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Agency Staff Request for Approval Form
Name
*
First
MI
Last
Phone
For the interview with 18WS leads
Postcode
Post Code
DOB
DD slash MM slash YYYY
Gender
*
-- Please select --
Female
Male
Role
*
-- Please select --
Nurse
Consultant
HCA
ODP
Mammographer
Specialty
*
-- Please select --
Anaesthetics
Colorectal Surgeon
Dermatology
Endoscopy
ENT
First Assistant
Gastroenterology Clinic
Gynaecology
Neurology
Ophthalmology
Oral Surgery
Outpatient Department
Radiography
Surgery
T&O
Urology
NI Number
*
Please submit Updated CV
*
Max. file size: 1 GB.
Reference 1
*
Max. file size: 1 GB.
Reference 2
*
Max. file size: 1 GB.
Compliance Documentation
NMC pin
*
Are they consultant grade?
*
Yes
No
GMC Number
*
Date on the Specialist Register
*
DD slash MM slash YYYY
Date of CCT
DD slash MM slash YYYY
Full Appraisal
*
Max. file size: 1 GB.
Indemnity Insurance
*
Max. file size: 1 GB.
Letter of Good Standing – Must Cover 5 Years
*
Max. file size: 1 GB.
Surgical Log Book
*
Max. file size: 1 GB.
Passport ( with visa if applicable)
*
Max. file size: 1 GB.
Fit to work
*
Max. file size: 1 GB.
Enhanced DBS Certification ( needs to be on update service)
*
Max. file size: 1 GB.
DBS update service check
*
Max. file size: 1 GB.
Mandatory Training
*
Max. file size: 1 GB.
Life Support
*
Max. file size: 1 GB.
Limited Company Name
Company Registration Number
Other supporting documentation
Max. file size: 1 GB.
Home Office Share Code (if EU national)
PPE and Fit Mask Testing
Have you completed Personal Protection Equipment training in your place of work?
*
Yes
No
Date PPE training completed
DD slash MM slash YYYY
Have you been Fit mask tested?
*
Yes
No
Date Fit mask test completed
DD slash MM slash YYYY
Which masks have you been fit test for?
FFP3 1863
FFP3 1873V
FFP3 8833
3M Aura 9332 FFP3 Valved Dust Mask Respirator
FFP3 FSM16
3M 3030V
GVS 3000
cardinal health RFP3FV
3M: 9330+
Spireor: VSP352TF
GVS: F31000
Please list any others you may have been FIT mask tested for
Have you had your Covid-19 vaccination?
*
Yes
No
Endoscopy Registered Nurse
Essential Skills (Enodscopy Registered Nurse)
*
Select All
1 year minimum recent experience within an acute Endoscopy Unit
Signed off as a competent Endoscopy Nurse with the ability to manage and participate in emergency situations and GI bleeds
Able to assist in therapeutic emergencies
Ability to work in unfamiliar work environments, using initiative and experience
Able to administer IV medication and fluids
Identify and escalate a deteriorating patient
All essential skills ticked
*
Yes
No
Desired Skills (Endoscopy Registered Nurse)
Endoscopy based training course
Ability to gain IV access
Mentorship course
18 WS Competencies Form (if you don’t have this we can send you a copy of our template)
*
Max. file size: 1 GB.
