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Download - the Prince and Princess of Wales Hospice

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In Patient UnitStaff Nurse – B<strong>and</strong> 5Fixed Term Contract – 6 monthsSalary scale:Hours:£21,124 to £27,376 + 12.5% shift allowance37.5 Hours, rotational shiftsThe <strong>Prince</strong> & <strong>Prince</strong>ss <strong>of</strong> <strong>Wales</strong> <strong>Hospice</strong> provides specialist palliative care to <strong>the</strong> people <strong>of</strong>Glasgow living with an advanced life limiting illness. Patients are at <strong>the</strong> heart <strong>of</strong> all that we do <strong>and</strong>as one <strong>of</strong> our In Patient Unit team you’ll ensure <strong>the</strong> implementation <strong>of</strong> a high st<strong>and</strong>ard <strong>of</strong> carewithin <strong>the</strong> service.The In Patient Unit is adapting in response to <strong>the</strong> needs <strong>of</strong> <strong>the</strong> community <strong>of</strong> Glasgow <strong>and</strong>embracing <strong>the</strong> challenges set by <strong>the</strong> innovative hospice strategy. As one <strong>of</strong> our multi pr<strong>of</strong>essionalteam you will be key in delivering <strong>the</strong> service to ensure high quality care <strong>and</strong> equity <strong>of</strong> access.With a strong commitment to providing <strong>and</strong> ensuring excellent patient centred care, you will be anRGN preferably with previous experience in a palliative or cancer care setting. An excellentcommunicator you will be able to work well on your own initiative <strong>and</strong> as part <strong>of</strong> a team.This position <strong>of</strong>fers attractive terms <strong>and</strong> conditions.For fur<strong>the</strong>r information or to request an application pack please contact our HR Department on0141 429 9885 or by email jobs@ppwh.org.uk or log onto our website at www.ppwh.org.uk todownload an application pack.If you wish an informal discussion about this role please contact Wilma Dobbin, Ward Manager on0141 429 5599.Closing date for applications is Friday 1 st October 2010 @ 12 midday.Interviews will be held on Monday 11 th October 2010.www.ppwh.org.uk


Staff Nurse – B<strong>and</strong> 56 month fixed term contractOutline Terms <strong>and</strong> ConditionsSalary RangeReporting ToHours <strong>of</strong> WorkBased AtHolidayEntitlementPensionArrangementsLife AssuranceSicknessBenefit£21,124 to £27,376 + 12.5% Shift AllowanceWard Manager37.5 hours ,rotational shifts71 Carlton PlaceGlasgow, G5 9TD25 Days Annual Leave + 10 Days Public HolidaysPossible continuation <strong>of</strong> existing NHS pensionarrangements or <strong>Hospice</strong> Contributory Scheme Available4 x SalaryUp to 5 years service, two months full pay followed by twomonths on half pay.Over 5 years service, three months full pay followed bythree months on half pay.Notice Period1 Calendar Month


