HCA Reg | Medsol

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Your Details
Next of Kin Details
Qualifications
References
Additional Info
Influenza

HCA Registration

1 Your Details

Your Details

First Name

Last Name

Address

Street

County

Country

City

Post Code

Contact Info

National Insurance Number

Main Contact Number

Other Contact Number

Email Address

Do you drive?*

Do you have access to your own vehicle?*

Additional Information

How did you hear about us?

If "Referral", "Friend", or "Other" please add more detail

What is the name of your recruitment consultant?

Grade and Speciality

HCA Registration

2 Next of Kin

Next of Kin Details

Name of Next of Kin

Relationship

Phone Number

Next of Kin Details

Street

County

Country

City

Post Code

HCA Registration

3 Qualifications

Qualifications

Please ensure you add all qualifications here using the "add new" section.

Qualification Details

Qualification

Institution

Location

Year Obtained

HCA Registration

4 References

References: Please add your last 3 years of Employment.

Please ensure you add all references here using the "add new" section. Please make sure you provide full references for the past 3 years.

Referee Details

Name of Referee

Hospital/Trust/Company Name

Referee email address

Referee contact number

Start date of employment

End date of employment

Name of Referee

Hospital/Trust/Company Name

Referee email address

Referee contact number

Start date of employment

End date of employment

HCA Registration

5 Additional Information

Additional Info

GDPR Consent Request *

GDPR Consent Request Medsol Group value the privacy of those who provide personal data to us. Full details about what information we collect about you, and how we collect, use, share and protect it, are set out in our Privacy Policy. This consent request relates to our processing of your: 1. medical information (including occupational health information); and 2. criminal records data your provide to us on this registration form; and 3. any further information you provide to us about the above; and 4. any information released to us by any of the Institutions listed in the Information Release above; 5. further information regarding your health and/or criminal convictions which come to light to us during the recruitment process or during your time on assignment with our client(s). Any such information we collect about you is known as special category data and is something we require your express, informed consent to us collecting and processing such data. Medical information We will, as the supplier of your services to our client, need to collect or will receive medical information relating to: your Health and disability as provided by you in this registration form; 1. your Health and disability as provided by you in this registration form 2. any updates to that information; 3. your Immunisation records; 4. your Occupational health, including as release by any of the Institutions listed in the Information Release above; 5. any further information regarding your health or medical records which come to light to us during the recruitment process or during your time on assignment with our client(s); 6. any absence from work you may require due to illness or disability or for the purpose of attending medical appointments. Such information will typically include doctors' sick notes and hospital admission letters. We will share this information with the relevant client. Criminal records We will also collect information (including from you and via DBS checks) about your criminal record, including information about unspent and spent convictions. This includes: 1. information you provide to us in this registration form; 2. any DBS check certificate(s) you provide to us; 3. the results of any DBS checks we carry out on you. We will share this information with the relevant client and, where applicable, any master vendor involved in the supply of your services. By ticking below, you consent to Medsol Healthcare Services Limited, GPS Locums Limited and Healthcare Staffing Solutions Limited processing the categories of personal data listed above as set out in our Privacy Policy and in particular for: 1. assessing your suitability to work in a role within the medical profession; and 2. complying with our legal and contractual obligations to our clients to collect such information. Please note that you are entitled to withdraw your consent at any time, and may do so by contacting info@medsolhealthcare.com If you withdraw your consent, then we will stop processing your special category personal data (as listed above), unless we have either a specific legal requirement, or an alternative legal basis, to continue processing it. Consequently, if you withdraw your consent, we may not be able to provide services to you (for example, if our client requires us to collect and use of your special categories of data). Information Release consent Medsol Healthcare Services Limited, GPS Locums Limited and Healthcare Staffing Solutions adhere to the NHS Executive Code of Conduct. Under this code it is our responsibility to check our candidates’ medical qualifications, History and work history as stated on their CV. To enable us to do this and maintain our compliance with the Code of Conduct we require your authorisation for the necessary Universities, Royal Colleges and NHS Trusts and Occupational Health departments to release the information to us. By signing below you are giving authorisation for the above institutions to release any relevant information they hold on file for you to the Compliance officers in accordance with the EU Regulation 2016/679 ("GDPR") and any laws or regulations ratifying, implementing, adopting, supplementing or replacing GDPR.

I consent Medsol Healthcare Services Ltd, GPS Locums Ltd and Healthcare Staffing Solutions Ltd processing my personal data and hereby give permission for the above mentioned Institutions to release any relevant information held on record about me, to the officers to enable them to confirm my qualifications, work history and Occupational Health.

