Staff Application Form

EMPLOYMENT APPLICATION (PRIVATE & CONFIDENTIAL)


Mobility:
Do you have access to a car which can be used for work purposes? Yes No
Do you hold a full UK Driving License? Yes No
Are you a citizen of the UK? Yes No
If no, are you permitted to work in the U.K.? Yes No
Have you ever worked for this company? Yes No
Have you ever been convicted of a offence? Yes No

EDUCATION/TRAINING

Did You Graduate? Yes No


REFERENCES

Please list three professional references.


PREVIOUS EMPLOYMENT

May we contact your previous supervisor for a reference? Yes No

RELEVANT TRAINING/QUALIFICATIONS IN HEALTHCARE

Manual handling :
Health and Safety :
Basic Food Hygiene :
First Aid :
NVQ Levels :
Others (please list) :

MEDICAL HISTORY

This is a confidential declaration of Personal Health.
Please complete all questions.


CURRENT WRITTEN RECORD OF YOUR MEDICATION

Immunisation status for:
Hepatitis B: Are you Immunised? Yes No
Please attach a copy certificate or a letter from you GP indicating you do not require one as the case may be:

Tuberculosis: Are you Immunised? Yes No
Please attach a copy certificate or a letter from you GP indicating you do not require one as the case may be:

Rubella: Are you Immunised? Yes No
Please attach a copy certificate or a letter from you GP indicating you do not require one as the case may be:

Varicella – Are you Immunised? Yes No
Please attach a copy certificate or a letter from you GP indicating you do not require one as the case may be:
Do you have a disability? Yes No

MEDICAL QUESTIONNAIRE

Have you ever had: Additional; Information If Yes
Tuberculosis, Asthma, Bronchitis or Chest Complaints? Yes No
Heart Condition, Raised Blood Pressure? Yes No
Blackouts, Fits, Attacks or Giddiness? Yes No
Depression, Mental Illness or Nervous Breakdown? Yes No
Rheumatism or Arthritis? Back Trouble Yes No
Typhoid, Paratyphoid or Dysentery? Yes No
Digestive or Bowel Disorder Yes No
Diabetes, Thyroid or other Gland trouble? Yes No
Bladder or Kidney trouble? Yes No
Dermatitis or Skin trouble? Yes No
Varicose Veins? Yes No
Any other accident, operation or illness? Yes No
Have you any reason to believe you may be infected by any communicable disease? Yes No
Any current/recent medication condition or treatment which might affect you attendance or performance at work? Yes No
Any illness/medical condition that prevented you from attending work, normal duties or activities for more than one week during the past year? Yes No
Any physical disabilities including defect of sight or healing? Yes No
Do you smoke? Yes No

WORK PREFERENCE

To assist us in finding suitable work for you, please place a tick next to all specialties of which you.
significant recent experience and are confident to carry out such duties.
Please keep us informed from time to time of all developments in your career as the work we assign to you depends on accurate up to date information.

Full-time or Part-time: Live-in Care Yes No
If part-time, how many hours per week do want to work Please state if you are able to work as a 24 hour Residential (live-in) Carer. Yes No
Home care and pop-in visit If Yes, would you like – long or short assignments? Yes No
Hospitals Would you accept a live-in assignment some distance from your home? If No, please state preferred areas Yes No
Nursing | Residential Home
Morning | Day | Evening | Night Sleeper Duty

CARE ASSISTANT ABILITY SCHEDULE

Please indicate Yes or No in the areas you have had previous experience.
PERSONAL HYGIENE: Yes No CARE DUTIES Yes No
Bath| Shower | Strip Wash Yes No Pressure Area Care Yes No
Bed Bath Yes No Simple Dressing Procedure Yes No
Use of Bath Aids Yes No Assisting with Medication Yes No
Shaving Yes No Terminal Care Yes No
Mouth Care (inc. dentures) Yes No PRACTICAL TASKS Yes No
Care of Hair Yes No Lighthouse Work Yes No
Care of Finger Nails Yes No Washing Personal Laundry Yes No
Care of Feet (exc. Toe nails) Yes No Shopping Yes No
Dressing | Undressing Yes No Bed-making | Changing Bed Linen Yes No
Collection Benefits Yes No
TOILETING Yes No ADMIN. ABILITIES Yes No
Continence Care Yes No Confidentiality Yes No
Bedpans | Commodes etc Yes No Report Writing Yes No
Changing a Catheter bag Yes No Recording instruction from GP | District Nurse Yes No
Empting Catheter bag Yes No Observing | Recording Yes No
Changes in Clients Condition Yes No
MOBILITY Yes No PREVIOUS EXPERIENCE Yes No
Maneuvering and handling course Yes No Private House Yes No
Use of Hoists (Manual | Electric) Yes No Nursing | Residential Home | Hospital Yes No
Use of Walking Aids Yes No

MONITORING

Please tick all the relevant boxes. The information is used for monitoring purposes only. It will be treated as confidential. It is the company’s policy to employ the best qualified personnel and provide equal opportunities for the advancement of employees including promotion and training and not to discriminate against any person because of race, colour, national origin, sex, marital status of disability.

Gender
Ethnic Group:
African
Afro-Caribbean
Asian
UK/Europe
Other European (Please Specify)
Disability: Do you consider yourself as having a disability? Yes No If Yes Please State Below

REHABILITATION OF OFFENDERS ACT 1974

You are advised that you are not entitled to withhold information about convictions, which are regarded as spent under the Act. This is due to the nature of the work involved renders to the post exempt from sec. 4(2) of the Act in accordance with the Rehabilitation of Offenders Act 974 (Exceptions) Order 1975. You are therefore required to give details of all convictions and cautions including ‘spent’ convictions. Any information which you many give will be strictly confidential and will be considered only in relation to this or a similar position for which you may be considered with Elite Careplus Ltd.

Have you ever been convicted of a Criminal Offence? Yes No If YES, please give details of all convictions and cautions, including spent convictions and cautions: (please use a separate sheet if necessary).

YOU ARE REQUIRED TO COMPLETE THE DISCLOSURE AND BARRING SERVICE (DBS)/CRB FORM. ALL HEALTH CARE PROFESSIONALS REGISTERED WITH ELITE CAREPLUS ARE SUBJECT TO THIS DISCLOSURE PROCESS IN THE INTEREST OF ALL PARTIES CONCERNED.

DISCLAIMER AND SIGNATURE

I certify that:
(i) All the information given is true in every respect. I have read and understood the Terms and Conditions and I agree to comply with the current Health and Safety Act at work.
(ii) I have never been charged with or convicted of an offence under any legislation dealing with Residential care or any offence involving dishonesty or violence.
(iii) I have been issued with a staff handbook and informed of the importance of reading and understanding it.

TO SUPPORT THE APPLICATION, PLEASE ATTACH ALL THESE DOCUMENTS IF AVAILABLE:

Birth Certificate:
Driving License:
Valid Visa | Work Permit:
National Insurance (NI) Card: - Or P45 | P60 or Letter confirming you have Applied for NI:
Registered Nurse Pin Card:
Passport (Other current Home Office Document authorizing you to Work in UK):
Proof of Address: Driving Licence, 3 Months Utility Bills, Any Formal Letter with your Name &Address:
2 Passport Size Photographs:
Disclosure and Barring Service (DBS)/ CRB Certificate or you can apply through Elite Careplus Ltd:
Training Certificates: Eg Moving & Handling, Basic First Aid, NVQ. If you do not have any formal qualification in care we can provide training: