NHS Standard Application Form - Day in the Life

www.nhs.uk/jobs
NHS STANDARD APPLICATION FORM
Please fill in the Application form and check it carefully before returning it. If you wish to
apply on-line you can do so at www.nhs.uk/jobs. Please note that questions marked with an
asterisk * are mandatory and therefore must be answered.
For Office Use Only
Online Reference Number:
APPLICATION FOR EMPLOYMENT WITH………
APPLICATION FOR EMPLOYMENT
Job Reference Number
Job Title
Department
62-PAW10-162N
Public Health Support Worker
Public Health Nurses Barnstaple
Personal Details
* Surname/Family Name
Smith
* First Names Helen Ann
Name in which you are
registered with a professional
body (if applicable)
Title Mrs UK National Insurance No GJ 49 26 71 H
Address
1 Hill Avenue
Barnstable
Devon
* Postcode/ Zip code
BA3 8GY
* Country
Home Telephone 01584 568921 Mobile Telephone
UK
n/a
Work Telephone
Email Address
n/a
Helen.smith@yahoo.co.uk
May we contact you at work No
* Do you require us to obtain a work permit for you to work in the UK under the terms of the Immigration and Asylum Act 1996
No
Please supply details of any permit currently held including number, validity and expiry date.
Are you a Department of Work & Pensions New Deal Candidate
Are you an NHS professional returning to practice
No
No
NHS Standard Application Form, v.1.1 Page 1 of 10

MONITORING INFORMATION
* Date of Birth 28 September 1981
* Gender Female
Race relations (Amendment) Act 2000
As Public Sector Employers, NHS Organisations are required to collect details about an applicant’s ethnicity. This information is collected to
fulfil that obligation and is used for monitoring purposes only.
* I would describe my ethnic origin as follows:
Asian or Asian British
Bangladeshi
Indian
Pakistani
Any other Asian background
Black or Black British
African
Caribbean
Any other Black background
Mixed
White & Asian
White & Black African
White & Black Caribbean
Any other mixed background
White
British - x
Irish
Any other White background
Other Ethnic Group
Chinese
Any other ethnic group
I do not wish to disclose my ethnic origin
Employment Equality Regulations
In order to comply with these regulations, NHS employers are monitoring sexual orientation and religion/belief in applications.
* Please select the option which best describes your sexuality
Lesbian
Gay
Bisexual
Heterosexual - x
I would rather not answer
* Please indicate you religion or belief
Atheism
Buddhism
Christianity
Islam
Disability Discrimination Act 1995
Jainism
Sikhism
Other
Judaism
Hinduism
I do not wish to disclose my religion/belief - x
Under the terms of the Act a disability is defined as a ‘physical or mental impairment which has a substantial and long term effect on a person’s
ability to carry out normal day to day activities’. NHS employers welcome applications from disabled people.
* Do you consider yourself to have a disability
If yes, do you need special arrangements to
enable you to attend for interview
No
Yes
No
If so, please give details below
Rehabilitation of Offenders Act
In order to protect certain vulnerable groups within society, there are a number of posts and professions that are exempt from the provisions of
the Rehabilitation of Offenders Act 1974. These include posts where, in the normal course of their duties, successful applicants will have
access to persons in receipt of health services. If the post you have applied for falls within the above category, it will be exempt from the
provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act (Exceptions Order) 1975.
Applicants are therefore not entitled to withhold any information about convictions which for other purposes are ‘Spent’ under the provisions of
the Act and in the event of employment; any failure to disclose such convictions could result in dismissal or disciplinary action by the employing
organisation. Any information given will be confidential and will be considered only in relation to posts to which the order applies.
* Have you at any time received, or had pending, a court conviction No
If yes, please give details
NHS Standard Application Form, v.1.1 Page 2 of 10

If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory
disclosure from the Criminal Records Bureau. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of
employment.
Relationships
If you are related to a director, or have a relationship with a director or employee of an appointing organisation, please state the relationship
No
DECLARATION
The information in this form is true and complete. I agree that any deliberate omissions, falsification or misrepresentation in the application form
will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. This applies equally to any medical
questionnaire/forms I may complete.
I agree to the above declaration
Signature
H Smith
Name Helen Ann Smith Date 01/06/2010
Where did you see this vacancy advertised
NHS Website - x
Local Newspaper
Search Engine
British Medical Journal
Other Website
Health Service Journal
National Newspaper
Hospital Doctor
Doctor
Therapy Weekly
Nursing Times
GP
Nursing Standard
Other Professional Journal
Jobcentre Plus
Radio
Other
NHS Standard Application Form, v.1.1 Page 3 of 10

