We care because you do
APPLICATION FORM
PRIVATE & CONFIDENTIAL
PERSONAL INFORMATION
Surname:
Forenames:
Telephone No
Mobile
Address:
Email
Date of
birth
Marital Status:
Next of kin:
Relationship:
Address:
Phone number:
DO YOU HAVE PERMISSION TO WORK IN THE UK? YES / NO
IF YES,
(Please tick where appropriate)
*You will need to submit proof of this.
You are a member of the EEA
You have a valid Work Permit
You have a Student Visa
Other (please state)
MOBILITY:
DO YOU HAVE ACCESS TO A CAR WHICH CAN BE USED FOR
WORK PURPOSES? YES / NO
DO YOU HOLD A FULL UK DRIVING LICENCE? YES / NO – OTHER …..........................
WHERE DID YOU HEAR ABOUT TINYWELL HEATHCARE?......................................
QUALIFICATIONS/TRAINING
Qualifications School/college Grade/Result Dates: From-To
Relevant training/qualifications in healthcare certificates
Manual handling………..………
yes/no ……………………………….
Health and safety………………
yes/no ………………………………
Basic food hygiene……………
yes/no .……………………………..
First aid………………………......
yes/no ………………………………
NVQ levels…………………….....
yes/no ………………………………
POVA/SOVA.....................
yes/no ...........................
Others (please list)………………….........................................
EMPLOYMENT HISTORY / WORK EXPERIENCE
(Please record all employment history including current employment by other agencies, and
any other relevant experience gained within the health care field). Please start with the most
recent.
EDUCATION/TRAINING RELEVANT TO POST
(please continue on a separate sheet if required, or enclose your C.V)
Name of School/College
From
To
Qualifications
Grade
EMPLOYMENT HISTORY
Please continue on a separate sheet if required, or enclose your C.V. Any gaps must be
explained
Name and address of
From
To
Position held and salary / hourly
Reason for
previous employer(s)
(Month/
(Month/
rate of pay
leaving
starting with most
Year)
Year)
recent
REFERENCES
Please provide details of your national insurance
number
REFEREES
One must be your present/most recent employer. Character testimonials from
professionals are only acceptable in exceptional circumstances, where you have no, or
limited, employment history.
NB WE WILL VERIFY REFERENCES RECEIVED BEFORE CONFIRMING EMPLOYMENT
Referee 1: Do not contact before interview
Company:
Name:
Position
Held:
Address:
Referee 2: Do not contact before interview
Company:
Name:
Position Held:
Postcode:
Telephone:
Fax:
email:
Postcode:
Telephone:
Fax:
email:
Address:
WORK PREFERENCE
To assist us in finding suitable work for you, please place a tick next to all
specialities of which you have 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.
WORK PREFERENCE: (Please tick)
Full time / Part time
If part time, how many hours per week do you want to work?
Home care and pop-in visits
Nursing/Residential Homes
Morning / Day / Evening / Night Sleeper duty
Please state if you are able to work as a 24-hour
Residential (live-in) Carer. YES / NO
If YES, would you like:
Long…… or short ……. assignments?
Would you accept a live-in assignment some distance from your home?
Yes / No
If No, please specify preferred areas:
….....................................................
Care assistant ability schedule
Please indicate Yes / No in the areas you have had previous experience.
Personal Hygiene
Care duties
Bath / Shower / Strip wash
Pressure area care
Bed bath
Simple dressing procedure
Use of bath aids
Assisting with medication
Shaving
Terminal care
Mouth care (inc. dentures)
Light housework
Care of hair
Care of feet (exe. toe nails)
Washing personal laundry
Dressing / undressing
Shopping
Bed making/changing bed linen
Collecting benefits
Toileting
Continence care
Bedpans/Commodes etc
Changing a catheter bag
Emptying catheter bag
Report writing
Recording instructions for GP/District Nurse
Mobility
Observing/Recording
Manoeuvring and handling course
Changes in client condition
Use of hoists (man/elec)
Use of walking aids
Private house
Yes
No
Nursing home
Residential home
EQUAL OPPORTUNITIES
Please tick all the relevant boxes. This 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 or disability.