Dermatology
Dermatology
Dermatology Roles
Outpatient Registered Nurse
Surgical Registered Nurse
HCA
Dermatology Roles
Outpatient Registered Nurse
Surgical Registered Nurse
HCA
Essential Skills (Outpatient Registered Nurse)
*
Minimum of 1 year's post registration experience in dermatology in an acute setting
Current practice in dermatology in an acute setting
Essential Skills (Outpatient Registered Nurse)
*
Minimum of 1 year's post registration experience in dermatology in an acute setting
Current practice in dermatology in an acute setting
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desired Skills (Outpatient Registered Nurse)
Wound management/tissue viability course
Experience of allergy testing
Recognised dermatology qualification
Desired Skills (Outpatient Registered Nurse)
Wound management/tissue viability course
Experience of allergy testing
Recognised dermatology qualification
Essential Skills (Surgical Registered Nurse)
*
Minimum of 1 year's post registration experience in dermatology in an acute setting
Current practice in dermatology in an acute setting
Essential Skills (Surgical Registered Nurse)
*
Minimum of 1 year's post registration experience in dermatology in an acute setting
Current practice in dermatology in an acute setting
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desired Skills (Surgical Registered Nurse)
Wound management/tissue viability qualification
Recognised dermatology qualification
1 year's experience of assisting in dermatological surgery
Administration of local anaesthetics
Desired Skills (Surgical Registered Nurse)
Wound management/tissue viability qualification
Recognised dermatology qualification
1 year's experience of assisting in dermatological surgery
Administration of local anaesthetics
ENT, Oral and Maxillofacial
ENT, Oral and Maxillofacial
ENT, Oral and Maxillofacial
ENT, Oral and Maxillofacial
ENT, Oral and Maxillofacial Roles
Registered Nurse
Dental Nurse
HCA
ENT, Oral and Maxillofacial Roles
Registered Nurse
Dental Nurse
HCA
ENT, Oral and Maxillofacial Roles
Registered Nurse
Dental Nurse
HCA
ENT, Oral and Maxillofacial Roles
Registered Nurse
Dental Nurse
HCA
Essential Skills (Registered Nurse)
*
1 year's post registration experience in an acute ENT setting
Current practice experience in an acute ENT setting, including discharge advice to patients post procedure
Experience of assisting in nasoendoscopic investigations
Essential Skills (Registered Nurse)
*
1 year's post registration experience in an acute ENT setting
Current practice experience in an acute ENT setting, including discharge advice to patients post procedure
Experience of assisting in nasoendoscopic investigations
Essential Skills (Registered Nurse)
*
1 year's post registration experience in an acute ENT setting
Current practice experience in an acute ENT setting, including discharge advice to patients post procedure
Experience of assisting in nasoendoscopic investigations
Essential Skills (Registered Nurse)
*
1 year's post registration experience in an acute ENT setting
Current practice experience in an acute ENT setting, including discharge advice to patients post procedure
Experience of assisting in nasoendoscopic investigations
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desirable Skills (Registered Nurse)
Post registration ENT nursing course
Mentorship course
IV cannulation and administration of medication
Desirable Skills (Registered Nurse)
Post registration ENT nursing course
Mentorship course
IV cannulation and administration of medication
Desirable Skills (Registered Nurse)
Post registration ENT nursing course
Mentorship course
IV cannulation and administration of medication
Desirable Skills (Registered Nurse)
Post registration ENT nursing course
Mentorship course
IV cannulation and administration of medication
Essential Skills (Dental Nurse)
*
National Examination Board for Dental Nursing Diploma in Dental Nursing
2 years' post qualification in a dental/OMF acute setting
Current practice as a dental nurse in an acute setting
Essential Skills (Dental Nurse)
*
National Examination Board for Dental Nursing Diploma in Dental Nursing
2 years' post qualification in a dental/OMF acute setting
Current practice as a dental nurse in an acute setting
Essential Skills (Dental Nurse)
*
National Examination Board for Dental Nursing Diploma in Dental Nursing
2 years' post qualification in a dental/OMF acute setting
Current practice as a dental nurse in an acute setting
Essential Skills (Dental Nurse)
*
National Examination Board for Dental Nursing Diploma in Dental Nursing
2 years' post qualification in a dental/OMF acute setting
Current practice as a dental nurse in an acute setting
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desirable Skills (Dental Nurse)
NEBDN Diploma in Dental Sedation Nursing
Experienced in providing advice to patients following maxillofacial procedures
Specific knowledge in the running of a max fax surgical list (ward, theatre and recovery)
Desirable Skills (Dental Nurse)
NEBDN Diploma in Dental Sedation Nursing
Experienced in providing advice to patients following maxillofacial procedures
Specific knowledge in the running of a max fax surgical list (ward, theatre and recovery)
Desirable Skills (Dental Nurse)
NEBDN Diploma in Dental Sedation Nursing
Experienced in providing advice to patients following maxillofacial procedures
Specific knowledge in the running of a max fax surgical list (ward, theatre and recovery)
Desirable Skills (Dental Nurse)
NEBDN Diploma in Dental Sedation Nursing
Experienced in providing advice to patients following maxillofacial procedures
Specific knowledge in the running of a max fax surgical list (ward, theatre and recovery)
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desirable Skills (HCA)
Phlebotomy certificate/experience
Desirable Skills (HCA)
Phlebotomy certificate/experience
Desirable Skills (HCA)
Phlebotomy certificate/experience
Desirable Skills (HCA)
Phlebotomy certificate/experience
Surgery
Surgery
Surgery Roles
Preoperative Registered Nurse
Operating Department Practitioner
Recovery Registered Nurse
Ward Nurse
HCA
Scrub Registered Nurse
Surgery Roles
Preoperative Registered Nurse
Operating Department Practitioner
Recovery Registered Nurse
Ward Nurse
HCA
Scrub Registered Nurse
Essential Skills (Preoperative Registered Nurse)
*
1 year's minimum experience in preoperative assessment in an acute setting
Current or recent practice in preoperative assessment in an acute setting
Current or recent practice in phlebotomy and ECGs
Essential Skills (Preoperative Registered Nurse)
*
1 year's minimum experience in preoperative assessment in an acute setting
Current or recent practice in preoperative assessment in an acute setting
Current or recent practice in phlebotomy and ECGs
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Essential Skills (Recovery Registered Nurse)
*
Minimum of 2 years' experience in various types of theatre recovery
Current practice in recovery (permanent/part time/bank/agency)
ILS or ALS course
IV medication administration certificate
Essential Skills (Recovery Registered Nurse)
*
Minimum of 2 years' experience in various types of theatre recovery
Current practice in recovery (permanent/part time/bank/agency)
ILS or ALS course
IV medication administration certificate
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desirable Skills (Recovery Registered Nurse)
Recovery training certificate
Airway management certificate
Pain management certificate
IV cannulation
Desirable Skills (Recovery Registered Nurse)
Recovery training certificate
Airway management certificate
Pain management certificate
IV cannulation
Essential Skills (Ward Nurse)
*
1 year's post-registration experience in an acute surgical setting
Current pradctice in an acute surgical setting
ALERT course or equivalent
Essential Skills (Ward Nurse)
*
1 year's post-registration experience in an acute surgical setting
Current pradctice in an acute surgical setting
ALERT course or equivalent
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desirable Skills (Ward Nurse)
IV administration of medication certificate
ILS course
Wound management course/experience
Desirable Skills (Ward Nurse)
IV administration of medication certificate
ILS course
Wound management course/experience
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Desirable Skills (HCA)
Phlebotomy certificate/experience
Experience of undertaking ECGs and bladder scanning
Desirable Skills (HCA)
Phlebotomy certificate/experience
Experience of undertaking ECGs and bladder scanning
Essential Skills (Scrub Registered Nurse)
*
Minimum 2 years' post registration experience in theatre scrub nursing in an acute setting
Current practice as a scrub nurse in an acute setting
Minimum 1 year's post registration experience in one or more scrub specialties. Please detail below:
Essential Skills (Scrub Registered Nurse)
*
Minimum 2 years' post registration experience in theatre scrub nursing in an acute setting
Current practice as a scrub nurse in an acute setting
Minimum 1 year's post registration experience in one or more scrub specialties. Please detail below:
All Essential Skills Ticked
*
Yes
No
All Essential Skills Ticked
*
Yes
No
Scrub Nurse Specialties
ENT
General surgery
Ophthalmology
Orthopaedics
Urology
Vascular surgery
Gynaecology
Scrub Nurse Specialties
ENT
General surgery
Ophthalmology
Orthopaedics
Urology
Vascular surgery
Gynaecology
Desirable Skills (Scrub Registered Nurse)
Post registration theatre scrub qualification
Desirable Skills (Scrub Registered Nurse)
Post registration theatre scrub qualification
Ophthalmology
Ophthalmology Roles
Registered Nurse (Outpatient and Ward)
Ophthalmic Technician
HCA
Ophthalmology Nursing Competencies
Glaucoma Outpatient
Cataract Outpatient
Medical Retina Outpatient
Adnexal Outpatient
Intravitreal Injection Nurse
Theatre Nurse
Day Surgery
Essential Skills (Glaucoma Outpatient)
*
Minimum 2 years’ experience in ophthalmology nursing
Recent practice experience in ophthalmology nursing
Proven ability/experience of visual acuity and visual field testing
Proven ability/experience of testing with slit lamp
Proven ability/experience of basic examination of the anterior chamber of the eye
Proven ability/experience of using pachymeter
Proven ability/experience of measuring intra ocular pressure by tonometer (GAT)
Proven ability/experience of checking Van Herrick and anterior chamber depth
Proven ability/experience of checking Relative Afferent Pupillary Defe
Proven ability/experience administer full range of common medications and provide patient advice on same
Proven ability/experience to undertake phasing
Essential Skills (Cataract Outpatient)
*
Minimum 2 years’ experience in ophthalmology nursing
Recent practice experience in ophthalmology nursing
Proven ability/experience of visual acuity and visual field testing
