Care Work Application

Care Worker

The role of the Care Worker is to perform duties and tasks to facilitate our service users to live at home in a safe, secure dignified and comfortable way. It is sometimes difficult to generalise about what the role of a Care Worker is. The best way of summing it up is that you will perform the tasks carried out by a close friend or relative but in a trained, professional, compassionate, and knowledgeable way.

Your Personal Information

Premium Healthcare Staffing Ltd. 8-10 South Parade. Wakefield. WF1 1LR Tel: 03333399289 Email: info@phcstaffing.co.uk; Website: www.phcstaffing.co.uk

Please, use capital letters throughout and tick the appropriate box where necessary)

Title

Mrs

Miss

Your Name

Surname Forename: Maiden Name

Marital Status:

Place of Birth:

Date of Birth:

Gender

Male

Female

Others

National Insurance:

Address

Street Address Address Line 2 City Nationality Post code Country

Mobile Number:

Telephone number:

Email Address

Preferred Contact Method:

OTHER INFORMATION

Do you have the right to work in the United Kingdom?

Yes

Do you require a work permit?

Yes

Date of Birth:

Work Permit Type:

Passport Number:

Nationality:

Ethnic Origin:

Religion:

Do you have you a driving license?

Yes

If yes, any endorsement?

Do you have your own transport?

Yes

Do you smoke?

Yes

Are you registered disabled?

Yes

Registration No:

Do you have professional indemnity insurance?

Yes

Name of Insurer:

PROFESSIONAL EDUCATION AND TRANING

Please, list any Training/Course/Nursing qualification you have and when you gained them.

School/College/University

Qualification

Date Gained (dd/mm/yyyy)

Please indicate if you had training/qualifications in the following areas:

Basic Life Support

Yes

Date

Health and Safety

Yes

Date

Infection Control

Yes

Date

Moving and Handling

Yes

Date

Food Hygiene

Yes

Date

First Aid

Yes

Date

Elderly Abuse Awareness

Yes

Date

Any other:

Please, tick the Specialities of which you have significant, post training experience. Please, remember you will be held accountable for any missing information.

SPECIALISM (Nursing)

Residential Homes

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Nursing homes

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Hospitals

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Elderly

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Mental health

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Mental health

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Adolescents

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Physical disability

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Learning Disability

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

HIV

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Children

< 6 MONTHS

> 6 MONTHS

1- 2 YEARS

2 YEARS +

Any other:

Employment History

Please record below the details of your full employment history beginning with your current or most recent first. Any gaps must be explained. Use a separate attached sheet if required; please sign the sheet(s)

Employment

Name & Address of Employer

Date (From):

Date (To)

Post

Main Duties

Reason(s) for leaving

Have you ever been dismissed from a job?

Yes

HEALTH DECLARATION

Have you been vaccinated or tested against the following?

Hepatitis B

Yes

Details (Plus dates if Yes)

HIV

Yes

Details (Plus dates if Yes)

Tetanus

Yes

Details (Plus dates if Yes)

Poliomyelitis

Yes

Details (Plus dates if Yes)

Typhoid

Yes

Details (Plus dates if Yes)

Rubella (German Measles)

Yes

Details (Plus dates if Yes)

Tuberculosis and BCG

Yes

Details (Plus dates if Yes)

Hepatitis B Antibodies

Yes

Details (Plus dates if Yes)

Do you or have you at any time suffered from any of the following?

Skin complaints - dermatitis, Psoriasis, Eczema

Yes

Details (Required if Yes)

Diabetes or glandular complaints

Yes

Details (Required if Yes)

Headaches or Migraine

Yes

Details (Required if Yes)

Hypertension/ heart problems/similar illness

Yes

Details (Required if Yes)

Back pains/Back injury or problems

Yes

Details (Required if Yes)

Jaundice/Hepatitis

Yes

Details (Required if Yes)

Epilepsy or fainting attacks

Yes

Details (Required if Yes)

Pleurisy/Bronchitis/Pneumonia

Yes

Details (Required if Yes)

Asthma

Yes

Details (Required if Yes)

Infections - ear/sore throat

Yes

Details (Required if Yes)

Psychiatric illness – Mental disorder/depression etc.