1) Job IdentificationJob title: Staff Nurse – B<strong>and</strong> 5Job DescriptionResponsible to:Department:Ward ManagerIn Patient UnitNo <strong>of</strong> Job Holders: 15Last Update: 6 th August 20102) Job PurposeAs part <strong>of</strong> a multidisciplinary team <strong>the</strong> post holder will have responsibility for assessment <strong>of</strong> care needs<strong>and</strong> <strong>the</strong> development <strong>of</strong> programmes <strong>of</strong> care, <strong>and</strong>/or <strong>the</strong> implementation <strong>and</strong> evaluation <strong>of</strong> <strong>the</strong>seprogrammes ensuring <strong>the</strong> delivery <strong>of</strong> high quality care to patients.In <strong>the</strong> absence <strong>of</strong> <strong>the</strong> in-patient unit senior staff nurse <strong>the</strong> post holder may provide cover to ensureeffective operation <strong>of</strong> <strong>the</strong> ward.They will be expected to supervise junior staff <strong>and</strong> be able to participate in <strong>the</strong> teaching <strong>of</strong> qualified <strong>and</strong>unqualified staff including students from various disciplines.3) Role dimensions‣ Works within a 14 bedded in-patient unit caring for:o Palliative care patients with complex problems <strong>and</strong> specialist intervention needs,which may include advanced pain <strong>and</strong> symptom control, spiritual <strong>and</strong> psychosocialaspects <strong>of</strong> care.o Families <strong>of</strong> hospice patients, including provision <strong>of</strong> a 24 hour nursing advice service.‣ Being <strong>the</strong> first point <strong>of</strong> contact for a 24 hour telephone advice service for queries relating topalliative care patients within <strong>the</strong> Glasgow area. Advice provided can be augmented through<strong>the</strong> medical team.‣ Coordinating safe <strong>and</strong> effective admissions <strong>and</strong> discharges from a variety <strong>of</strong> care settings:o Local acute hospitalso Local community settings (home)o Both elective <strong>and</strong> emergency admissions‣ Coordinating skill mix on shift according to <strong>the</strong> needs <strong>of</strong> <strong>the</strong> patients, ensuring adequatestaffing levels are available. Take charge <strong>of</strong> <strong>the</strong> unit in <strong>the</strong> absence <strong>of</strong> <strong>the</strong> Senior Staff Nurse.‣ Assessing, implementing <strong>and</strong> evaluating <strong>the</strong> provision <strong>of</strong> care for patients <strong>and</strong> relatives.‣ Providing supervision <strong>and</strong> mentorship <strong>of</strong> junior staff <strong>and</strong> students‣ Working flexibly to provide a 24/ 7 service. A 24 hour shift rotation system is in operation <strong>and</strong>nurses will be asked to undertake both daytime <strong>and</strong> nighttime shifts.


4) Organisational positionDirector <strong>of</strong>Clinical ServicesWard ManagerWard SisterStaff Nurses –B<strong>and</strong> 5SeniorHealthcareAssistantsHealthcareAssistants5) Role <strong>of</strong> Department‣ To work as part <strong>of</strong> <strong>the</strong> multidisciplinary team providing care to ward patients who have complexpain, symptom, spiritual <strong>and</strong> psychosocial needs which require Specialist Palliative Careinterventions.‣ To provide <strong>the</strong> first contact for a 24 hour telephone service providing advice to o<strong>the</strong>rpr<strong>of</strong>essionals, <strong>Hospice</strong> patients, relatives <strong>and</strong> carers <strong>of</strong> patients. Triaging calls, ei<strong>the</strong>r providingadvice or referring to o<strong>the</strong>r staff.‣ To provide high quality nursing care to patients with complex palliative care needs, includingnon cancer conditions, e.g. COPD <strong>and</strong> heart failure <strong>and</strong> neurological conditions such as MND‣ To participate in <strong>and</strong> support in-patient unit service changes in collaboration with <strong>the</strong> wardmanager‣ To participate in <strong>the</strong> implementation <strong>of</strong> clinical governance activities e.g. audit <strong>of</strong> clinicalpractice, implementation <strong>of</strong> best practice statements‣ To provide an educational resource in conjunction with Glasgow Caledonian University,supporting clinical placements in palliative care to students