Information Release Consent*

Medsol Group adhere to the NHS Executive Code of Conduct. Under this code it is our responsibility to check our candidates’ medical qualifications, History and work history as stated on their CV. To enable us to do this and maintain our compliance with the Code of Conduct we require your authorisation for the necessary Universities, Royal Colleges and NHS Trusts and Occupational Health departments to release the information to us. By signing below you are giving authorisation for the above institutions to release any relevant information they hold on file for you to the Compliance officers in accordance with the EU Regulation 2016/679 ("GDPR") and any laws or regulations ratifying, implementing, adopting, supplementing or replacing GDPR

I hereby give permission for the above mentioned Institutions to release any relevant information held on record about me, to the officers of Medsol Group to enable them to confirm my qualifications, work history and Occupational Health.

By signing this registration form you confirm the following*

Medsol Healthcare Services Limited, GPS Locums Limited and Healthcare Staffing Solutions adhere to the NHS Executive Code of Conduct. Under this code it is our responsibility to check our candidates’ medical qualifications, History and work history as stated on their CV. To enable us to do this and maintain our compliance with the Code of Conduct we require your authorisation for the necessary Universities, Royal Colleges and NHS Trusts and Occupational Health departments to release the information to us. By signing below you are giving authorisation for the above institutions to release any relevant information they hold on file for you to the Compliance officers in accordance with the EU Regulation 2016/679 ("GDPR") and any laws or regulations ratifying, implementing, adopting, supplementing or replacing GDPR

I have read and fully understood Medsol Healthcare, GPS Locum’s and Healthcare Staffing Solution’s Candidate Handbook V4180118 and will adhere to these procedures which include Company Complaints procedure • I have read and understood the Agency Workers Regulations which are stated in Candidate Handbook V4180118 • I have read and agree to Medsol Healthcare, GPS Locum’s and Healthcare Staffing Solution’s terms and conditions which are stated in Medsol Group Candidate Terms of Business - v3. • All of the information I have provided in my application with Medsol Group is true and correct • I understand that the information provided to Medsol Group will be provided to our clients for the purposes of the recruitment and at times may be made available to external bodies (i.e. auditors) to enable us to meet our contractual obligations. • I have read and understood Medsol Healthcare Services Limited, GPS Locums Limited's and Healthcare Staffing Solutions privacy policy. • I can confirm that I will maintain my Right to Work status for my full term of employment and inform Medsol of any changes.

Equal Opportunity Statement*

Medsol Group are committed to a policy of equal opportunities for all work seekers and shall adhere to such a policy at all times and will review on an on-going basis on all aspects of recruitment to avoid unlawful or undesirable discrimination. We will treat everyone equally irrespective of sex, sexual orientation, marital status, age, disability, race, colour, ethnic or national origin, religion, political beliefs or membership or non-membership of a Trade Union and we place an obligation upon all staff to respect and act in accordance with the policy. Medsol Group shall not discriminate unlawfully when deciding which candidate/temporary worker is submitted for a vacancy or assignment, or in any terms of employment or terms of engagement for temporary workers. Medsol Group will ensure that each candidate is assessed only in accordance with the candidate’s merits, qualification and ability to perform the relevant duties required by the particular vacancy.

I confirm I have read and understand the above Equal Opportunities Statement.

Payslip Request*

By contracting via Medsol healthcare I hereby agree that if I am paid via a third-party umbrella company then I give permission for Medsol to audit and view my payslips at any time to ensure I am complying inside of IR35 legislation

I confirm I have read and understand the above Equal Opportunities Statement.

Do you have any health issues or a disability relevant to the position or role you seek?*

If "Yes", please specify

If you have a disability, what are your needs in terms of reasonable adjustmentin order to perform the role sought, access this recruitment service and attend an interview, or to take aptitude tests etc?

Working Time Regulations*

I have read and understood Medsol Group Working Time Regulations within Candidate Handbook V4190516 and agree that the 48 hour average weekly working limit will not apply in my case. Should you wish to opt out please tick this box:

I wish to opt out of the working time regulations

I do not wish to opt out of the working time regulations

DBS Update Service Consent*

I hereby give Medsol Healthcare Services Limited, GPS Locums Limited and Healthcare Staffing Solutions consent to conduct a DBS online service check if registered, using my DBS I have provided which will enable my Disclosure to become portable for their agency use.

Please read and confirm you have read and adhere that applications for Locum medical positions are exempt from the Rehabilitation of Offenders Act 1974 and you are required to declare prosecutions or convictions, including those considered 'spent' under the Act.*

Yes, I have read and confirm

Have you been convicted of a criminal offence, been bound over or cautioned or are currently the subject of any police investigations, which mightlead to conviction, an order binding over or a caution in the UK or other country?*

Have you ever been the subject of any professional misconduct proceedings or suspensions for an employer, or are such pending or threating against you either in the UK or abroad?*

HCA Registration

6 Influenza Declaration

Influenza Declaration

Have you had the Influenza vaccine within the last year?*

If you have declined the Influenza vaccine, please can you provide a reason as to why?

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