Independent Contractor Information Form - Sep 2021

Which role are you applying for?*

Nurse
HCA
Phlebotomist

Section Break

Please attach current CV

Personal Details

Name*

Title First Last

Address*

Street Address City County Post Code Country

Mobile Number

Home Number

Work Number

Email address*

Date of Birth*

Your DOB is required to verify your PIN number

NMC Pin Number*

Do you have the right to work in the UK? (We will undertake right to work checks)*

Yes
No

Qualifications

Please list below all Professional Qualifications you have obtained

Qualification, Grade and Level Obtained	Date Obtained

Other Qualifications

Please list below any other relevant training or qualifications

Details of Courses or Qualifications	Date Obtained

Employment History

*

Please list below your most recent work experience first, including any other companies or agencies you work for, whether on a permanent or ad-hoc basis: (or fill with 'See CV' if CV has been uploaded)

Date From - Date To	Name of Employer	Position Held

Referees

Please give details of two people of whom we can obtain references. One should be your current or most recent employer.

Referee Name*

Occupation*

Email address (full postal address if not available)*

Referee Name*

Occupation*

Email address (full postal address if not available)*

Blood Testing

I am trained in venepuncture*

Yes
No

How many years experience do you have?*

When did you last actively practice venepuncture?*

I can use the vacutainer system*

Yes
No

Professional Indemnity

It is a requirement of MSS for all Independent Contractors to have valid Professional Indemnity Insurance (typically this is provided via full RCN membership).

Professional Indemnity

Please confirm that you have appropriate RCN indemnity insurance in place.*

Yes
No

We will require evidence of your Professional Indemnity Insurance if you are selected to join the Network

Do you have any personal professional indemnity insurance?*

Yes
No

Driving License

Do you hold a current full valid driving license?*

Yes
No

Disclosure of Convictions

Do you have any criminal convictions except those ‘spent’ under the Rehabilitation of Offenders Act 1974.*

Yes
No

We will require a copy of a current DBS check if you are selected to join the Network

Please note convictions below:

Employment Dismissal

Have you ever been dismissed from employment for any reason other than redundancy?*

Yes
No

Please give details

Availability

Please select from below when you would be generally be available to undertake appointments for Medical Screening Solutions*

In order to ensure continuity of service to our clients we would request that you provide us with advance notice of any periods of unavailability, e.g. holidays, sickness etc. However, as a self-employed independent contractor, you are not obliged to accept instructions from MSS.

Where did you hear about this role?*

Who recommended the role to you?

Where did you here about the role?

Declaration*

I confirm that to the best of my knowledge, the information given is true and correct. I understand that should I knowingly make a false statement or conceal any material in connection with this information form, this may disqualify my appointment to MSS’s independent contractor network.

Independent Contractor Information Form – Sep 2021

Section Break

Please attach current CV

Personal Details

Qualifications

Employment History

Blood Testing

Professional Indemnity

Professional Indemnity

Driving License

Disclosure of Convictions

Employment Dismissal

Availability