6) Key ResultsClinical‣ To work as part <strong>of</strong> <strong>the</strong> multidisciplinary team providing care to ward patients who havecomplex pain, symptom, spiritual <strong>and</strong> psychosocial needs which require Specialist PalliativeCare interventions.‣ To provide high quality nursing care to patients with complex palliative care needs,including non cancer conditions, e.g. COPD <strong>and</strong> heart failure <strong>and</strong> neurological conditionssuch as MND‣ To ensure st<strong>and</strong>ards <strong>of</strong> care are maintained to <strong>the</strong> highest level throughout <strong>the</strong> 24-hourperiod.‣ To coordinate safe <strong>and</strong> effective admissions <strong>and</strong> discharges as part <strong>of</strong> <strong>the</strong> multi pr<strong>of</strong>essionalteam, liaising with external agencies as necessary.‣ To assess, plan, implement <strong>and</strong> evaluate <strong>the</strong> provision <strong>of</strong> care for patients <strong>and</strong> relatives‣ To provide a co-operative, supportive <strong>and</strong> holistic approach to care <strong>and</strong> care needs within <strong>the</strong>multidisciplinary team setting.‣ To develop <strong>and</strong> demonstrate specialist palliative care expertise <strong>and</strong> acts as a pr<strong>of</strong>essionalrole model.‣ To be knowledgeable <strong>of</strong> <strong>Hospice</strong> <strong>and</strong> ward policies <strong>and</strong> procedures in order to maintain highst<strong>and</strong>ards <strong>of</strong> care.‣ To maintain <strong>the</strong> safe custody <strong>of</strong> drugs in accordance with <strong>Hospice</strong> policy <strong>and</strong> in accordancewith NMC guidelines.‣ To maintain patient records accurately, in accordance with <strong>Hospice</strong> policy <strong>and</strong> pr<strong>of</strong>essionalst<strong>and</strong>ards.‣ To act as a resource in Specialist Palliative Care, providing information <strong>and</strong> support topatients, carers <strong>and</strong> pr<strong>of</strong>essional colleagues.‣ To ensure initial care <strong>of</strong> family following death with practical input <strong>and</strong> emotional support.‣ To participate in bereavement risk assessments to ensure appropriate support is <strong>of</strong>fered tobereaved families <strong>and</strong> carers.‣ To be knowledgeable about differing cultural beliefs <strong>and</strong> preferences <strong>and</strong> ensure equitablecare provided regardless <strong>of</strong> race or religion.‣ To provide a safe environment for patients <strong>and</strong> staff by being aware <strong>of</strong> <strong>and</strong> wherenecessary implementing relevant policies <strong>and</strong> procedures.‣ To provide direct support to junior staff, students <strong>and</strong> volunteers, as appropriate, regarding<strong>the</strong> provision <strong>of</strong> care for <strong>the</strong> patient.‣ To maintain economical <strong>and</strong> efficient use <strong>of</strong> drugs <strong>and</strong> ward stores.‣ To maintain sufficient supply <strong>of</strong> stores in accordance to stores ordering system <strong>and</strong> <strong>the</strong>needs <strong>of</strong> <strong>the</strong> <strong>Hospice</strong>.‣ To act as a link nurse developing knowledge within <strong>the</strong> <strong>Hospice</strong>, ensuring clinical practice isevidence based.‣ To liaise effectively with o<strong>the</strong>r healthcare pr<strong>of</strong>essionals, out with <strong>the</strong> <strong>Hospice</strong>, involved with<strong>the</strong> care <strong>of</strong> <strong>the</strong> patient <strong>and</strong> family.‣ To participate in <strong>the</strong> implementation <strong>of</strong> clinical governance activities e.g. audit <strong>of</strong> clinicalpractice, implementation <strong>of</strong> best practice statements‣ To assist in <strong>the</strong> development <strong>and</strong> implementation <strong>of</strong> hospice policies to provide high qualitycare.‣ To adhere to <strong>the</strong> hospice policy on <strong>the</strong> safe moving <strong>and</strong> positioning <strong>of</strong> patients.Managerial‣ To encourage <strong>and</strong> develop teamwork within <strong>the</strong> ward, acting as a role model for junior staff.‣ To co-ordinate skill mix on shift according to <strong>the</strong> needs <strong>of</strong> <strong>the</strong> patients, taking charge <strong>of</strong> <strong>the</strong>unit in <strong>the</strong> absence <strong>of</strong> <strong>the</strong> Ward Sister.‣ To co-ordinate <strong>the</strong> provision <strong>of</strong> care for ward patients <strong>and</strong> relatives.‣ To participate in <strong>the</strong> performance review <strong>of</strong> relevant staff as directed by <strong>the</strong> Ward Manager.‣ Providing supervision <strong>and</strong> mentorship <strong>of</strong> junior staff <strong>and</strong> students


