Clinical Response Group CIC Application Form

CONFIDENTIAL APPLICATION FOR CLINICAL RESPONSE GROUP CIC SELF EMPLOYED CONTRACTORS

This form will be used to process your application for working with us. If successful it will be held on file for reference as required. If you are unsuccessful or wish to terminate your application, we will destroy it. If you wish to temporarily hold your application we will retain it until such time as you advise us otherwise.

Successful Applicants must update Clinical Response Group CIC with any information on the form which may have changed since the point of application.

When completing this form, please contact us using enquiries@teamcrg.co.uk if you have any questions or would like to discuss an answer in confidence using the subject line of 'Your Name - Application Query'.

You are required to supply full and correct information. Any application that is found to contain false information or fraudulent information will be immediately terminated and any offer of contractor work from us immediately withdrawn.

Personal Details

Full Name*
Address*

Right to Work

Please upload the following evidence of your right to work in the UK.

Documents Proving Right to Work in the UK:

If you're a British or Irish Citizen:

You could use the following:

  • British or Irish Passport / Passport Card (Current or expired)

Or if you do not have a Passport:

  • A UK Birth or Adoption Certificate
  • An Irish Birth or Adoption Certificate
  • A certificate of Registration or Naturalisation as a British Citizen

In conjunction with the above, if you do not have a passport, you must also provide an official letter or document from a previous employer or government agency. For example, you could use a letter from HM Revenue and Customs (HMRC), the Department for Work and Pensions (DWP), or the Social Security Agency in Northern Ireland.

The letter must show your name and National Insurance number.

If you're not a British or Irish Citizen:

If you are not a British or Irish Citizen, you can prove your right to work with:

  • A Share Code - You can get a share code online.
  • Your eligible immigration documents.

You can choose which option you use. We will not reject your application because you provided eligible immigration documents instead of a share code.

If you cannot prove your right to work:

If you're not a British or Irish Citizen, we can check if you can work using the Employer Checking Service.

If you're a Commonwealth Citizen, you may be able to get documents to show that you can work in the UK through the Windrush Scheme.

Accepted formats: PDF, JPG, PNG. You can select multiple files.
Do we need to undertake a check using the Employer Checking Service? *

Professional Qualifications and Skills

Please list any professional qualifications and skills including the date obtained.

Are you looking for Paid work or Voluntary Work? (Please note, this will not affect your application) *

Employment History

Please provide employment details from the past 3 Years. Please explain any reasons for gaps in employment.

May we contact them? *
Are there any gaps in employment within the last 3 years? If YES, please give details below. *
Have you ever been under investigation by an employer/regulatory body or received any formal disciplinaries including any warnings/restrictions or dismissals? *

References

It is the applicant's responsibility to confirm with referees that they are happy to be contacted using the details supplied and provide a reference. Clinical Response Group CIC collects this information under the grounds of Legitimate Interest as outlined by the Data Protection Act 2018 and will only use the information for the purposes intended.

Please supply the details of TWO referees. One of which must be your current/most recent employer. This is to ensure we have two suitable references from you.

Please Note: Referees must not be related to you and cannot be any member of the company involved in the process of recruiting you.

Referee 1
May we contact them prior to interview? *
Referee 2
May we contact them prior to interview? *

Emergency Details

Please note that all information provided will be held in the strictest confidence and only accessed by the relevant manager/s in the event of an emergency or for safety purposes.

Please list your emergency contacts in the order in which you would like us to contact them.

N.B. All details throughout this application must be full and correct information. Any application that is found to contain false information or fraudulent information will be immediately terminated and any offer of contractor work from us immediately withdrawn.

Clinical Response Group CIC Confidential Declaration

Under the terms of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, the people you will be working with includes those defined as a 'vulnerable' group. This means that you are exempt from the act and can be asked to declare any previous criminal convictions including spent convictions. This information can then be used as a basis for deciding whether or not you are suitable to work with these groups of people.

Disclosing an offence does not necessarily mean automatic barring from appointment to the role you are applying for.

Failure to disclose any criminal convictions will result in the immediate termination of your application or services engaged by us.