Yes

Details (Required if Yes)

Please, answer the following.

At present, are you having any injections/medications?

Yes

Details (if Yes)

At present, are you having any injections/medications?

Yes

Details (if Yes)

Have you had any major operations?

Yes

Details (if Yes)

Any physical disabilities?

Yes

Details (if Yes)

How much time have you taken off work in the last 5 years due to illness?

Please state any other information about your health which may affect your work.

If you do not have vaccination information, please provide details of where we can request them below. I certify the above information is correct and hereby give permission to Premium Healthcare Staffing LTD to request a further report from my GP/Occupational Health/Hospital for clarification if required and for my health report.

GP/Occupational health/ Hospital:

Address:

Phone

Signature

WORK PREFERENCE

What kind of Caring Work are you interested in? (Please, tick all that apply)

Interest

Residential Home

Nursing Home

NHS

Private Hospital

Long-Term

Short-Term

Please, indicate when you would like to work. Please, tick all relevant boxes.

Part-Time

Full-Time

Days (M-F)

Evenings (M-F)

Nights (M-F)

Days (Sat-Sun)

Evenings (Sat-Sun)

Nights (Sat-Sun)

Availability

When will you be available to work?

For an interview, which date?

Do you have any holiday booked?

Yes

If Yes, when?

REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4.2 Rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are, therefore, entitled to withhold information about convictions, which for other purposes are 'spent' under the provision of the Act in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Information provided will be kept confidential and use in relationship to the post applied for.

Have you ever been convicted of a criminal offence?

Yes

If yes, please specify:

Do you have any spent or unspent convictions?

Yes

If yes, please specify:

Have you instigated an enhanced disclosure within the last six years?

Yes

I CONSENT TO PREMIUM HEALTHCARE STAFFING LTD CHECKING THE DETAILS I HAVE PROVIDED AGAINST THE VARIOUS DATA SOURCES IN ORDER TO VERIFY MY IDENTITY AND PROCESS THIS APPLICATION. THESE DETAILS MAY BE USED TO ASSIST OTHER ORGANISATIONS SUCH AS CRB, NMC ETC IN IDENTITY PURPOSES.

Signature

Date

References

Please, give the names and addresses of two of most recent employers who can comment on your work ability and experience, starting with your present to most recent employer if possible.

Referee One

Contact Name:

Address

Address Post Code

Phone

Referee Two

Contact Name:

Address

Address Post Code

Phone

NEXT OF KIN

Name of Emergency Contact:

Relationship to you:

Address

Address: ZIP / Postal Code

Phone

WORKING TIME REGULATIONS

I have read and understood the Working Time Regulations and I hereby consent that the working time limit shall not apply to my assignments.

Print Name:

Signature

Date

BUILDING SOCIETY/BANK DETAILS

Bank Name:

Holders Account Name:

Bank Address:

Building Society Bank Roll:

Sort Code:

Account No:

I authorise Renee Healthcare Services to pay my weekly wages into the above bank account and I will notify Renee Healthcare Services if changes occur to my details.

Signature

Date

FINAL STATEMENT

I declare that the information provided on this application is true to the best of my knowledge. I have read the terms and condition of engagement and agree to comply with the current Health and Safety at Work Act. I understand that my appointment is subject to the receipt of two satisfactory references, and it subjects to Enhanced CRB Disclosure. Premium Healthcare Staffing LTD is free to make any other enquiries they may find necessary relating to my application. I agree to respect the confidentiality of patients and clients and any other information I may have access to.

Full Name:

Signature

Date

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Care Worker

Your Personal Information

Please, use capital letters throughout and tick the appropriate box where necessary)

OTHER INFORMATION

Please indicate if you had training/qualifications in the following areas:

Please, tick the Specialities of which you have significant, post training experience. Please, remember you will be held accountable for any missing information.

Employment History

HEALTH DECLARATION

Do you or have you at any time suffered from any of the following?

Please, answer the following.

WORK PREFERENCE

REHABILITATION OF OFFENDERS ACT 1974

References

NEXT OF KIN

WORKING TIME REGULATIONS

BUILDING SOCIETY/BANK DETAILS

FINAL STATEMENT

Contact Details

Address

Opening Hours