Educational‣ To participate in induction <strong>and</strong> orientation process for new members <strong>of</strong> staff.‣ To supervise student nurses on placement.‣ To act as a ‘mentor’ when necessary.‣ To be proactive in identifying <strong>and</strong> addressing own personal education <strong>and</strong> development needs‣ To participate in <strong>the</strong> educational programmes <strong>of</strong>fered by <strong>the</strong> hospice, internally <strong>and</strong> externally,taking an active role in <strong>the</strong> delivery <strong>of</strong> education in <strong>the</strong> specialist field <strong>of</strong> palliative care‣ To ensure clinical placements are effectively facilitated in conjunction with <strong>the</strong> EducationFacilitator‣ To undertake teaching <strong>of</strong> qualified <strong>and</strong> unqualified nursing staff, including basic <strong>and</strong> post-basicstudents e.g. utilising equipment or symptom management strategiesPr<strong>of</strong>essional‣ To work within <strong>the</strong> Nursing <strong>and</strong> Midwifery Council code <strong>of</strong> pr<strong>of</strong>essional practice.‣ To maintain active registration with pr<strong>of</strong>essional regulatory body.‣ To maintain CPD folder as required by regulatory body.‣ To participate in clinical supervision as required.‣ To participate in <strong>the</strong> hospice pr<strong>of</strong>essional development <strong>and</strong> review process to promotepersonal <strong>and</strong> service developments.‣ To attend education courses <strong>and</strong> study days to be aware <strong>of</strong> developments in own clinicalspecialty <strong>and</strong> in <strong>the</strong> wider nursing discipline.7a) Equipment <strong>and</strong> MachineryThe Staff Nurse is expected to have a knowledge <strong>of</strong> all equipment used in <strong>the</strong> area however may nothave daily clinical involvement.Medical Equipment – Syringe drivers, vital signs machine, nebuliser, suction units, TENS, heat packs,ice packs, Oxygen delivery systems, PEG tubes, Tracheostomy tubes, Urinary Ca<strong>the</strong>ters, Glucometers,Nasogastric Tubes, Alaris pumpInvasive Equipment – Venflons, Intravenous lines central/ subcutaneous linesMoving <strong>and</strong> H<strong>and</strong>ling Equipment - Mobilators, zimmers, delta frames, elbow crutches, quadropods,sticks, specialty walking frames, sliding boards, sliding sheets, turn tables, wheelchairs, Riser/reclinerchairs, hoist, st<strong>and</strong> aid, bathing hoist, commode, electric beds, pressure relieving mattresses, cot sidesIT equipment - Personal Computer7b) Systems‣ Maintain ward diary system‣ Use IT systems‣ Maintain nightly recording systemso Midnight returnso Staff Attendance recordso Fire safety registero Controlled drug checkso Equipment checkso Any o<strong>the</strong>r relevant checks‣ Maintain patient records including appropriate outcome <strong>and</strong> evaluation documentation‣ Maintain CPD folder <strong>and</strong> record <strong>of</strong> training undertaken‣ Timesheet recording, rotas <strong>and</strong> <strong>of</strong>f duty records‣ Electronic Patient Record System