This form is strictly confidential and except where allowed in law, will only be seen by those responsible for the appointment and, when appropriate, the Safeguarding Manager.

All declarations will be kept securely under the terms of the Data Protection Act 2018.

If you answer YES to any question, you will be required to provide details in the box provided at the bottom of this section, ensuring that you provide the number to the question you are answering.

ALL PREVIOUS CONVICTIONS, WITH THE EXCEPTION OF MINOR MOTORING CONVICTIONS LEADING TO ONLY A FINE AND/OR ENDORSEMENT POINTS, MUST BE DISCLOSED.

Significant harm involves the serious ill treatment of any kind including: Neglect, physical, emotional, or sexual abuse, or impairment of physical or mental health development.

Please be aware you will be expected to confirm at the bottom of this section declaring that the information you have provided is Accurate and Factual.

Please also be aware that knowingly supplying false information may constitute a criminal offence and will immediately terminate your application.

1a) Have you ever been convicted of a criminal offence? (Including any spent convictions under the Rehabilitation of Offenders Act 1974) *
1b) Have you ever been cautioned by the police, given a reprimand, warning or bound over to keep the peace? *
1c) Are you currently under investigation? *
1d) Have you ever been found by a court exercising Civil Jurisdiction (Incl matrimonial or family jurisdiction) to have caused significant harm to a child or young person under the age of 18... *
2a) Has your conduct ever caused or likely to have caused significant harm to a child or young person... *
2b) Has your conduct ever caused or likely to have caused significant harm to a vulnerable adult... *
2c) To your knowledge, has it ever been alleged that your conduct has resulted in any of these things... *
3) Has a child in your care... been removed from your care, been placed on the Child Protection Register or been the subject of a Care Order... *
4) Do you/Have you had any health problem(s) which might affect your work with children, young people under the age of 18 or vulnerable adults? *
Do you have a current Enhanced DBS with Adult and Child Barred lists on the Updates Service? *
Please be aware that Clinical Response Group CIC has the right to undertake regular checks of your DBS certificate using the Updates Service. If you checked NO in regard to already having a DBS, please input N/A

Disclaimer:

Please be aware that Clinical Response Group CIC must see a physical copy of your DBS certificate. Legally, we cannot retain a copy of it on file but must see the original certificate. If you are supplying us with a DBS that you already have, we will need to see further documents to verify your identity and that the DBS certificate belongs to the person supplying it. Please use the DBS Documents box below to supply these. If you are unsure what you need to supply please visit: DDC Documentation Required

Obtaining a DBS Certificate:

If you answered no to the above, you will be required to obtain one and register it with the Updates Service.

Clinical Response Group CIC can facilitate this for you for the cost of the DBS check + an administration fee of £10. Volunteers will only need to pay the cost of the DBS check.

Registering with the DBS Updates Service:

For paid contractors, you will also bear the annual cost of the Updates Service Subscription at £13 per annum. For Volunteers, Registering with the Updates Service is completely free.

Disclaimer:

If we facilitate you obtaining a DBS, it will be delivered directly to you. Once you have received it you must contact us to arrange a time for us to see the certificate in person.

Accepted formats: PDF, JPG, PNG. You can select multiple files.
I confirm that the information provided is Factual and Accurate and that I will update Clinical Response Group CIC immediately if any of the above circumstances change. *

Media Consent

Please be aware you can withdraw consent at any time via email enquiries@teamcrg.co.uk.

Do you consent to your image being used for social media purposes within Clinical Response Group CIC? *

Clinical Response Group CIC 48 Hour Agreement

Please complete the following below in regards to the working time regulations. Please be aware that the 48 hour agreement applies to the total hours worked in ANY and ALL employment whether paid or voluntary.

I DO/DO NOT agree to work for more than an average of 48 hours per week. *
I understand that I can change my mind at any time about my agreement to work more than an average of 48 hours per week and if I do change my mind I will give 7 days notice... *

ID Card Photo

Please upload an image of yourself for use on your ID card.

(Please ensure this is of Head and Shoulders only and against a white background. Headwear should not be worn unless for religious reasons. Prescription lenses may be worn.)

Declaration

I confirm that all information provided within this application form is true and accurate... *

How did you hear about us?

(Optional)