APPLICATION FOR EMPLOYMENT
Details entered in this part of the form will be held in the HR department of the recruiting organisation and will be made available to the shortlisting
panel.
Job Reference Number 62-PAW10-162N Online reference number n/a
Job Title
Department
Public Health Support Worker
Public Health Nurses Barnstaple
Education & Professional Qualifications
Include in this section all the relevant qualifications. Please also indicate subjects currently being studied.
Subject/Qualification Place of Study Grade/result Year
English - GCSE South Dartmoor School C 1996
Maths – GCSE South Dartmoor School C 1996
French - GCSE South Dartmoor School D 1996
Geography - GCSE South Dartmoor School D 1996
Science - GCSE South Dartmoor School D 1996
History - GCSE South Dartmoor School B 1996
RE - GCSE South Dartmoor School D 1996
H&S at Work – NVQ 2 Petroc college - Barnstable Pass 1999
Training Courses Attended
Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.
Course Title Training Provider Duration Date Completed
E Typing On line 10 weeks 2001
1 st Aid at Work Petroc college - Barnstable 5 days 1999
NHS Standard Application Form, v.1.1 Page 4 of 10

Membership of Professional Bodies
Include in this section any relevant professional registrations or memberships.
* Please indicate your Professional Registration status:
Not Required for this post
I have current UK registration
UK registration applied for
UK registration not yet applied for
I am a student
If professional registration is not required then go to Employment History.
If you are registered then please enter the relevant details below:
Professional Body
Membership or Registration type
Membership/Registration
PIN
Expiry/Renewal
Date
If you are applying for a post that requires professional registration you are required to provide the following information:
Are you currently the subject of a fitness to practise investigation or proceedings by a licensing or regulatory
body in the UK or in any other country
Have you been removed from the register or have conditions been made on your registration by a fitness to
practise committee or the licensing or regulatory body in the UK or in any other country
No
No
Employment History
Please record below the details of your current or most recent employer
Employer Name
Address
Ashleigh CofE Primary School
Bevan Road, Barnstaple, Devon , EX32 8LJ
Type of Business Education Telephone 01271 345143
Job Title
School Office Support
Start Date 1997 End Date 2002
Start of continuous NHS service
Grade
Reporting to (job title)
Salary
Notice Period
Reason for leaving (if applicable)
To raise a family
Description of your duties and responsibilities – Good Example
General office duties such as ordering office supplies, filing and generally ensuring that the office was presentable and welcoming. I was the
first point of contact for anyone contacting the school and handled all enquiries made by teachers, pupils, visitors and parents either in person,
by phone or in an email. I was required to coordinated staff meetings and type up notes and minutes and I was the appointed 1st Aider at work
and designated H&S person for the school.
Description of your duties and responsibilities – Bad Example
NHS Standard Application Form, v.1.1 Page 5 of 10

General office duties like answering the phone and talking to people who come into the school. Helping out with meetings and doing 1st aid if
a child hurts themselves.
NHS Standard Application Form, v.1.1 Page 6 of 10

Previous Employment
Please record below the details of your previous employment beginning with the most recent first. Please explain any gaps in employment in
the ‘Supporting Information’ section below. Please add additional employers/information on a separate sheet.
Previous Employer 1
Employer Name
n/a
Address
Job Title
From Date
Grade
To Date
Reason for Leaving
Description of your duties and responsibilities
Previous Employer 2
Employer Name
n/a
Address
Job Title
From Date
Grade
To Date
Reason for Leaving
Description of your duties and responsibilities
NHS Standard Application Form, v.1.1 Page 7 of 10