8) Assignment <strong>and</strong> Review <strong>of</strong> Work‣ Works within clinical discipline, with or without supervision, providing advanced nursing carein <strong>the</strong> field <strong>of</strong> specialist palliative care‣ Is responsible to <strong>the</strong> Ward Manager for guidance, pr<strong>of</strong>essional management, review <strong>of</strong> work<strong>and</strong> formal appraisal <strong>of</strong> performance‣ Is responsible to <strong>the</strong> Ward Sister for day to day performance management‣ The Staff Nurse will delegate/allocate work to <strong>the</strong> team in <strong>the</strong> absence <strong>of</strong> senior staff.‣ Anticipates <strong>and</strong> responds appropriately to problems/needs <strong>of</strong> <strong>the</strong> in-patient unit servicedelivery <strong>and</strong> take steps to resolve <strong>the</strong>m involving appropriate colleagues.‣ Meets regularly with o<strong>the</strong>r team members/ attends staff meetings/ attends departmentaldevelopment meetings.9) Decisions <strong>and</strong> Judgments‣ Clinically <strong>and</strong> pr<strong>of</strong>essionally expected to make clinical nursing decisions on a daily basistaking into account guidance from <strong>the</strong> Nursing <strong>and</strong> Midwifery Council, Core St<strong>and</strong>ards,specialist Guidelines, Protocols <strong>and</strong> <strong>Hospice</strong> Policies <strong>and</strong> Procedures‣ Monitors patient condition to establish any change.‣ Uses flexible <strong>and</strong> innovative approach to problem solving <strong>and</strong> decision making in order toprioritise own workload‣ Recognises own limitations in <strong>the</strong> provision <strong>of</strong> clinical care <strong>and</strong> urgency <strong>of</strong> patients needsreferring to o<strong>the</strong>r Health Care Pr<strong>of</strong>essionals as appropriate‣ Provision <strong>of</strong> advice <strong>and</strong> support to junior staff‣ Ensures safe level <strong>of</strong> staffing each day in absence <strong>of</strong> Ward Sister10) Most Challenging / Difficult parts <strong>of</strong> <strong>the</strong> job‣ Maintaining <strong>and</strong> continually developing advanced clinical knowledge in specialist field‣ Undertake emotionally <strong>and</strong> mentally dem<strong>and</strong>ing job, whilst at <strong>the</strong> same time taking care tosafeguard own health <strong>and</strong> safety <strong>and</strong> that <strong>of</strong> colleagues, patients <strong>and</strong> carers‣ Imparting unwelcome news to patients, family / carers, staff <strong>and</strong> volunteers‣ Supporting patients <strong>and</strong> relatives at <strong>the</strong> end <strong>of</strong> life‣ Ensuring confidentiality is maintained within <strong>the</strong> service‣ In <strong>the</strong> absence <strong>of</strong> <strong>the</strong> Ward Sister provide cover to ensure <strong>the</strong> effective operation <strong>of</strong> <strong>the</strong>ward.‣ Managing aggressive behaviour.‣ Working rotational shifts in particular during <strong>the</strong> night.11) Communication <strong>and</strong> RelationshipsPatients‣ Delivers unwelcome news‣ Provides accurate <strong>and</strong> comprehensive information to <strong>the</strong> patient regarding <strong>the</strong>ir care. Patientswill predominantly have complex medical problems <strong>and</strong> this requires highly developedinterpersonal, motivational <strong>and</strong> persuasion skills.‣ Deals with verbal complaints


Relatives / carers‣ Delivers unwelcome news‣ Provides <strong>and</strong> receives information regarding complex <strong>and</strong> sensitive issues‣ Deals with verbal complaints‣ Uses advanced communication skills to provide support to relatives / carers via <strong>the</strong> telephoneExternal Agencies‣ Communicates with, makes <strong>and</strong> receives referrals from o<strong>the</strong>r agencies concerning transfer /discharge <strong>of</strong> patients.Multi disciplinary Team:‣ Collaborate with wider MDT regarding patient needs‣ Reports patient assessment findings, progress with treatment <strong>and</strong> suggests o<strong>the</strong>r pr<strong>of</strong>essionalinput requirements‣ Identifies potential <strong>and</strong> existing challenges in care options for patients, carers <strong>and</strong> staff <strong>and</strong>uses negotiation <strong>and</strong> advanced communication skills to resolve problems.‣ Promotes <strong>and</strong> maintains good relationships within <strong>the</strong> department <strong>and</strong> with all members <strong>of</strong> <strong>the</strong>multidisciplinary team throughout <strong>the</strong> hospice.‣ Regularly attends ward meetings or participates via written communication.12 ) Physical, Mental, Emotional <strong>and</strong> Environmental Dem<strong>and</strong>s <strong>of</strong> <strong>the</strong> JobPhysical‣ Frequent use <strong>of</strong> manual positioning equipment with patients i.e. wheelchair, hoists etc‣ St<strong>and</strong>ing <strong>and</strong> walking for majority <strong>of</strong> work sessions‣ Performs wide range <strong>of</strong> advanced nursing techniques requiring highly developed dexterityMental‣ Concentration required when assessing <strong>and</strong> treating patients throughout shift‣ Concentration required when checking documents including patients notes‣ Concentration when calculating drug dosages <strong>and</strong> administering <strong>of</strong> drugs‣ Concentration required when observing patient behaviors which may be unpredictable <strong>and</strong>identify urgent healthcare needs.Emotional‣ Frequently communicating with distressed/anxious/worried patients <strong>and</strong> carers‣ Imparting unwelcome news regarding patient’s prospects‣ Working daily with terminally ill patients‣ Being present at <strong>the</strong> time <strong>of</strong> death‣ Carrying out last <strong>of</strong>fices <strong>and</strong> mortuary dutiesEnvironmental‣ Frequent exposure to bodily fluids.‣ Moderate exposure to verbal / physical aggression


13 ) Knowledge, Training <strong>and</strong> Experience required to do <strong>the</strong> JobFirst Level Registered Nurse - RGNExperience within relevant clinical area (desirable).Evidence <strong>of</strong> fur<strong>the</strong>r education, or willingness to undertake relevant Diploma/Degree in Palliative CareEvidence <strong>of</strong> team working skills with ability to work using own initiative.Effective listening <strong>and</strong> interpersonal skills.Time management skills.


IN CONFIDENCENAME:POSITION APPLIED FOR: In Patient UnitStaff Nurse – B<strong>and</strong> 5Fixed Term Contract – 6 monthsThe information that you supply in this application form will be used to decide whe<strong>the</strong>r toinvite you to an interview.Whilst all sections may not be relevant to you personally, you should complete <strong>the</strong> form asfully <strong>and</strong> as accurately as possible to enable your application to be given full consideration.CV’s will not be consideredWhen completed this form should be returned to:HR DepartmentThe <strong>Prince</strong> & <strong>Prince</strong>ss <strong>of</strong> <strong>Wales</strong> <strong>Hospice</strong>71 Carlton PlaceGlasgowG5 9TDClosing date for receipt <strong>of</strong> applications is:Date: Friday 1 st October 2010 at 12 midday.Applications received after this will NOT be consideredThe Information provided within your application form will be processed in accordance with<strong>the</strong> Data Protection Act 1998.


Personal InformationFull Name:Home Address:Postcode:Home telephone number:Mobile telephone number:Business telephone number:Email address:May we contact you at work?: yes/noRefereesPlease give details <strong>of</strong> two referees. They should be qualified to comment on your ability<strong>and</strong> experience for this appointment <strong>and</strong> should include a referee from your current ormost recent employer. The <strong>Prince</strong> & <strong>Prince</strong>ss <strong>of</strong> <strong>Wales</strong> <strong>Hospice</strong> does not acceptreferences from family members.If you do not wish your current employer to be approached before a verbal <strong>of</strong>fer hasbeen made, please indicate in <strong>the</strong> box below.Name:Job Title:Company:Address:Name:Job Title:Company:Address:Postcode:Email:Tel No:Fax No:Do not approach: Postcode:Email:Tel No:Fax No:Do not approach:


Secondary Education (please list subjects passed)St<strong>and</strong>ard/’O’ Grade orequivalentGradeHigher Grade orequivalentGradeFur<strong>the</strong>r EducationUniversity or Fur<strong>the</strong>rEducation EstablishmentCourse(s) & SubjectsStudiedDegrees, Diplomas,Certificates ObtainedPr<strong>of</strong>essional QualificationsName <strong>of</strong> Awarding BodyQualifications Obtained, Membership <strong>of</strong>Pr<strong>of</strong>essional Institution etc


