Optimal CareTech Application Form

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Personal Details

Name
Current Address
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.

Emegency Contact Details

Emergency Contact Name
Pay Type

Working Hours

Checkboxes

Source

Where did you hear about us?

Additional Information

Professional References

Please enter your first referee's details
Name of Referee
Address
Can we contact immediately
Please enter your second referee's details
Name of Referee
Address

Declaration of Criminal Convictions

Have you ever been subject to the following
Have you ever been the subject of a conviction, caution, reprimand and warning?
Do you have any criminal proceedings pending?
Do you have an original DBS disclosure certificate?
Are you signed up to Update Service?

General Data Protection Regulation (GDPR) & Contact Consent

All personal data provided by you (the applicant) will be treated as confidential and stored / managed on our secure servers. We do however require your consent to process and transmit your information to third parties for the purpose of finding you suitable employment and obtaining essential supporting documentation. This consent covers all information we may require whilst representing you; including but not limited to your application, training & compliance, work placements, payroll and general day-to-day correspondence. Temporary work dictates the need for quick, effective communication for us to secure assignments for you. It is therefore essential for us to maintain regular contact with you across multiple channels. This includes; phone, Email, SMS and in-app push notifications (where applicable). Your consent is required for us to do so. We take data privacy and security very seriously and your personal information will be processed and secured in accordance with The General Data Protection Regulations (GDPR). Our privacy policy can be viewed on our website.

Do you give consent?

Declaration

I declare that the details given by me on this application form are correct to the best of my knowledge and belief. I understand that if I have given any information which is false, or I withhold any relevant information, this may lead to my application being rejected, or if already appointed, to my dismissal. I understand that information given on this form will be processed by a computer and used for registration purposes under the Data Protection Act. I authorise XP Medical to disclose any convictions declared above to any potential employers in accordance with the DBS Code of Practice and the Rehabilitation of Offenders Act. I also accept the Terms & Conditions of Business.

NEW EMPLOYEE MEDICAL QUESTIONNAIRE

The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by Optimal Care Tech and may need to be seen by an occupational health advisor or physician. Your record will be held on file for a short period of time and may be subject to audit. Your file may also be used to cross reference should you be registered on our system by one employer.

Medical History

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
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 in the box that will appear below
Do you think you will need any adjustments or assistance to help you do the job?

Tuberculosis

Clinical diagnosis and managment of tuberculosis, and measures for its prevention and control (NICE 2006)
Have you lived continuously in the UK for the last 5 years?
Have you had a BCG vaccination in relation to Tuberculosis

Do you have any of the following

A cough which has lasted for more than 3 weeks
Unexplained weight loss
Unexplained fever
Have you had tuberculosis (TB) or been in recent contact with open TB?

Chicken Pox or Shingles

Have you ever had chicken pox or shingles?

Immunisation History

Have you had any of the following imunisations?
Triple vaccination as a child (Diphtheria / Tetanus / Whooping cough)
Polio
Tetanus
Hepatitis B (if Yes please give dates below)

Proof of Immunity

Please send the following to application@optimalcaretech.co.uk or upload below

Varicella
You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity

Tuberculosis
We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare)

Rubella,Measles
Certificate of "two" MMr vaccinations or proof of a positive antibody for Rubella and Measles

Hepatitis B
You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above

Click or drag a file to this area to upload.
Upload proof of Varicella, TB, rubella/Measles and Hep B immunity

Exposure Prone Procedures

Will your role involve Exposure Prone Procedures

Declaration

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for Optimal CareTech to make recommendations to my employer.
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Package overview
Refund reason

Refund reason

Refund reason
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