If any of the provisions of these Terms 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.
2. NOTICES
   All notices which are required to be given in accordance with these Terms 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.
3. GOVERNING LAW AND JURISDICTION
   These Terms are governed by the law of England & Wales / Scotland and are subject to the exclusive jurisdiction of the Courts of England & Wales

Ankit Ranjan
Director – Operations
Kolloco Medical Services Limited

GDPR Consent

In order to continue to keep you up to date with your payslips and future job opportunities, please respond below verifying you are happy to continue to receive this communication from us. As of the 25th May 2018, we can no longer continue to communicate with you via Email, SMS or Post, unless we receive your permission to do so due to the new GDPR regulations.

Failure to respond will result in us being unable to send you your payslip via email on a weekly basis as well as any communication relating to Kolloco Medical Services's activity.

I would like to receive communications via:

Personal Declaration

• I hereby confirm that the information provided on my application is correct and true to the best of my knowledge and that I have not withheld any information that should be taken into account when offering me work.
• I understand that providing false or inaccurate information may result in the termination of any placement.
• I agree that I will make best endeavours to make myself aware of the Health & Safety procedures for each client I am assigned to.
• I confirm that I have read and understood the Terms of Engagement and the terms of the declaration and agree to be bound by them.
• I hereby declare to the best of my knowledge that the information given above, including any supporting documents is true and correct.
• I consent to my personal data and CV being forwarded to clients.
• I consent to references being passed on to potential employers.
• I consent to the processing of personal data, and for any enquiries to be made to confirm all matters concerning my application, and employment such as qualifications, dates of employment, experience, Disclosure and Barring Services check, and health checks, and for the release by other people and organisations for that information might be necessary for that purpose.
• I understand that false information might lead to y dismissal.
• If during the course of a temporary assignment, the Client wishes to employ me direct, I acknowledge that Kolloco Medical Services, will be entitled either to charge the client an introduction/transfer fee, or to agree an extension of the hiring period with the Client (after which I may be employed by the client without further charge being applicable to the client).
• I understand that acceptance on to the Kolloco Medical Services, register may only be granted after relevant checks are made, satisfactory references are received and I have attended an interview / Agency Induction.

REGISTRATION FORM DECLARATION

I declare that by signing this form I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without the relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities.

I agree that Kolloco Medical Services LTD retains the right to hold this registration form and any other data required to process it and pass onto any authorized third party and the details held within. I also agree to use all reasonable efforts to assist to comply with the Data Protection Act 1998.

I agree that Kolloco Medical Services LTD retains the right to share my information with:

• the Authority, its representatives and any Professional Body,
• Participating Authorities, their representatives and any relevant Professional Body; and
• in the case of any approved Sub-Contractor relationships that Kolloco Medical Services Ltd may contractually enter into under the NHS Framework Agreement, the Managed Service Provider chosen by the Participating Authority to deliver the Services,

In addition, I confirm that that all the information provided is true and accurate and that I have received and agree to Kolloco Medical Services LTD terms of engagement and Staff Handbook.