Supporting Information
In this section please give your reasons for applying for this post and additional information which shows how you match the person
specification for the job (you will have been sent this document with the application form). This can include relevant skills, knowledge,
experience, voluntary activities and training etc. If relevant to the post for which you are applying you should include details about research
experience, publications or poster presentation, clinical care (knowledge and skills) and clinical audit.
Supporting information (Please continue on additional sheets if necessary). – Good Example
I would like to apply for the role of Public Health Support Worker as advertised on NHS Jobs website. I feel that it
would be a rewarding job to which I could bring my office management skills (8) and customer care experience
(25). I also highly value the work of the NHS as I have first hand knowledge of the difference it can make and
would be delighted to work for this organisation. I like working in a variety of places (23) and with different types of
people as I find this very interesting and motivating.
I am looking for a part time role that is challenging, varied and where I can use the experiences that I gained from
5 years working in a busy school office (30). It was in that role that I was able to develop my verbal and written
communication skills (3) as I was required to handle all office enquiries. These could sometimes be very
challenging (13) as they came from pupils, teachers, visitors and parents who were sometime very upset about an
issue. I had to learn how to deal with stressful situations (19) calmly and know how to help find a quick solution to
a problem. I had to act in a professional manner at all times and adhere to the school strict equality (24) and
confidentiality policies (5, 21) as I was handling children’s data and personal details.
I was required to organise staff meetings which could be tricky trying to coordinate 30 busy people’s diaries. I
became skilled at getting all the paperwork ready on time (17). I was also responsible for minute taking during the
meetings so I put myself through an online E-typing course to improve my speed and typing accuracy (2, 12).
I was expected to use a wide range of IT programmes (6) and often helped out the other office staff who were not
quite so good on Word and Excel (12). I used all forms of communication (3, 4) such as phone, email, face-toface
to contact and respond to queries coming into the office and I am confident with them all.
I have had to learn effective time management strategies (7) in order to get both children to school or to their after
school activities on time. I often have to do this on my own as my husband works away from home a lot. It
required me to be very organised and prioritise (20) everything to make sure everything gets done.
I drive a car (10) and am used to taking all of the equipment (11) to and from the Scouts hut when I help out there
everything week. I love helping out and interactive with young children and encouraging them to do new activities.
I am enthusiastic about most things that I do and I think this helps a lot with the Scouts as you often have to
encourage some children to get involved. You really need to be able to use your own initiative (15, 18) and think
on your feet as to what activities you could be doing with the children to make sure they don’t get bored and
misbehave. It requires good team working (9) as there are lots of people all trying to get different things done. I
have been CRB checked for this role and understand child protection issues (29)
I have had experience of dealing with distressed people (13, 22), particularly in the NHS Clinic where I am a
volunteer play worker (28). Some parents are understandably upset when their child is ill in the clinic and I find it
rewarding if I can provide some comfort for them. I have experience of dealing with sensitive situations (16) as I
see many vulnerable young children and their families and you have to learn how best to support them during their
time at the clinic. I started helping out at the Clinic as my son has to regularly go there himself. I have 2 children
of my own so can empathise with their distress (26, 27).
Whilst acting as the school’s PTA Finance Officer for the last 2 years, I have had to use many interpersonal skills
(14) to negotiate with other members about what to spend the schools funds on. I have the responsibility of
completing the finance paperwork (17) which has to be very accurate and delivered on time.
I would very much like to undertake this role so I hope that you will consider my application.
NHS Standard Application Form, v.1.1 Page 8 of 10

Supporting information (Please continue on additional sheets if necessary). – Bad Example
I would like this job as I would like to earn some more money to spend on my holidays. It seems interesting and
similar to the job I used to do (8).
I have children of my own and get involved in their activities. I help out with the Scouts group and also at the local
NHS Clinic. I have been a member of the school PTA for a few years and like sorting out the finances.
I am good on the computer (6, 12) and can manage my time well (7) . I enjoy meeting and talking to new people
and like to play badminton with my friends.
Thanks
Additional Personal Information
Preferred Employment Type
Part Time
Do you have a valid driving licence for the UK
Please specify the vehicle category for which you hold a licence
Yes
Motorbike (A)
Car (B) - x
Car with Trailer (B + E)
Medium Sized Vehicle (C1)
Medium Sized Vehicle with Trailer (C1 + E)
Minibus (D1)
Minibus with Trailer (C1 + E)
Large Goods Vehicle (C)
Large Goods Vehicle with Trailer (C + E)
Passenger Carrying Vehicle (D)
Passenger Carrying Vehicle with Trailer (D + E)
Do you have access to a vehicle which can be used for work purposes
Yes
Do you hold a POPUMET certificate (required for radiologists) Yes No
NHS Standard Application Form, v.1.1 Page 9 of 10

References
Please give the names of the people who have agreed to supply references. For all positions you must provide 2 references. If you are, or
have been employed, these should be your two most recent employers. These may include your line manager or someone in a position of
responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. If you are a student
please provide contact details of a teacher at your school, college or university. Please note that personal references such as friends and
relatives are not acceptable. For all posts written references obtained must cover the preceding 3 years of employment. All referees will be
approached prior to interview unless you indicate otherwise.
Referee 1 - Good Example
*Surname/Family name Brown First Name Jodie
Job Title
*Address
NHS Clinic Manager
7 Orchard Road
Barnstable
Devon
*Post Code/ Zip Code Ex3 8HS *Country UK
Telephone 01298 325947 Fax
Email
J.brown@nhs.net
* Relationship Volunteering Line Manager
Referee 2 - Good Example
*Can the referee be contacted
prior to interview
Yes
*Surname/Family name
Job Title
*Address
Thomas First Name Paul
Barnstable Scout Leader
19 The Avenue
Barnstable
Devon
*Post Code/ Zip Code EX1 9AM *Country UK
Telephone 01246 325978 Fax
Email
Paul2.thomas@hotmail.co.uk
* Relationship Scout Pack Coordinator
* Can the referee be
contacted prior to interview
Yes
-------------------------------------------------------------------------------------------------
Referee 1 - Bad Example
*Surname/Family name Smith First Name John
Job Title
*Address
Mr
45 High Street
Exeter
Devon
*Post Code/ Zip Code
*Country
Telephone 07985461324 Fax
Email
* Relationship Father
Does not have one
*Can the referee be contacted
prior to interview
Yes
NHS Standard Application Form, v.1.1 Page 10 of 10