Training Courses(please give details <strong>of</strong> any relevant short courses or training undertaken)Course(s) UndertakenProvider(s)Computer Skills (please detail your experience)Driving LicenceDo you possess a full current driving licence?YES/NO (please delete as appropriate)Is it Clean? YES/NOIf no please give details:Asylum & Immigration Act 1996The Asylum & Immigration Act 1996 makes it an <strong>of</strong>fence to employ anyone who is notentitled to live or work in <strong>the</strong> UK. All applicants selected for interview will be required toprovide evidence that <strong>the</strong>y are entitled to live <strong>and</strong> work in <strong>the</strong> UK. Appropriatedocumentation may include <strong>the</strong> original <strong>of</strong> your current passport, or birth/marriagecertificate <strong>and</strong> National Insurance Number (found on NI Card/P45/P60 etc)Do you require a work permit?YES/NO (please delete as appropriate)


Present or Most Recent EmploymentName & Address <strong>of</strong> Employer:Date From:Position Held:Date To:Salary & o<strong>the</strong>r benefits/payments:Notice Required:Reason for leaving:Nature <strong>of</strong> Post (please describe your main duties):


Employment History (list in order with most recent post first)Name & Address <strong>of</strong>previousEmployer(s)FromMonth/YearToMonth/YearPosition held, Main Duties <strong>and</strong>Reason for LeavingPlease continue on a separate sheet if necessary.Additional InformationPlease provide any relevant information not covered elsewhere on this form, which mayinclude o<strong>the</strong>r activities e.g. voluntary work, major achievements, projects to date <strong>and</strong>indicate how this will enable you to contribute fur<strong>the</strong>r to this post.


State <strong>of</strong> HealthPlease list below all periods <strong>of</strong> absence due to sickness that you have had in <strong>the</strong> last 2years, stating a reason, dates (approximate) <strong>and</strong> number <strong>of</strong> days absent.Are any <strong>of</strong> <strong>the</strong> above absences related to an ongoing medical condition?Assistance for people with disabilitiesDo you consider that you have a disability?YES/NOIf YES, are <strong>the</strong>re any arrangements we can make for you if you are called to interview or ifsuccessfully employed? Please give details below:Relationship to Staff MembersIf you are related to any member <strong>of</strong> staff <strong>of</strong> The <strong>Prince</strong> & <strong>Prince</strong>ss <strong>of</strong> <strong>Wales</strong> <strong>Hospice</strong> oranyone who has been employed as a staff member in <strong>the</strong> last 12 months, please providedetails:DeclarationI certify that <strong>the</strong> above information is correct. I underst<strong>and</strong> that my application may berejected or that I may be dismissed for withholding relevant details or giving falseinformation. I underst<strong>and</strong> that any employment <strong>of</strong>fer will be subject to satisfactoryreferences, disclosure check (where appropriate), occupational health check <strong>and</strong>pr<strong>of</strong>essional registration if appropriate. I have read <strong>the</strong> information on data protection <strong>and</strong>agree to my details being used in <strong>the</strong> specified ways.Signed: ___________________________________ Date: ____________________


