Positive Impacts Healthcare Ireland Ltd

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Surname:

Forenames:

Title (Please Tick): Mr. Mrs. Miss Ms.

Address:

Eircode:

PPS Number:

Occupation:

Email Address:

Tel Mobile:

Home:

Date of Birth:

Sex: Male Female

IBAN:

BIC:

Emergency Contact Name:

Relationship:

Emergency Contact Tel Number:

EU Passport or GNIB Card:

Nationality (as per passport):

Where did you hear about us?

Referral (Please Specify Name):

Organisation:

Department:

Name:

Title:

Address:

Contact Tel:

Email:

Start date:

End date:

Organisation:

Department:

Name:

Title:

Address:

Contact Tel:

Email:

Start date:

End date:

Professional Qualification (Please Tick):

NMBI Retention Certificate (Nurses Only)

Fetac Level 5 or Equivalent (HCA only)

Student Nurse ID

Social Care Degree/ Certification

Proof of Occupational Health (Please Tick):

Immunity to MMR

Immunity to Varicella

Hepatitis B Immunity

Course Experience Duration/Comments:

Course	Tick	Experience (Years)	Additional Comments
A&E
Burns/Plastic
Cardio Thoracic
CCI
ENT
Geriatrics
ICU (Adults)
ICU (Paeds)
IVC Policy
Medical
Midwifery
Neonates
Nephrology
Neurosurgery
Obstetrics/Gynae
Occ Health
Oncology
Orthopaedics
Paediatrics
Phlebotomy
Psychiatry
Renal
Special Care (Babies)
Surgical
Theatre / OR
Non-Violent Crisis Intervention (Psychiatric Nurses only)

Medical History (For Nurses Only):

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.

Questions	Yes	No
Do you have any illness/impairment/disability which may affect your employment?
Have you ever had any illness/impairment/disability which may have been caused or made worse by your employment?
Do you think you may need any adjustments or assistance to help you to carry out 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

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?	Yes	No
If yes, please provide date:
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 questions above, please provide additional information below:

Signed:

Date:

Declaration Form

The information above is true and I agree to inform Positive Impacts Healthcare Ireland 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.

Please Read Each Point Below Carefully:

I, HEREBY DECLARE THAT:

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; I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform Positive Impacts Healthcare Ireland.
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); I have never unlawfully distributed or sold a controlled substance (drug); 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 committing of a crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable);
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 Positive Impacts Healthcare Ireland if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Positive Impacts Healthcare Ireland.
I acknowledge that my personal details will be stored and handled correctly by Positive Impacts Healthcare Ireland 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).
I give permission to Positive Impacts Healthcare Ireland to confirm reference letters with the referees and to validate passport and GNIB Cards with the passport office and immigration.
I agree that Positive Impacts Healthcare Ireland can send me texts and emails regarding jobs and relevant information. I give permission to Positive Impacts Healthcare Ireland to give copies of relevant documents to the relevant appraisal bodies including the HSE for Auditing purposes.
I give permission to Positive Impacts Healthcare Ireland to give my timesheets to Clients for auditing purposes and for the purpose of verification of signatures and to authorize payment.
I give Positive Impacts Healthcare Ireland permission to use my date of birth when verifying my registration by email with the Nursing and Midwifery Board of Ireland (NMBI).
I acknowledge that I have been given a copy of the terms and conditions of service issued by Positive Impacts Healthcare Ireland which is mine to keep, and furthermore that I have read those terms and conditions and agree to abide by them.
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.
I acknowledge and confirm that Positive Impacts Healthcare Ireland is authorised to apply for and obtain a Garda Vetting check and references from any previous employers and educational establishments.
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 Positive Impacts Healthcare Ireland.
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 Positive Impacts Healthcare Ireland.
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 Positive Impacts Healthcare Ireland, I must inform Positive Impacts Healthcare Ireland.
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.
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, Positive Impacts Healthcare Ireland 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 Positive Impacts Healthcare Ireland.

Are there any fitness to practice issues with your registrations? Yes No

Signed

Name:

Date: