Competency Application Form
Applicants Name:
Position Applied For Clinical Nurse Specialist in Palliative Care – Winter Initiative
(Please tick the post you are interested in)
2.5 WTE Fixed Term Contracts
Based in Harold’s Cross for South and West Dublin
1.0 WTE Fixed Term Contract
Based in Blackrock Hospice for South East Dublin
Closing Date:
** Applications must be received no later than 12pm Wednesday 28th October 2015
How to Apply:
To apply for this position please forward an electronically completed application form, to the Human
Resources Department, Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin 6w before
closing date stated above. Please ensure that you include details of a current daytime contact number
and/or e-mail address on your application.
The information you supply should be in font ARIAL size 10 and should not be in colour, bold or italics.
Please email your application to
CURRICULUM VITAES WILL NOT BE ACCEPTED
Our Lady’s Hospice and Care Services is an Equal Opportunities Employer and welcomes applications
from all sections of the community regardless of gender, age, race, religion, marital status, sexual
orientation, disability, membership of the travelling community, or family status.
Should you have any difficulty in completing this application form, please contact the Human Resources
Department, Our Lady’s Hospice and Care Services, Harold’s Cross, Dublin 6w,
Tel: 01 4068 709, Fax: 497 4639 (email: hr@olh.ie ), so that we can assist you.
The information which you give on this form will be treated as strictly confidential and all or part may be
retained in a computerised system, in which case the Hospice will comply fully with the requirements of
the Data Protection Act.
Thank you for your interest in Our Lady’s Hospice and Care Services
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PRIVATE AND CONFIDENTIAL
Position Details:
Position Applied For:
Where did you see this position advertised?
Personal Details:
Title:
Forename:
Surname:
Home Address:
Contact Number:
Email Address:
Questionnaire Section:
Do you require authorisation to work in Ireland?
If yes, please provide details:
Yes
No
(please circle)
A level of proficiency in the English language is a requirement of Our Lady’s Hospice and Care
Services. Please rate you proficiency in the English language:
Excellent
Good
Average
Fair
* IMPORTANT Your proficiency in written English will be assessed at application stage.
Your proficiency in spoken English will be assessed during interview.
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Poor
Have you ever availed of a Redundancy/Early Retirement Scheme within the Public Sector?
Yes
No
If yes, give full details:
Details of Current Employment:
Start Date:
Employer Name:
Employer Address:
Job Title:
Notice Period:
Duties and Responsibilities of current post:
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Previous Employment Details:
PREVIOUS EMPLOYER 1:
Position:
Job Description:
Employer Name:
Employer Address:
Start Date:
End Date:
Reason for Leaving:
PREVIOUS EMPLOYER 2:
Position:
Job Description:
Employer Name:
Employer Address:
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Start Date:
End Date:
Reason for Leaving:
Employment History (Previous posts)
Please list all further previous posts beginning with the most recent including periods out of employment or training
Name and address
of Employer
Job Title
Start
Date
End
Date
(mth/yr)
(mth/yr)
Reason for
leaving
Duties
If you have any gap(s) in your career history, please state the period(s) of the gap and explain the
reason(s) in the box below. Please include any post graduate training periods completed if
appropriate
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Essential Criteria Transport: please refer to the Job Specification for this post and answer the
following question:
Do you hold a full driving License? (Please tick answer that
Yes:
applies)
Do you have access to a car or form of transport which will allow
you to undertake the duties of this post? (Please tick answer Yes:
that applies)
No:
No:
Essential Criteria: Qualification:
Please refer to the Person Specification for this post in order to complete this section.
Information provided by the applicant in this section will be used for shortlisting to the next stage
of the recruitment process – please ensure you provide explicit information on how you meet the
Essential Qualification Criteria for this post.
Evidence of qualification must be submitted with the application.
Essential Qualification
Course Name: Be a registered nurse on the live Register of Nurses kept by An Bord Altranais
agus Cnáimhseachais na hÉireann (Nursing and Midwifery Board of Ireland)
Qualification:
Awarding Body:
Institute:
Country:
Duration:
From Year:
weeks/months/years
To Year:
Result:
Essential Qualification
Course Name:Have acquired a level 8 post-registration Quality and Qualifications Ireland (QQI),
National Framework of Qualifications (NQF) major academic award relevant to the specialist
area (palliative care), prior to application
Qualification:
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Awarding Body:
Institute:
Country:
Duration:
weeks/months/years
From Year:
To Year:
Result:
Professional Bodies:
It is the policy of the HSE to require nurses and midwives to certify registration with the NMBI annually, by
way of the Patient Safety Assurance Certificate (PSAC).
Name:
Grade of Membership:
Year Admitted:
Expiration Date:
Membership Number:
Desirable Criteria: Qualification:
Please refer to the Person Specification for this post in order to complete this section.
Please provide information on any qualification you have relevant to this position.
NB: In the event we receive a high volume of applications for this post the desirable criteria
qualification may be used for shortlisting to the next stage
Desirable Qualification (If Applicable)
Course Name: Management Training
Qualification:
Awarding Body:
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Institute:
Country:
Duration:
weeks/months/years
From Year:
To Year:
Result:
Desirable Qualification (If Applicable)
Course Name: Teaching qualification
Qualification:
Awarding Body:
Institute:
Country:
Duration:
From Year:
weeks/months/years
To Year:
Result:
Essential Criteria: Experience: Please refer to the Person Specification for this post.
Information provided by the applicant in this section will be used for shortlisting to the next stage
of the recruitment process – please ensure you provide explicit information on how you meet the
Essential Experience Criteria for this post.
Criteria: Essential Experience
Essential Experience - Have extensive experience and clinical expertise i.e. minimum of 5
years post registration experience (following registration in the division of the register in which
the application is being made)
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Essential Experience - Have a minimum of 2 years’ experience in the specialist area of
palliative care nursing
Essential Experience - Have the ability to practice safely and effectively fulfilling his/her
professional responsibility within his/her scope of practice
Essential Experience - Have evidence of continuing professional development.
Desirable Criteria: Experience:
Please refer to the Person Specification for this post in order to complete this section.
Please provide information on any desirable experience you have relevant to this position.
NB: In the event we receive a high volume of applications for this post the desirable criteria
experience may be used for shortlisting to the next stage
Criteria: Desirable Experience
Desirable Experience- Experience in community nursing
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Desirable Experience- Experience in policy and procedure development.
Desirable Experience- Experience with quality assurance, audit and nursing research
Core Competencies:
Please refer to the Person Specification for this post.
Information provided by the applicant in this section will be used for shortlisting to the next stage
of the recruitment process – please ensure you provide clear examples on three of the Core
Competencies required for this role. One example per competency is sufficient.
Competency 1 - Professional Knowledge & Skills – Please provide an example that will
demonstrates how you have displayed a high level of clinical knowledge & competence in
specialist palliative care
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Competency 2 – Organisational Knowledge & Skills – Please provide an example that
will demonstrate your ability to to lead on clinical practice and service quality?
Competency 3 – Planning & Organising - Please provide an example that will
demonstrate your ability to plan & organise resources effectively
Additional Information:
Please provide details of any additional relevant achievements, whether personal or professional, gained
to date:
Maximum 200 words
Details:
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Reference Details:
Two references will be required for all vacancies within Our Lady’s Hospice and Care Services.
Please give details of three referees whom we may contact. Please note that we will not contact your
referees without first informing you.
Referee 1 must be your current manager to whom you directly report to.
Referees 2 must be the person who you reported to in previous positions. This person must have
sanctioned and monitored your leave and performance. OLH&CS will determine at reference stage if the
referees provided are appropriate or if other referees may be requested.
Referee 1 (Employer/Manager/Supervisor)
Title: Mr/Mrs/Miss/
Ms/Dr/Other
First Name
Family Name
Role/Position
Company
Contact Address
e-mail address
Phone Number
Professional Relationship:
Yes:
Can we contact this referee post interview?
(Please tick answer that applies)
Referee 2
Title:Mr/Mrs/Miss/
Ms/Dr/Other
First Name
Surname
Role/Position
Company
Contact Address
e-mail address
Phone Number
Professional Relationship:
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No:
Equal Opportunities Monitoring:
Our Lady’s Hospice and Care Services is an equal opportunities employer and operates a “Positive
Towards Disability” approach. Please indicate if you have any special requirements should you be invited
to interview:
Details of Special Requirements:
Important – Canvassing
Any canvassing by or on behalf of candidates may result in disqualification and exclusion from the
recruitment process.
Declaration:
I declare that all the particulars furnished in connection with this application are true, and that I am aware
of the qualifications and particulars for this position. I understand that I will be required to submit
documentary evidence in support of any particulars given by me on my Application Form. I understand
that any false or misleading information submitted by me will render me liable to automatic disqualification
or render me liable to dismissal, if employed.
**Please tick the box below prior to emailing your application form. Failure to do so may render it
invalid.
□ I confirm that I am in agreement with the statement above
Name of Candidate: ……………………………………
(Type in full name if applying by e-mail)
Signature: ……………………………………………….Date: ………………………………… (Insert Date)
** When your Application Form is completed, please review and ensure all information is correct. Do not
change layout or format. However, please review the document for any unnecessary extra pages etc and edit
for presentation purposes as appropriate.
Recruitment Process:





Applicants will be shortlisted for interview based on information supplied in the application form at the
closing date.
The criteria for short-listing are based on the qualification, experience, core competencies and the
information supplied in the application form.
Presentation, content, spelling and grammar will also so be assessed during shortlisting stage.
If the form is illegible or incomplete it may result in you being disqualified from the process
All applicants will be responded to in due course.
If you require further information regarding this organisation, or the role for which you are applying, please
contact:
Human Resources
Our Lady’s Hospice and Care Services
13
Harold’s Cross
Dublin 6w
Tel: 00 353 1 406 8709
Fax: 00 353 1 497 4639
Email: hr@olh.ie
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