Candidate
Application Form
Personal Details
Surname:
Forenames:
Title: (Please Tick) Mr Mrs Miss Ms
Address:
Eircode:
PPS Number:
Occupation Nurse Health Care Assistant
Email address:
Tel Mobile:
Home:
Date of Birth:
Sex: Male Female
Bank Details
IBAN:
BIC:
Emergency Contact
Name:
Relationship:
Tel Number:
Eligibility Of Employment
Please state your Nationality:
Irish Work status:
EU Passport: Work Permit - stamp type (0-5): 
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)
Access Nursing Website Referral Please specify name: 
Indeed Search Engine Exhibition Irishjobs.ie
Other Please specify: 
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 Compliance 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
NMBI retention certificate (Nurses only)
Yes No

Professional qualification (Please Tick)

Nursing degree (Nurses only)
Yes No
Fetac Level 5 or equivalent (HCA only)
Yes No
Non-violent crisis intervention training (Psychiatric nurses only)
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. Computers
6. ENT
7. Geriatrics
8. ICU (Adults)
9. ICU (Paeds)
10. IV Policy
11. Medical
12. Midwifery
13. Neonates
14. Nephrology
15. Neurosurgery
16. Obstetrics/Gynae
17. Occ Health
18. Oncology
19. Orthopaedics
20. Paediatrics
21. Phlebotomy
22. Psychiatry
23. Renal
24. Special Care (Babies)
25. Surgical
26. Theatre/OR
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 Nursing 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 Nursing 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 Nursing Limited if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Access Nursing Limited.
7.
I acknowledge that my personal details will be stored and handled correctly by Access Nursing 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 Nursing 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 Nursing Limited can send me texts and emails regarding jobs and relevant information.
10.
I give permission to Access Nursing Limited to give copies of relevant documents to the relevant appraisal bodies including the HSE for Auditing purposes.
11.
I give permission to Access Nursing 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 Nursing Limited permission to use my date of birth when verifying my registration by email with the Nursing 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 Nursing 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 Nursing 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 Nursing 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 Nursing 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 Nursing Limited, I must inform Access Nursing 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 Nursing 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 Nursing Limited.
Print name:
Date:
Sign Here: