Pinnacle Occupational Health Specialists

Joining Pinnacle Occupational Health Specialists couldn't be easier! Simply complete the form below, click on the "Submit" button, and your details will be sent through to us. You will then be contacted by one of our staff and invited to attend an interview, at which point you will be asked to sign a declaration that the information given in the form below is accurate and that you agree to abide by the Pinnacle Occupational Health Specialists Conditions of Membership.

If you need more room to answer any of the questions fully, please use the "Any other information" box at the bottom of the form.

If you have any difficulty submitting the form, you can also download a copy of the form here (requires Acrobat Reader) and send it to us, or contact us to request a form to be sent by post.

In accordance with the Data Protection Act 1998, the data gathered on this Application Form is used by Pinnacle Occupational Health Specialists to inform you of potential work opportunities by mail, telephone or email. We may also use this data to conduct market research and to keep you informed of the latest healthcare developments, legislation and policy changes and company initiatives. We may also contact you with offers of goods or services that we believe may be of interest to you from carefully selected third parties. If you do not wish to receive details of these offers by mail, telephone or email, please tick this box.

Any sensitive data such as racial or ethnic origin, religious beliefs, health and criminal records is for monitoring and selection purposes only. By submitting this Application Form you are expressly permitting us to use this information in this way.

[To help us deal with your enquiry promptly please complete all fields marked *] .

Branch you are applying to:
(if you are making a general application rather than applying for a specific job)

Personal Details

Surname:	*	First Name(s):	*
Title:	*	Maiden/Previous Names:
Address:	*	Home Tel No:	*
		Work Tel No:
Town:	*	Mobile Tel No:
County:		Email address:	*
Post code:	*
DOB:		Nationality:

NI Number:	*	Professional Registration:
Passport No:		UKCC No:	*
Do you require a work permit/visa?	*	Expires:
Do you hold a clean UK driving licence?		Professional Indemnity:
Do you have a car?		RCN Unison MDU
Language spoken:		Other:
		Renewal date:

Education (please continue in the "Any other information" box at the bottom of the form if necessary)
Secondary schools attended:	From:	To:	Qualifications obtained:

Names of Colleges / Universities / Training Hospitals attended:	From:	To:	Qualifications obtained:	Dates:

Current Employer
Name of Employer:	From:	To:	Position:	Brief details of job:

Employment History (please list in order, with most recent first)
Name of Employer:	From:	To:	Position:	Brief details of job:

References: please supply the names and contact details of two professional referees, one of which should be your most recent employer.
	Referee 1	Referee 2
Name:
Designation:
Address:
Post code:
Tel no:
Fax no:
May we contact them immediately?

Next of kin for contact in an emergency
Name:	*	Address:
Relationship:		Contact number:

Criminal Convictions

In order to protect the public the post for which you have applied is exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders Act (exemptions) Order 1975. It is not therefore in any way contrary to the Act to reveal any convictions you have had which would otherwise be considered spent. Any such information will be kept in strictest confidence and used only in the suitability of the application for a position where such an exemption is appropriate.
Do you have a criminal record? *
If yes, please give details in the "Any other information" box at the bottom of the form.

Equal Opportunities
Pinnacle Occupational Health Specialists is committed to the establishment and development of a positive policy of equal opportunities in employment and in the delivery of its services. The sole criterion for selection or promotion is the suitability of any applicant for the job.

Declaration
You will be asked at interview to sign the following declaration:
The information I have given above is accurate to the best of my knowledge. I understand that deliberate omission or mis-statement of the facts may result in refusal or termination of employment with Pinnacle Occupational Health Specialists.

Health Declaration Please complete by answering yes or no to the following questions. Where you have answered yes, please give details in the appropriate box.
Question	Response	Details
1. Have you visited your GP in the last 2 years?
2. Have you attended hospital as an in-patient or out-patient in the last 5 years?
3. Do you suffer from any of the following:
Chest condition, including asthma
Heart / circulatory disorder
Diabetes
Skin complaint
4. Have you ever suffered from fits, faints or blackouts?
5. Have you ever suffered from back problems or any musculo-skeletal disorder?
6. Have you ever suffered from any mental illness?
7. Do you take any medicines?
8. Do you have any allergies?
9. Do you have any physical or mental impairment which may affect your ability to work safely?

Immunisation History
	Immunity	Vaccination	Date	Details
Hepatitis A
Hepatitis B
Polio
Tetanus
Chicken Pox
Rubella
BCG

You will be asked at interview to sign to confirm that the information given in this health declaration is correct to the best of your knowledge.

Skills Checklist
Activity		Competency
Pre employment health assessment	*
Health screening and surveillance	*
Lifestyle screening	*
Health education / promotion	*
Drug & Alcohol screening	*
Counselling	*
Spirometry	*
Audiometry	*
Phlebotomy	*
Keystone / vision testing	*
ECGs	*
Work station / ergonomic assessment	*
Manual handling	*
Risk assessment	*
Environmental monitoring	*
Safety audit	*
Advice on PPE	*
Travel vaccination / Travel advice	*
BCG & Mantoux test	*
Yellow Fever	*
Malaria Prophylaxis	*
First Aid teaching	*
Computer literate	*
Additional skills: please note any relevant skills, not already listed.
Please let us know when you acquire new skills, so that we may update our records.
Any other information
Please use this box to provide us with any additional information you believe important to your application, including any family / commitments, and to continue answering any of the above sections.