Male __________________________ Female ________________________
White:
Black Other
Asian British
Irish
Indian
Chinese/Other Asian
Black African
Pakistani
Mixed race
Black British
Bangladeshi
Other (please specify)
DISABILITY
Do you consider yourself as having a disability Yes/ No Please state__________________
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 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 in formation, which you may 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
Tinywell Healthcare Services Ltd.
Have you ever been convicted of a criminal offence? YES I 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 Criminal Records Bureau’s (CRB) Disclosure form.
All health professionals registered with Tinywell Healthcare Services Ltd are subject
to this disclosure process in the interests of all parties concerned.
MEDICAL HISTORY
This is a confidential declaration of personal health. Please complete all questions.
G.P Name ______________________________________
Address ________________________________________
Tele No: ________________________________________
Hepatitis B - Are you Immunised? Yes/ No
Tuberculosis - Are you Immunised? Yes/ No
Tetanus – Are you Immunised? Yes/No
Rubella - Are you Immunised? Yes/ No
Polio - Are you Immunised? Yes/ No
3. Do you have a disability? Yes/ No
(If Yes, please provide details on a separate page)
MEDICAL QUESTIONAIRE
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
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 medical condition or treatment which might affect your 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 hearing? Yes/No
Do you smoke? Yes/No
Your Height:
Your Weight:
WORKING TIME REGULATIONS 1998 OPT – OUT
1.
1.1
Definitions
In this Agreement the following definitions apply:
'Employee' means the the temporary worker
'The Employer' is Tinywell healthcare Services Ltd
'Working Week; means an average of 48 hours each week over a 17 week period
1.2
Unless the context require otherwise, references to the singular include the
plural and references to the masculine include the feminine and vice versa.
1.3
The heading contained in these Terms are for convenience only and do not affect
their interpretation
2.
Restrictions
The Working Time Regulations 1998 provide that an Employee shall not work in excess of the
Working Week unless he agree in writing that this limit should not apply.
3.
Consent
The Employee hereby agrees that the Working Week limit shall not apply to his contract of
employment with his employer
4.
Withdrawal of consent
4.1
The employee may end this agreement by giving the Employer three month's notice in
writing
4.2
For the avoidance of doubt, any notice bringing this agreement to an end shall not be
construed as termination by the Employee of this contract of employment with the Employer
4.3
Upon the expiry of the notice period set out in clause 4.1 the working Week limit shall
apply with immediate effect.
5.
The law
5.1
These terms are governed by the law of England & Wales and are subject to the
exclusive jurisdiction of the courts of England & Wales
_______________________________________
Signed by the employee
BANK DETAILS
Wages are paid direct into your account. Please give below details of your account you would
like your wages paid into:
Name and Address of Bank or Building Society ___________________________________
Name of Account Holder ____________________________________________________
Type of Account (Current, Deposit etc) _________________________________________
Account No:___________________________ Sort Code __________________________
Reference number if Building Society__________________________________________
I hereby request and authorise you to remit all amounts due to me for the Credit of account
detailed above.
Signed: _________________________________ Date: ___________________________
DECLARATION
I declare that:
All 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 at work Act.
I declare that I consider myself to be physically and mentally fit to perform the duties of post I
have applied for.
I have been issued with a staff handbook and informed of the importance of reading and
understanding it.
I consent to the Company checking any information provided on this form, and I understand
that giving false information may lead to any job offer being withdrawn, or to formal action up
to and including termination of my employment.
Signature. …………………………. Date……………………………
(To support the application, please attach all these documents if available: Birth
Certificate, Driving License,2 x passport photos, Passport, Visa/ Work permit, NI
Card, and 2 x Proof of address, all valid training certificates).
Information give out:
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Skills for Care
Job Specification
Company Handbook