Agency Nurse Application Form

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Your Personal Information

Role Applied for:

Your Name(Required)

First Last

Surname at Birth(Required)

Your Email Address(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile(Required)

Telephone

Date of Birth(Required)

DD slash MM slash YYYY

PPS Number(Required)

Best Time To Call You

When is the best time for us to reach you via telephone?

Where did you hear about PE Global?

In case of emergency contact / Next of kin(Required)

First Last

Phone(Required)

Relationship(Required)

Education & Career History

CV(Required)

Max. file size: 700 MB.

Education / Career History

Max. file size: 700 MB.

Referees

Please provide contact details for 3 referees: One must be from most recent employer, management level

Referee 1(Required)

Please list your previous employers, the dates you worked and the position you held

Name

Job Title

Company

Phone

Referee 2(Required)

Please list your previous employers, the dates you worked and the position you held

Name

Job Title

Company

Phone

Referee 3(Required)

Please list your previous employers, the dates you worked and the position you held

Name

Job Title

Company

Phone

Medical History and Health Declaration

Personal Details

Surname

First Names

Address

Date of Birth

Gender

Home Telephone

Mobile Telephone

GP Name

GP Telephone

GP Address

Sickness Absence

Please indicate time lost from work or education in the last 2 years due to illness. Please specify the date, length and reason for absence.

Questionnaire

Please tick the appropriate Yes or No box for the following questions.

1. Do you have, or have you ever had, any medical conditions or operations in the past 5 years?(Required)

Yes

2. Are you at present attending a doctor for medical care, taking any medication or on a waiting list for hospital assessment or treatment?(Required)

Yes

3. Have you ever suffered a work related illness, or given up work because of ill health?(Required)

Yes

4. Do you have any impairment/disability (physical or mental) or specific learning disability which may affect your ability to work?(Required)

Yes

5. Have you ever had any kind of back, joint or muscle problem?(Required)

Yes

6. Have you ever had: Dermatitis, Eczema, Psoriasis or any other skin condition?(Required)

Yes

7. Have you ever had any mental illness which might affect your ability to work? (including anxiety, depression, self-harm, eating disorders, psychological or emotional problems)(Required)

Yes

8. Have you ever suffered from tuberculosis (TB)?(Required)

Yes

8(a). Within the past 12 months?(Required)

Yes

8(b). Has any family member or close contact been treated for TB?(Required)

Yes

8(c). Have you had a cough for more than 3 weeks?(Required)

Yes

8(d). Have you coughed up blood?(Required)

Yes

8(e). Have you had any unexplained weight loss?(Required)

Yes

8(f). Have you suffered from night sweats or fever?(Required)

Yes

9. Have you ever had a drug or alcohol problem?(Required)

Yes

10. Do you have difficulty with your eyesight (including colour blindness)?(Required)

Yes

11. Do you have difficulty with your ears or hearing?(Required)

Yes

12. Have you ever suffered from any of the following: loss of consciousness including fainting attacks, blackouts, dizziness, epilepsy?(Required)

Yes

13. Have you ever suffered a disorder of the bladder or kidneys?(Required)

Yes

14. Have you ever suffered from any of the following: Heart disease or circulatory problems: including high blood pressure, varicose veins?(Required)

Yes

15. Have you ever suffered with chest or lung problems; Asthma, Bronchitis?(Required)

Yes

16. Do you have any allegeries; including allergies to drugs, food or latex?(Required)

Yes

17. Have you ever received treatment for a bowel or gastric problem?(Required)

Yes

18. Do you have any other medical condition not previously mentioned here?(Required)

Yes

19. Have you received your Covid 19 vaccine?(Required)

Yes

If you answered "yes" to any of the above, please provide more information below.

If you have ever had any other Health issues not mentioned above, please provide more information below.

Declaration(Required)

I declare that the above is true to the best of my knowledge. I declare that I understand, accept and confirm the entitlement of PE Global to reject my application or terminate my employment (in the event of a contract of employment having been entered into) where I have omitted to furnish PE Global with any information relevant to this health assessment or where I have made any false statement or misrepresentation relevant to this health assessment.

I agree to this declaration.

Declarations

Data Sharing and Internal Communications(Required)

I hereby confirm that I give permission to PE Global Healthcare for the following:

I give my permission to confirm reference letters with referees and to validate passport and GNIB cards with the passport office and immigration.

I give my permission to give copies of relevant documents to relevant appraisal bodies including HSE or Private Organisations for Auditing purposes and for the purpose of verification of signatures to authorise payment.

I give my permission to PE Global to verify my documents.