71 Carlton PlaceGlasgow G5 9TD(t) 0141 429 5599(f) 0141 429 2566www.ppwh.org.uk


Equal Opportunities Monitoring FormBoth sides <strong>of</strong> this form must be completed <strong>and</strong> returned along with your application form. Whereyou would prefer not to answer a particular question, you can tick <strong>the</strong> relevant box. The datacollected in this form will be used only to review <strong>and</strong> report on <strong>the</strong> effectiveness <strong>of</strong> <strong>the</strong> <strong>Hospice</strong>’sequal opportunities policies. The information provided on this form will be treated in <strong>the</strong> strictestconfidence <strong>and</strong> held securely within <strong>the</strong> HR Department <strong>and</strong> will not be used in <strong>the</strong> shortlistingprocess.NOTE: Where did you hear about this post? -------------------------------------1. GENDER IDENTITYHow would you describe your gender?FemaleMaleI prefer not to answer this questionWould you consider yourself to be transgender?YesNoI prefer not to answer this question2. ETHNIC GROUPWhat is your ethnic group?For this question, please choose one section from A to E <strong>and</strong> <strong>the</strong>n tick <strong>the</strong> appropriate box in thatsection in order to indicate your ethnic group.A. WhiteScottishO<strong>the</strong>r BritishIrishAny o<strong>the</strong>r White background- Please specifyB. MixedAny mixed backgroundC. Asian, Asian Scottish or Asian BritishIndianPakistaniBangladeshiChineseO<strong>the</strong>r Asian background - Please specifyD. Black, Black Scottish or Black BritishCaribbeanAfricanO<strong>the</strong>r Black background - Please specifyE. O<strong>the</strong>r ethnic backgroundAny o<strong>the</strong>r ethnic background - Please specifyI prefer not to answer this question


3. AGEWhat is your age?Please specify age (in years)4. RELIGIONI prefer not to answer this questionWhich <strong>of</strong> <strong>the</strong> following religions, religious denominations or bodies do you currently belongto? If you do not belong to any <strong>of</strong> <strong>the</strong>se, please tick “None”.NoneChurch <strong>of</strong> Scotl<strong>and</strong>Roman CatholicO<strong>the</strong>r Christian - Please specifyBuddhistHinduJewishMuslimSikhO<strong>the</strong>r religion - Please specifyI prefer not to answer this question5. SEXUAL ORIENTATIONHow would you describe your sexual orientation?HeterosexualGay ManLesbianBisexual ManBisexual WomanO<strong>the</strong>r - Please specifyI prefer not to answer this question6. DISABILITYThe Disability Discrimination Act 1995 defines disability as “a physical or mentalimpairment which has a substantial <strong>and</strong> long term adverse effect on a person’sability to carry out normal day to day activities”.Do you consider that you have a disability?(a)(b)(c)YesNoI prefer not to answer this question


CRIMINAL CONVICTION DECLARATIONThrough your employment with The <strong>Prince</strong> <strong>and</strong> <strong>Prince</strong>ss <strong>of</strong> <strong>Wales</strong> <strong>Hospice</strong> you may be involved inworking with children, young people <strong>and</strong> vulnerable adults. It is <strong>the</strong> policy <strong>of</strong> <strong>the</strong> <strong>Hospice</strong> to carryout disclosure checks on all individuals who work within <strong>the</strong> <strong>Hospice</strong> building. The informationrequested below is only required as a preventative measure against abuse <strong>of</strong> children, youngpeople <strong>and</strong> vulnerable adults <strong>and</strong> will not be used for o<strong>the</strong>r purposes. It will be treated in <strong>the</strong>strictest <strong>of</strong> confidence <strong>and</strong> will not be used to discriminate against you unfairly. All convictions mustbe declared as exemption under <strong>the</strong> rehabilitation <strong>of</strong> <strong>of</strong>fenders act 1974 applies.A. Personal DetailsFull NameAddress <strong>and</strong> PostcodeDate <strong>of</strong> BirthOccupationTelephone NumberB. DeclarationabHave you ever been convicted <strong>of</strong> a criminal <strong>of</strong>fenceDo you have a court appearance pending or have you beencharged by <strong>the</strong> police for a criminal <strong>of</strong>fence.YES/NOYES/NOC. Additional DetailsDate Court Details <strong>of</strong> Offence SentenceD. I certify that:a. I have not withheld information that may affect my application for employment.b. I underst<strong>and</strong> that false information or omissions may lead to dismissal or termination <strong>of</strong>contract.Print Name:Signed:Date:_____________________________________________________________________________________________________________________

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