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Personal Information

Have there been any proceedings of medical negligence or professional misconduct against you and have you ever been suspended or dismissed?
Have you been convicted of an offence?

Address History

Any individual paid by Pennine Social Care must complete an address history form to give us a list of all addresses where you have lived for the last 5 years.


This is required for DBS (Disclosure and Barring Service) purposes. You must disclose all addresses including anywhere you have lived in the United Kingdom or any other countries, along with approximate dates (to the nearest month) when you lived at each address. 

Address One

Address Two

Address Three

Address Four

Address Five

Bank Details

We pay your wages directly into a bank account. Please provide details below.

Please provide the address associated with your Bank Account.

Next of Kin Details

Reference Details

Please provide the details of two referees if you have them.

Previous employers are preferred, however, if you do not have a second employer a character reference will suffice.

Medical Questionnaire

The purpose of this questionnaire is to assess you are medically fit to work as a Healthcare Assistant/Nurse and are fit to work nights.

Do you suffer from any of the following health conditions?

Heart or Circulatory Disorders?
Stomach or Intestinal Disorders?
Hepatitis B or C?
Sickle Cell Anaemia?
COPD, Asthma or any other respiratory disorder?
HIV or any other immune system disorder?
Any condition which causes difficulty sleeping?
Any medical condition requiring medication to a strict timetable?
Any other health factors that might affect fitness at work?

If you have answered 'yes' to any of the above questions, you may be asked to see a doctor or nurse.

Compliance Documents

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