Nursing Reg

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Nursing Registration

1 Your Details

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First Name

Last Name

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Street

County

Country

City

Post Code

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Grade and Speciality

Professional Body Registration Number

National Insurance Number

Main Contact Number

Other Contact Number

Email Address

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How did you hear about us?

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

What is the name of your recruitment consultant?

Nursing Registration

2 Next of Kin Details

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Name of Next of Kin

Relationship

Phone Number

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Street

County

City

Post Code

Country

Nursing Registration

3 Appraisal

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Are you prepared for your next appraisal?*

Appraisers Name

Appraisers Contact Details

Appraisers Grade

When was your last NHS appraisal?

When is your next revalidation due?

Were there any areas of concerns raised in your most recent appraisal?*

If "Yes", please detail what steps have been agreed to deal with these concerns below

If you cannot supply us with an appraiser details please give a brief explanation as to why?

4 Qualifications

Appraisal

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

Qualification Details

Insurance

I currently hold personal indemnity insurance*

If "Yes" Name of Insurer

If not held I have been aware of the limits of the indemnity available under the authority's clinical negligence scheme and have been advised of the availability of personal professional indemnity insurance

Nursing Registration

5 Referee Details

References: Please add your last 3 years of Employment.

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

Referee Details

Nursing Registration

7 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

Nursing Registration

8 Self-Appraisal

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Full Name

NMC Number

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How many hours are you working a week?

Has your job role changed in the last year?

Do you feel that you are up to date with your training? Can Medsol Healthcare support you with any further/future training?

What do you find most difficult about your role working as a locum?

What strengths/skills do you posses which help you deliver high standards of care?

Are there any barriers in place that prevent you from developing or utilising certain skills?

What are your plans for the next 12 months?

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Nursing Registration

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Appraisal

Qualification Details

Insurance

Nursing Registration

References: Please add your last 3 years of Employment.

Referee Details

Nursing Registration

Additional Info

Nursing Registration

Influenza Declaration

Nursing Registration

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