I declare that the above is true to the best of my knowledge. I declare that I understand, accept and confirm the entitlement of PE Global to reject my application or terminate my employment (in the event of a contract of employment having been entered into) where I have omitted to furnish PE Global with any information relevant to this health assessment or where I have made any false statement or misrepresentation relevant to this health assessment.

I hereby confirm that I give permission to PE Global Healthcare for the following:

I give my permission to confirm reference letters with referees and to validate passport and GNIB cards with the passport office and immigration.

I give my permission to give copies of relevant documents to relevant appraisal bodies including HSE or Private Organisations for Auditing purposes and for the purpose of verification of signatures to authorise payment.

I give my permission to PE Global to verify my documents.

I give my permission to be contacted by phone, email or text message regarding accounts (timesheets, pay slips etc.), human resources (Training/upskilling/registration/application), bookings and operations (new shifts, change to shifts, uniform policy etc.), recruitment (new permanent and temporary roles) and other communications deemed necessary by PE Global Healthcare. (To opt out of this simply email health@peglobal.net)

I hereby confirm that I am aware of the following:

I am aware of my obligations under the Working Time Act 1997 (http://www.irishstatutebook.ie/eli/1997/act/20/enacted/en/html). The current limit is a maximum average net weekly working time of 48 hours per week over a period of 4 months. I confirm I have read and understand the working time regulations and it is my responsibility to adhere to same.

I am aware that I am responsible for ensuring my compliance documents are kept up to date. Failure to comply will result in work being withheld until the relevant course or registration is renewed.

I am aware I am responsible for ensuring I am immunized against Hepatitis B, Varicella and TB. I am aware I am responsible for keeping a regular check on my antibodies so that I am not putting myself or others at risk.

I hereby confirm that:

I have never been arrested for, or convicted of, an offence or crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable), either in Ireland or in any other state.

I have never unlawfully distributed or sold a controlled substance (drug).

I am not currently nor have I ever been to my knowledge under investigation by the Garda Siochana/Police force of any state in relation to the commission of a crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable).

I am not currently nor have I ever been the subject of disciplinary action by any professional or statutory body with responsibility for regulation of nursing or medical professions.

I hereby authorise PE Global Healthcare and/or its relevant HSE or Private organization to verify any part of this declaration with relevant party (Garda Siochana or relevant regulatory body).

I hereby confirm that I will inform PE Global Healthcare of any convictions, pending or otherwise that occur after the date of signing this document.

I hereby confirm that I am aware as an agency staff of PE Global Healthcare who will carry out a shift/assignment in either the HSE or private sector, I agree to abide by the following:

I undertake never to discuss patients, their families or otherwise with anybody other than an authorised person. I will not disclose to any person (unless authorised) any information acquired by me concerning any HSE or Private organisation, its staff or procedures. I accept that any breach of confidentiality may be pursued through the legal systems. I undertake and agree to inform PE Global Healthcare immediately if I come in contact with any clinical risk of if I pose a risk to patient or staff safety.

I accept that should any dispute arise between agency staff member and another party, it will be dealt with by PE Global Healthcare and not by placement facility. I understand and accept that PE Global Healthcare have the right to relocate me at any time.

I confirm that I will not disclose to any person, any information regarding PE Global Healthcare, its staff, its clients or procedures to any authorised person.

I confirm that on arrival to assigned shift I will make myself aware and familiar with fire exit locations, emergency response procedures and each departments safety statement. I confirm I will report any unsafe condition, practice, substance, equipment or situation as soon as reasonably practicable to the person in charge.

I confirm I will notify PE Global Healthcare if I have any special health and safety requirements. For example: Pregnancy, if you have just given birth or are breastfeeding.

This is so that we can assign you to suitable environments.

Hand washing is the single most important procedure in the implementation of infection control.

It is essential to wash hands frequently and correctly. All Agency workers are obliged to follow hand washing procedures whilst of duty, according to the HSE Guidelines for Hand Washing Technique.

(Copy of the Hand Washing Technique is available to you upon your request.)

I confirm I have read and understand the information regarding hand washing procedures and will adhere to this technique whilst on duty for PE Global.

I agree to the following:

I confirm that the information given on this application form is complete and correct. I agree to PE Global Healthcare terms and conditions and I confirm that I have read and understood the PE Global Healthcare Staff Handbook. I understand that if I have a need for any clarification, I can contact PE Global on 021-4297900.

The Agency is authorised to acquire any information sought concerning the application and regarding my work character or skills and that this information may be forwarded to PE Global Client Organisations.

I agree to treat as confidential any information received concerning the business of PE Global or its Client Organisations.

PE Global will not be liable for professional negligence, errors, omissions, or accidents whilst you are under the Client Organisations direction and control.