Unicare Professionals

3 Church Passage
Bridgwater
Somerset TA6 3ED
01278 422600
Fax 01278 423312
E-mail info@unicareprofessionals.com
www.unicareprofessionals.com

Please complete the questionnaire with as much detail as possible.

Please click in the boxes and place an X for your response.
1.
2.
3.

Question
What is your current role:
Date available to start employment:

Answer
Registered Nurse, Clinical IT Consultant-Soarian
MedSuite
1. 03.2014

Current situation
4.
5.
6.
7.
8.

9.

How much notice required by current

employer (if applicable)?
How long have you been practicing
as a nurse?
NMC Pin Number (if applicable):
Have you had practical experience in
the UK?
In what capacity?
Level of English (please tick the most
relevant box that meets your
capability see attached guide for
how to score yourself)

Clinical Skills
10. Do you have experience of peg
feeding?
11. When did you last support a client

Working now

Not working

NA
7 years
NA
No
Obstetrics Gynaecology, New Born, Operating Theatre,
Intensive Therapy
Listening
Reading
Talking-to others
Talkingconstruction
Writing

A1 A2 B1 B2 C1 C2
x
x
x
x

Yes

x
No

7 years ago

with a peg feed?

12. Are you able to take bloods?
13. If you have taken bloods when was

Yes

No

7 years ago

the last time you did it?

14. Can you catheterize?

15. Have you experience of a syringe

driver?
16. When did you last support a client

x Yes, female patients

patients
No
x Yes
7 years ago

x Yes, male

No

Unicare Professionals
3 Church Passage
Bridgwater
Somerset TA6 3ED
01278 422600
Fax 01278 423312
E-mail info@unicareprofessionals.com
www.unicareprofessionals.com

with a syringe driver?

17. Have you professional experience of

Alzheimers?

Yes

No

If yes please explain

18. Have you experience of Dementia?

Yes

No

If yes please explain

19. Have you had any experience of the

management of pressure wounds? (If

yes please explain what pressure
wounds you have managed and what
you did)
20. What interactions have you had with
multidisciplinary teams (i.e.
physiotherapists, community nurses,
communal GPs etc)?
21. Have you directly managed staff?

Yes

No

GPs, Nurses

Yes

No

22. Please indicate which professional

areas you have had experience in?

Geriatrics (care
of elderly)
Alzheimers
Dementia

23. Have you any reason to believe you

Palliative care
Mental Health
Surgical
Homecare
Yes

x
x

may have been infected with a

communicable or high risk
If yes please provide details
infection/disease?
24. Have you knowingly had contact with
Yes
x
MRSA or an MRSA environment?
If yes please provide details
25. Have there ever been any proceedings

of medical negligence or professional

misconduct against you and have you
ever been suspended or dismissed?
26. Have you ever at any time been

Yes

Community
nursing/care
Intensive care
Learning
disabilities
Renal
Medical
Paediatrics
Occupational
Health
No

No

No

No

If yes please provide details

Yes

Unicare Professionals
3 Church Passage
Bridgwater
Somerset TA6 3ED
01278 422600
Fax 01278 423312
E-mail info@unicareprofessionals.com
www.unicareprofessionals.com

convicted of any offence?

If yes please provide details