Proven ability/experience of testing with slit lamp
Proven ability/experience of basic examination of the anterior chamber of the eye
Proven ability/experience of measuring intra ocular pressure by tonometer (GAT)
Proven ability/experience of checking Relative Afferent Pupillary Defect
Proven ability/experience administer full range of common medications and provide patient advice on same
Proven ability/experience to use Auto Refraction
Proven ability/experience to undertake basic biometry
Proven ability/experience of preoperative assessment
Proven ability/experience to interpret ocular coherence topography images and act on results
Proven ability/experience to assess and treat : raised intra ocular pressure; cystoid macular oedema; inflammation of the eye
Proven ability/experience in the use of atmospheric lenses to examine and check the fundus and posterior pole of the eye
Essential Skills (Medical Retina Outpatient)
*
Minimum 2 years’ experience in ophthalmology nursing
Recent practice experience in ophthalmology nursing
Proven ability/experience of visual acuity and visual field testing
Proven ability/experience of testing with slit lamp
Proven ability/experience of basic examination of the anterior chamber of the eye
Proven ability/experience of measuring intra ocular pressure by tonometer (GAT)
Proven ability/experience of checking Relative Afferent Pupillary Defect
Proven ability/experience administer full range of common medications and provide patient advice on same
Proven ability/experience to undertake blood glucose and BP testing
Assist as a runner in an intravitreal clinic
Proven ability/experience to assist in Fluorescine Angiography
Essential Skills (Adnexal Outpatient)
*
Minimum 2 years’ experience in ophthalmology nursing
Recent practice experience in ophthalmology nursing
Proven ability/experience of visual acuity and visual field testing
Proven ability/experience of measuring intra ocular pressure by tonometer (GAT) and ICare
Proven ability/experience of checking Relative Afferent Pupillary Defect
Proven ability/experience to check Ishihara
Proven ability/experience to undertake probing and syringing of the lacrimal sac
Proven ability/experience in minor surgery
Proven ability/experience of preoperative assessment
Essential Skills (Theatre Nurse)
*
Minimum 2 years’ experience in ophthalmology nursing
Recent practice experience in ophthalmology nursing including scrub nurse
Proven ability/experience in operation of the phaco machine and surgical microscope
Proven ability/experience administer full range of common medications and provide patient advice on same
Essential Skills (Day Surgery)
*
Minimum 2 years’ experience in ophthalmology nursing
Recent practice experience in ophthalmology nursing
Proven ability/experience in admission and discharge of patients including follow up and post op care and advice
Proven ability/experience administer full range of common medications and provide patient advice on same
All Essential Skills Ticked
Yes
No
Outpatient Department
Outpatient Department
Outpatient Department Roles
Registered Nurse
HCA
Outpatient Department Roles
Registered Nurse
HCA
Essential Skills (Registered Nurse)
*
1 year's post-registration experience and an outpatient or ambulatory acute setting
Essential Skills (Registered Nurse)
*
1 year's post-registration experience and an outpatient or ambulatory acute setting
All Essential Skills Ticked
Yes
No
All Essential Skills Ticked
Yes
No
Desirable Skills (Registered Nurse)
Phlebotomy certificate/experience
Experience of undertaking ECGs and bladder scanning
Desirable Skills (Registered Nurse)
Phlebotomy certificate/experience
Experience of undertaking ECGs and bladder scanning
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
Essential Skills (HCA)
*
1 year's experience in the specialty in an acute setting
Current practice in the specialty in an acute setting
All Essential Skills Ticked
Yes
No
All Essential Skills Ticked
Yes
No
Desirable Skills (HCA)
Phlebotomy certificate/experience
Experience of undertaking ECGs and bladder scanning
Desirable Skills (HCA)
Phlebotomy certificate/experience
Experience of undertaking ECGs and bladder scanning
Essential Skills (Mammographer)
*
Able to provide specialist clinical technical services, including the carrying out of complex diagnostic procedures and calibrating highly specialist equipment
Undertakes mammography and assessment procedures, ensuring that nationally agreed quality assurance guidelines are met
Able to assist with digital stereotactic breast biopsies and wires
Ensures safe and efficient use of all x-ray equipment, taking action to resolve faults/problems and advising the Superintendent (Principal) Radiographer of action taken
Aware of the sensitive nature of the examination and respond appropriately to the diverse needs of the client e.g. uncertainty, anxiety, fear, denial and aggression
Records accurate radiation factors in line with IR (ME)R 2000 regulations and audit purposes
Endoscopists only
Do they undertake regular IBD screening Lists?
Yes
No
Do they undertake regular Barretts screening lists
Yes
No
Are they Bowel Cancer Screening Accredited?
Yes
No
Are they Bowel Scope Accredited
Yes
No
Which reporting systems do they use?
Are they registered with NED Database?
Yes
No
NED Data
Max. file size: 1 GB.
Any other comments
Person Filling in the Form
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