Nursing and Care Worker Screening Form

Nursing and Care Worker Screening Form

Thank you for your interest in registering with MHR. Kindly complete the following screening form in full, providing us with all the required details. The fields marked with a * are mandatory fields.


Personal Information

(e.g 0821231234)


Type N/A if you are a care worker

Education and Training

Year highest qualification was completed

Year training was completed
Area, Hospital/Facility and Ward/Unit of Preference

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

NB: Only list specialised wards you have worked in for 6 or more months post-training/post-community service.

Employment Information (Excluding Practical Training)

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

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


As MHR prefers two professional references, state a reason for one reference

First Reference

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

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


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