MHR Screening Form

Have you previously applied at MHR?

Yes

Which branch?

Personal Information

Name

Surname

Cell phone number(e.g 0821231234)

Email address

Job Title

Are you a South African Citizen?

Yes

SANC membership number
Type N/A if you are a care worker

Do you have internet access and will you be able to complete an electronic assessment on an electronic device?

Yes

Education and Training

Do you have a post-basic nursing qualification?

Highest qualification

Education institution name

Year completed
Year highest qualification was completed

Where did you complete your practical training?

Year completed
Year training was completed

Area, Hospital/Facility and Ward/Unit of Preference

Area of preference
NB: Note that MHR has clients in all provinces across South Africa, except Eastern Cape.

Ward(s)/Unit(s) of preference
NB: Only list specialised wards you have worked in for 6 or more months post-training/post-community service.

Hospital(s)/Facility(ies) of preference

Which City/Town do you live in?

Employment Information (Excluding Practical Training)

Most recent employment status

NB: This section focuses on your work experience. Please do not include practical experience gained during your studies.

Do you have any work experience?

Yes

Number of years' work experience according to rank (nursing) or as care worker

List your work experience below, starting with your current or most recent employer.
NB: Click on ‘Confirm Employment’ once you have completed the fields and on ‘Add Additional Employment’ to add additional work experience.

Hospital/Facility

Ward/Unit

Permanent or Agency

Care worker/ Nursing rank

Period employed (From - To)

References

Please provide two professional contactable references not older than five years (Preferably no cell phone numbers)

Are you able to provide a second professional reference?

Yes

REASON FOR PROVIDING ONE REFERENCE
As MHR prefers two professional references, state a reason for one reference

First Reference

Please tick to confirm that you obtained permission from the person below to list his/her details as your reference, as per the Protection of Personal Information Act

Referrer Name and Surname

Referrer company/facility where you worked

Referrer landline number
NB: Only list a cell phone number if no landline no. is available (e.g. 0821231234)

Type of reference
NB: Please only select lecturer if you are a newly qualified student and consulted the lecturer in advance for a reference.

When did you start working at this facility?

Are you still working at this facility?

Yes

Indicate the date you completed your service at the facility

SUBMISSION TERMS AND CONDITIONS

Please tick to confirm that you have read, understood and accept the terms and conditions.

If you need help with this form, please contact a representative who will gladly assist you.

	Hospital/Facility	Ward/Unit	Permanent/Agency	Care worker/Rank	Period Employed

Nursing and Care Worker Screening Form

Nursing and Care Worker Screening Form

NB: This section focuses on your work experience. Please do not include practical experience gained during your studies.

List your work experience below, starting with your current or most recent employer.
NB: Click on ‘Confirm Employment’ once you have completed the fields and on ‘Add Additional Employment’ to add additional work experience.

Please provide two professional contactable references not older than five years (Preferably no cell phone numbers)

First Reference

Second Reference

Nursing and Care Worker Screening Form

Nursing and Care Worker Screening Form

NB: This section focuses on your work experience. Please do not include practical experience gained during your studies.

List your work experience below, starting with your current or most recent employer. NB: Click on ‘Confirm Employment’ once you have completed the fields and on ‘Add Additional Employment’ to add additional work experience.

Please provide two professional contactable references not older than five years (Preferably no cell phone numbers)

First Reference

Second Reference

List your work experience below, starting with your current or most recent employer.
NB: Click on ‘Confirm Employment’ once you have completed the fields and on ‘Add Additional Employment’ to add additional work experience.