I give my permission to be contacted by phone, email or text message regarding accounts (timesheets, pay slips etc.), human resources (Training/upskilling/registration/application), bookings and operations (new shifts, change to shifts, uniform policy etc.), recruitment (new permanent and temporary roles) and other communications deemed necessary by PE Global Healthcare. (To opt out of this simply email health@peglobal.net)

I Consent and Give My Permission

Compliance in accordance with the HSE(Required)

I hereby confirm that I am aware of the following:

I am aware of my obligations under the Working Time Act 1997 (http://www.irishstatutebook.ie/eli/1997/act/20/enacted/en/html). The current limit is a maximum average net weekly working time of 48 hours per week over a period of 4 months. I confirm I have read and understand the working time regulations and it is my responsibility to adhere to same.

I am aware that I am responsible for ensuring my compliance documents are kept up to date. Failure to comply will result in work being withheld until the relevant course or registration is renewed.

I am aware I am responsible for ensuring I am immunized against Hepatitis B, Varicella and TB. I am aware I am responsible for keeping a regular check on my antibodies so that I am not putting myself or others at risk.

I Am Aware and Confirm

Declaration of Disclosure(Required)

I hereby confirm that:

I have never been arrested for, or convicted of, an offence or crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable), either in Ireland or in any other state.

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 commission of a crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable).

I am not currently nor have I ever been the subject of disciplinary action by any professional or statutory body with responsibility for regulation of nursing or medical professions.

I hereby authorise PE Global Healthcare and/or its relevant HSE or Private organization to verify any part of this declaration with relevant party (Garda Siochana or relevant regulatory body).

I hereby confirm that I will inform PE Global Healthcare of any convictions, pending or otherwise that occur after the date of signing this document.

I Confirm

Confidentiality Agreement and Health & Safety Practice(Required)

I hereby confirm that I am aware as an agency staff of PE Global Healthcare who will carry out a shift/assignment in either the HSE or private sector, I agree to abide by the following:

I undertake never to discuss patients, their families or otherwise with anybody other than an authorised person. I will not disclose to any person (unless authorised) any information acquired by me concerning any HSE or Private organisation, its staff or procedures. I accept that any breach of confidentiality may be pursued through the legal systems. I undertake and agree to inform PE Global Healthcare immediately if I come in contact with any clinical risk of if I pose a risk to patient or staff safety.

I accept that should any dispute arise between agency staff member and another party, it will be dealt with by PE Global Healthcare and not by placement facility. I understand and accept that PE Global Healthcare have the right to relocate me at any time.

I confirm that I will not disclose to any person, any information regarding PE Global Healthcare, its staff, its clients or procedures to any authorised person.

I confirm that on arrival to assigned shift I will make myself aware and familiar with fire exit locations, emergency response procedures and each departments safety statement. I confirm I will report any unsafe condition, practice, substance, equipment or situation as soon as reasonably practicable to the person in charge.

I confirm I will notify PE Global Healthcare if I have any special health and safety requirements. For example: Pregnancy, if you have just given birth or are breastfeeding.

This is so that we can assign you to suitable environments.

I Accept and Confirm

Hand Washing Technique Declaration(Required)

Hand washing is the single most important procedure in the implementation of infection control.

It is essential to wash hands frequently and correctly. All Agency workers are obliged to follow hand washing procedures whilst of duty, according to the HSE Guidelines for Hand Washing Technique.

(Copy of the Hand Washing Technique is available to you upon your request.)

I confirm I have read and understand the information regarding hand washing procedures and will adhere to this technique whilst on duty for PE Global.

I Accept and Confirm

Declaration(Required)

I agree to the following:

I confirm that the information given on this application form is complete and correct. I agree to PE Global Healthcare terms and conditions and I confirm that I have read and understood the PE Global Healthcare Staff Handbook. I understand that if I have a need for any clarification, I can contact PE Global on 021-4297900.

The Agency is authorised to acquire any information sought concerning the application and regarding my work character or skills and that this information may be forwarded to PE Global Client Organisations.

I agree to treat as confidential any information received concerning the business of PE Global or its Client Organisations.

PE Global will not be liable for professional negligence, errors, omissions, or accidents whilst you are under the Client Organisations direction and control.

I Agree and Confirm

Optional

Note: Failure to submit will mean you will default to the basic rate of pay. Please not that you are responsible for notifying PE Global each year that you progress up an increment.

Verification of Service Form

Forms to be completed by each relevant organisation.

Upload Verification of Service Form Here
Upload your resume in .pdf, .doc or .docx format
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Upload Prone Procedures and Occupational Health Form Here
Upload your resume in .pdf, .doc or .docx format
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Upload Garda Vetting Form Here
Upload your resume in .pdf, .doc or .docx format
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Agency Nurse Application Form

Agency Nurse Application Form