NHS STANDARD APPLICATION FORM

Please fill in the application form below. Do not type using

only capital letters and please remember to check it carefully,
as once the form has been submitted it cannot be changed.
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
Details entered in this part of the form will be held in the HR department of the recruiting
organisation. Access to this information will be withheld from the shortlisting panel. Please do
not type using only capital letters, as this could lead to your application being automatically
rejected. Please use the appropriate mixture of capital and lowercase letters in standard written
text.
Job Reference Number

TTM Healthcare

Job Title

Band 5 Nurse

Department
Personal Details

*Surname/Family Name
*First Names
Title (Mr/Mrs/Miss)

OBIDIGWE
NKECHI BLESSING
Mrs

UK National Insurance No

Address

24/26 SIJUOLA STREET, OFF AGO PALACE WAY

OKOTA. LAGOS STATE

*Postcode/ Zip code

234

* Country

NIGERIA

Home Telephone
Mobile Telephone

08038534389

Work Telephone
Yes

No

May we contact you at work?

Email Address

udu.obidigwenkechi@gmail.com

*Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA)
National?

Yes

No

Please select the category that relates to your current immigration status. This status will be

subject to checking before interview. (If you are from the EU you have indefinite leave to remain)

HSMP/Tier 1
Indefinite Leave to remain/enter
Work Permit/Tier 2
Dependant / Spouse visa
Clinical attachment visa
Student
Visitor

Post Graduate Doctors and Dentists

Tier 5 Temporary Workers
Working Holiday Visa/Tier 5 Youth Mobility
Refugee
Other, please specify below

Please supply details of any visa currently held, including number, start/expiry dates and details of
any restrictions.
Visa No:
Start Date: (DD/MM/YY)
Expiry Date: (DD/MM/YY)
Details of Restriction:
Does your visa have a condition restricting employment or occupation in the UK?

Yes

No

Are you a Department of Work & Pensions New Deal Candidate?

Yes

No

Are you an NHS professional returning to practice?

Yes

No

Do you currently work in the NHS?

Yes

No

* DECLARATION

The information in this form is true and complete. I agree that any deliberate omission,
falsification or misrepresentation in the application form will be grounds for rejecting this
application or subsequent dismissal if employed by the organisation. Where applicable, I
consent that the organisation can seek clarification regarding professional registration details.
I agree to the above declaration
Signature
Name

NKECHI B. OBIDIGWE

Where did you see this vacancy advertised?

X TTM Healthcare

Date

3rd JUNE, 2016

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 short-listing panel.
Job Reference Number

TTM Healthcare

Job Title

Band 5 Staff Nurse

Online reference
number

N/A

Department

Education & Professional Qualifications

Include in this section all the relevant qualifications. Please also indicate subjects currently
being studied. All qualifications disclosed will be subject to a satisfactory check.
Subject/Qualification
Place of Study
Grade/result
Year
REGISTERED MIDWIFE (RM)

REGISTERED NURSE (RN)

SCHOOL OF MIDWIFERY
LAGOS UNIVERSITY
TEACHING HOSPITAL
(LUTH)
SCHOOL OF NURSING
UNIVERSITY OF NIGERIA
TEACHING HOSPITAL
(UNTH)

PASS

2010

PASS

2007

Training Courses Attended

Include in this section any relevant training courses that you have attended or details of
courses that you are currently undertaking.
Date
Course Title
Training Provider
Duration
Completed
MANDATORY CONTINUOUS
PROFESSIONAL DEVELOPMENT
PROGRAMME
NATIONAL HOSPITAL ABUJA
CUSTOMIZED BUBBLE CPAP.
DIABETES IN PRACTICE COURSE

SEXUAL AND REPRODUCTIVE HEALTH

AND FAMILY PLANNING FOR NURSES
PATIENT SAFETY: NURSES ROLE IN
COMBAT AGAINST COUNTERFEIT AND
SUB-STANDARD MEDICINES.

NURSING AND
MIDWIFERY COUNCIL

5 DAYS

6th May, 2016

NEONATAL UNIT,
NATIONAL HOSPITAL
ABUJA
PAEDIATRIC
ENDOCRINOLOGY
TRAINING CENTER FOR
WEST AFRICA LUTH.
PLANNED PARENTHOOD
FEDERATION OF
NIGERIA.
SCHOOL OF NURSING
UNIVERSITY OF NIGERIA
TEACHING HOSPITAL
ENUGU

2 DAYS

6th March, 2014

6 DAYS

3rd December,
2012

6 WEEKS

11th September
2009

2 DAYS

11th May, 2005

Membership of Professional Bodies

Include in this section any relevant professional registrations or memberships. If you are
registered then please enter the relevant details below; this information will be subject to a
satisfactory check.
* Please indicate your Professional Registration status if relevant to this post:
I do not have the relevant UK professional
registration status
UK professional registration required
I have current UK professional registration
but not yet applied for
X UK professional registration required and
I am a student
applied for
Not required for this post

If professional registration is not required then go to Employment History.

If you are registered then please enter the relevant details below:
Membership or
Membership/Registratio
Professional Body
Registration type
n PIN
NURSING AND MIDWIFERY COUNCIL
OF NIGERIA
NURSING AND MIDWIFERY COUNCIL
OF NIGERIA

Expiry/Renewal
Date

REGISTERED NURSE

RN 127734

APRIL, 2018

REGISTERED MIDWIFE

RM 95427

APRIL, 2018

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?

Yes
X No

Yes
X No

If applicable, please provide details of any conditions/restrictions you may have.

Employment History
Please record below the details of your current or most recent employer
Employer Name
Address

LAGOS STATE UNIVERSITY TEACHING HOSPITAL (LUTH)

IDI ARABA, SURULERE. LAGOS. NIGERIA

Type of Business
Job Title

NURSING OFFICER II

Start Date

15th Nov. 2010

Telephone

(+1) 234 567 8901

End Date

TILL DATE

Start of continuous NHS service

Grade
Reporting to (job
title)
Reason for leaving (if applicable)

Salary
Notice
Period

Description of your duties and responsibilities

Assisting in the supervision and development of health care
assistants. Assessing the care needs of patients.
Administration of medicines.
Development, implementation and evaluation of programmes of care.
Looking after patients with severe and enduring illness.
Performing administrative duties.
Involved in the screening, assessment and follow up support of
patients.
Liaising with other health care professionals and social workers.
Reporting to senior managers.
Intravenous cannulations, giving of intravenous fluids and input and output monitoring.

Previous Employment
Please record below the details of your previous employment, beginning with the most recent
first. Up to 5 previous employments can be entered here. If required, please provide additional
information regarding your employment history within the Supporting Information section.

Previous Employer 1
Employer
Name

RAO SPECIALIST HOSPITAL

Address

RANDLE AVENUE, SURULERE. LAGOS STATE. NIGERIA.

Job Title

STAFF NURSE

Grade

From Date

2007

To Date

2008

Reason for Leaving

TO START MY MIDWIFERY PROGRAMME.
Description of your duties and responsibilities
Responsible for fixing clinic appointment for patients.
Participation in formulation of appropriate care plans and delivery of care coordination.
Prioritizing cases for allocation.
Maintaining a safe and secure environment for the patient.
Regular ward care, constant monitoring of patient vital signs and patient
progress and challenges, intravenous lines setting and monitoring.
Pre and post op care of surgical patients.
Supervising junior staff.
Ensuring maintenance of a high standard of nursing care during procedures and
treatments.

Previous Employer 2
Employer
Name
Address
Job Title

Grade

From Date

To Date

Reason for Leaving

Description of your duties and responsibilities

Previous Employer 3
Employer
Name
Address
Job Title

Grade

From Date

To Date

Reason for Leaving

Description of your duties and responsibilities

Previous Employer 4
Employer
Name
Address
Job Title

Grade

From Date

To Date

Reason for Leaving

Description of your duties and responsibilities

Previous Employer 5
Employer
Name
Address
Job Title

Grade

From Date

To Date

Reason for Leaving

Description of your duties and responsibilities

Please add additional employers/information on a separate sheet.

