PLEASE NOTE OUR DUBLIN OFFICE HAS NOW MOVED TO 16 HARCOURT STREET, DUBLIN 2

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1 PLEASE NOTE OUR DUBLIN OFFICE HAS NOW MOVED TO 16 HARCOURT STREET, DUBLIN 2 For any queries, please call or interviewer@nurseoncall.ie

2 REF NO: Application Form Registered Nurse Nurse on Call Carer NurseOnCall Hospital Support Other NurseOnCall Hospital Support Interview took place in: Dublin Cork Drogheda Waterford Elsewhere Have you ever registered/worked with Nurse on Call/ NurseOnCall Hospital Support before? Yes No Where did you hear about Nurse on Call/ NurseOnCall Hospital Support? Form: 184 Revision Status: 2

3 REF NO: APPLICANT DETAILS (BLOCK CAPITAL LETTERS PLEASE) Position Applied for Surname Forenames Recent Photo Please sign back of photo Maiden Name Address Telephone Date of Birth Passport Number Means of Transport Mobile Gender EU or Non EU Driving License PPS Number (optional until after commencing work) NMBI No NMBI 1 st Reg Date Next of Kin(this person will only be contacted in the case of an emergency) Name Address Tel No Relationship QUALIFICATIONS RGN RNID RPN RSCN RM OTHER Form No:184 Revision Status: 3

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16 REF NO: Confidential Disclosure Agreement Confidential Disclosure agreement between Nurse On Call/ NurseOnCall Hospital Support Services, 59 Ranelagh, Dublin 6 And All nurses/carers and support staff who carry out assignment/shifts or work in HSE Locations, All Hospitals, Nursing Homes, Private Home or any other Location. I the undersigned shall regard as confidential and shall not disclose to any person, other than a person authorised, any information acquired by me concerning the HSE/all other locations, its staff or procedures; concerning the identity of any patient at HSE/all other locations premises or concerning the medical condition of or treatment received by any such patient. I undertake never to discuss patients, their families or otherwise with anybody other than an authorised person. I accept that any breach of confidentiality may be pursued through the legal system or in the case of a nurse may be referred to fitness to practise within An Bord Altranais. I undertake and accept that is my responsibility to ensure Manual Handling, CPR, NVCIT, Infection Prevention and Control are kept up to date at all times. I undertake and accept that Garda Vetting is carried out by Nurse On Call/NurseOnCall Hospital Support Services. I also undertake to inform Nurse On Call immediately if any new court case proceedings are commenced or convictions recorded against me. I undertake and agree to inform Nurse On Call/NurseOnCall Hospital Support Services immediately if I come in contact with any clinical risk or if I pose a risk to patient or staff safety. I understand and accept when I am placed in a hospital/or any location that I am not considered any employee of that hospital/nurse on Call/NurseOnCall Hospital Support Services or any other location at time irrespective of how ever long I may be placed there. I accept that I will at no point become an employee of the HSE/Nurse on Call/ NurseOnCall Hospital Support Services or any location where I am assigned by Nurse On Call/NurseOnCall Hospital Support Services irrespective of however long I am placed there, but the HSE/or any location will provide supervision and I will be under their direction and control for the duration of the shift. I accept that if there are any disputes of any nature that they will be dealt with by Nurse On Call/ NurseOnCall Hospital Support Services and not by the HSE/or any location where I am placed. I understand and accept that Nurse On Call/NurseOnCall Hospital Support Services has the right to relocate me any time. I the undersigned shall regard as confidential and shall not disclose to any person any information regarding Nurse On Call NurseOnCall Hospital Support Services, its staff, its clients or procedures to any unauthorised person. Signed Date Print Form: 205 Revision Status: 3

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29 Ref No: INTERNAL COMMUNICATIONS DECLARATION I give Nurse on Call permission to contact me by phone, or text message with regards to: Accounts e.g. Payslips, Timesheets, Tax etc. Human Resources e.g. Training Programmes, Training Updates, Registration & Application Process etc. Bookings/Operations e.g. Shifts available, Change or cancellation of shifts, client policies (parking/infection control/uniform policy) etc. Recruitment: e.g. Temporary & Permanent Roles Available Other important communications as deemed necessary by our Management Team Please be assured that Nurse on Call will never send on your contact details to a 3 rd party. If you have left the company or wish to opt out of receiving s/texts, please nurseoncalljobs@nurseoncall.ie or call Please note this will stop all and text communications so if you then wish to receive payslips you will need to write to the Accounts Department, Nurse on Call, 59 Ranelagh Village, Dublin 6 Signed: Date: Print Name: Mobile Phone Number to be used for communications: address to be used for communications: Form: 229 Revision Status: 1 st Issue