If you have any gaps within your employment history, please state below.
Yes, I do have a gap between March and November 2010. I took the time to start a family.

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).
My duties and experiences includes but not limited to the following:
Caring for patients experiencing physical distress or who have an enduring illness.
Assessing and talking to patients about their problems and discussing the best
way to plan and deliver their care.
Building relationships with patients to encourage trust, while listening to and
interpreting their needs and concerns.
Ensuring the correct administration of medication, including injections, and
monitoring the results of treatment.
Responding to distressed patients in a non-threatening manner and attempting to
understand the source of distress.
Applying 'de-escalation' techniques to help people manage their emotions and
behaviour.
Organizing social events aimed at developing patients' social skills and helping
to reduce feelings of isolation.
Preparing and maintaining patient records.
Producing care plans and risk assessments for individual patients.
Ensuring that the legal requirements appropriate to a particular setting or group
of patients are observed.
Promoting a 'recovery' based approach to care.
Maintaining a safe and secure environment for the patient.
Regular ward care, constant monitoring of patient vital signs and patient
progress and challenges, intravenous lines setting and monitoring.
Pre and post op care of surgical patients.
Supervising junior staff.
Ensuring maintenance of a high standard of nursing care during procedures and
treatment.

Additional Personal Information

Preferred Employment X Full Time Part Time Job Share Secondment
Type
Flexible Hours
If applicable to the post, do you hold a certificate to
X Yes
No
support your responsibilities under IR(ME)R 2000?
Evidence of relevant training and experience is required for those justifying or undertaking xrays, interventional radiology, CT scans etc. Please place this evidence within your supporting
statement.

References
Please state the names and contact details of the people who have agreed to supply references
covering a minimum of 3 years employment/training. If you are or have been employed, these
should include your two most recent employers, 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. If you have not been in employment for a considerable amount of
time but have had previous employment, then you should seek one reference from your last
known employer and a personal reference from a person of some standing within your
community i.e. doctor, solicitor, MP etc. Where it is not possible to obtain any employer
reference at all then please obtain two personal references. Where no personal reference can
be obtained then references should be sought from personal acquaintances not related to or
involved in any financial arrangement with you. If you have undergone training to return to work
then the academic institution should be contacted. Personal references such as friends and
relatives are not acceptable unless stated previously.
Please note, all reference requests will be sought through your line manager or other relevant
department manager and your employment history will be verified through the organisations
Human Resources department or other relevant recruitment function. Please ensure that you
provide full contact details. Referees may be contacted prior to interview.

Referee 1
*Surname/Family
name
Title

TIJANI

First Name

HABEEB

Dr

Job Title

CONSULTANT UROLOGIST

*Address

LAGOS UNIVERSITY TEACHING HOSPITAL, IDI-ARABA, LAGOS

*Post Code/ Zip

Code
Telephone

234

*Country

08023049739

Fax

Email

habeeb_tijani@yahoo.com

* Relationship

UNIT CONSULTANT

NIGERIA

*Can the referee be

contacted prior to
interview?

X Yes
No

Referee 2
*Surname/Family
name
Title

EJERE

Job Title

ZONAL CHIEF NURSING OFFICER

*Address

NURSING SERVICE DEPARTMENT, LAGOS UNIVERSITY TEACHING

HOSPITAL, IDI-ARABA.

*Post Code/ Zip

Code
Telephone

First Name

LUCY

MRS

234

*Country

08163661342

NIGERIA

Fax

Email
* Relationship

SUPERVISOR

* Can the referee

be contacted prior
to interview?

If you have applied to us within the last 3 months,

are you happy for us to use the references from
your earlier application?

Yes

No

X Yes

No