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Application Form – Carers

Application Form – Carers

Application - CARER

SECTION 1: Personal Details

NAME(Required)

TITLE FORENAMES (in full) MAIDEN NAME SURNAME

PREVIOUS NAMES (if any)

First Last

ADDRESS(Required)

Street Address City Post Code Country

EMAIL ADDRESS(Required)

Enter Email Confirm Email

TELEPHONE NUMBER (HOME)

MOBILE(Required)

NATIONALITY(Required)

DATE OF BIRTH(Required)

Day

Month

Year

N.I. NUMBER(Required)

NAME OF BANK(Required)

SORT CODE(Required)

ACCOUNT NAME(Required)

ACCOUNT NUMBER(Required)

EMERGENCY CONTACT NAME(Required)

EMERGENCY CONTACT NUMBER(Required)

RELATIONSHIP(Required)

EMERGENCY CONTACT ADDRESS(Required)

Street Address City Post Code Country

SECTION 2: Education

DETAILS OF EDUCATION(Required)

EDUCATIONAL INSTITUTION

COURSES TAKEN

DATE FROM

DATE TO

ACHIEVEMENTS

Click the "+" to add more details

SECTION 3: Employment History

Please list details of all your employment history for the past ten years and explain reasons for any gaps in between jobs. Start with your more previous jobs.

NAME & ADDRESS OF EMPLOYER(Required)

NAME & ADDRESS OF EMPLOYER

POSITION/ DUTIES & RESPONSIBILITIES

DATE FROM

DATE TO

REASON FOR LEAVING

Click the "+" to add more rows

SECTION 4: Qualifications/ Training Certificates

QUALIFICATIONS / TRAINING(Required)

TRAINING DETAILS

COURSES TAKEN

DATE FROM

DATE TO

ACHIEVEMENTS

Click the "+" to add more rows

SECTION 5: Professional Details

Please tick the relevant boxes in which you are experienced:

PERSONAL HYGIENE(Required)

Bath/shower/strip wash

Bed Bath

Care of eyes

Care of feet

Care of fingernails

Care of hair

Dressing/ Undressing

Mouth care (incl dentures)

Shaving

Use of bath aids

TOILETING(Required)

Applying a conveen

Attaching a night bag

Bedpans/ commodes etc

Changing a catheter bag

Continence bag

Stoma bag

PRACTICAL TASKS(Required)

Bed making / changing a bed

Collecting benefits

Cooking

Light housework

Recording of blood pressure

Recording of temperature

Recording of respiration

Shopping

Washing personal laundry

MOBILITY(Required)

Moving & handling clients

Moving & handling course

Use of hoists (man/elec)

Use of walking aids

ADMINISTRATIVE ABILITIES(Required)

Confidentiality

Observing / recording changes in clients' conditions

Recording instructions from GP/Nurse

Report writing

CARE DUTIES(Required)

Assisting with medication

Pressure area care

Simple dressing procedures

Terminal care

NUTRITION(Required)

Feeding

Food handling

Preparing meals

Previous experience: please list how you gained experience in the following:(Required)

HOSPITAL

NURSING/ RESIDENTIAL HOME

PRIVATE HOUSE

Please indicate your level of profiency according to the scale below:

I - no experience

II - previously performed but not proficient

III - competent to perform independently

Please indicate which areas you have experience in:

AREA: NURSING HOME

Frail/ Elderly
EMI
Other

NHS/PRIVATE/LOCAL AUTHORITY(Required)

MONTHS/YEARS(Required)

LEVEL OF PROFICIENCY(Required)

I

II

III

AREA: RESIDENTIAL HOME

Frail/ Elderly
EMI
Other

NHS/PRIVATE/LOCAL AUTHORITY(Required)

MONTHS/YEARS(Required)

LEVEL OF PROFICIENCY(Required)

I

II

III

AREA: HOME CARE

Client's Own Home

NHS/PRIVATE/LOCAL AUTHORITY(Required)

MONTHS/YEARS(Required)

LEVEL OF PROFICIENCY(Required)

I

II

III

AREA: HOSPITAL

Specific area of work

NHS/PRIVATE/LOCAL AUTHORITY(Required)

MONTHS/YEARS(Required)

LEVEL OF PROFICIENCY(Required)

I

II

III

AREA: COMMUNITY

Specific area of work

NHS/PRIVATE/LOCAL AUTHORITY(Required)

MONTHS/YEARS(Required)

LEVEL OF PROFICIENCY(Required)

I

II

III

AREA: MENTAL HEALTH

Specific area of work

NHS/PRIVATE/LOCAL AUTHORITY(Required)

MONTHS/YEARS(Required)

LEVEL OF PROFICIENCY(Required)

I

II

III

LEVEL OF PRACTICE(Required)

DATE ACHIEVED(Required)

Please state if you are currently undertaking an NVQ course and what level:

TRAINING RECEIVED

MANUAL HANDLING

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

INFECTION CONTROL

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

FIRE SAFETY

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

FIRST AID

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

ESSENTIAL FOOD HYGIENE

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

OBSERVATION SKILLS

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

LONE WORKER

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

MANAGEMENT OF AGGRESSIVE / VIOLENT BEHAVIOUR

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

ABUSE AWARENESS

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

HEALTH & SAFETY

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

OTHER

DATE

MM slash DD slash YYYY

CERTIFICATE SUPPLIED

Max. file size: 256 MB.

SECTION 6: General Information

Do you hold a current FULL driving license?(Required)

Yes

No

Do you have your own transportation?(Required)

Yes

No

Do you have a VALID passport?(Required)

Yes

No

Do you have typing/ computer skills?(Required)

Yes

No

Do you speak any other languages?(Required)

Yes

No

How did you hear about our agency?(Required)

Are you a member of a Union or Professional Organisation offering Indemnity Insurance for carers?(Required)

Yes

No

Please provide details:

BODY NAME

AMOUNT OF COVER

POLICY NUMBER

EXPIRY DATE

SECTION 7: Work Preferences

Please specify which type of work you would prefer:

TYPE OF WORK(Required)

PART TIME

FULL TIME

DAYS

NIGHTS

Do you have any other commitments?(Required)

When are you available to commence work?(Required)

SECTION 8: Convictions

Rehabilitation of Offenders Act 1974:(Required)

State any convictions/ offences, information of which you are not entitled to withhold, under the Rehabilitation Act 1974 (Exceptions) Order 1975, in view of the nature of the work for which you are applying:

Criminal Record Bureau / Disclosure Scotland Statement

If your application is successful, you will be required to provide a satisfactory Enhanced Disclosure or equivalent from country of origin if in the UK for less than three months.

Care Standards Act 2000:(Required)

State any police cautions and incidents with the police, in view of the nature of the work for which you are applying:

The information above will be disclosed by the Criminal Records Bureau check which will be required if your application is successful.

SECTION 9: References

A minimum of five years work history must be provided. Referees must be a previous / current supervisor / manager / employer.

PLEASE NOTE THAT THE WORK HISTORY WITH REFERENCES MUST COVER A MINIMUM OF 5 YEARS. ANY GAPS IN WORK HISTORY MUST BE EXPLAINED.

1st Reference:

Name:(Required)

Position:(Required)

Address:(Required)

Post Code:(Required)

Tel no:(Required)

Email:(Required)

How long has this person known you?(Required)

2nd Reference:

Name:(Required)

Position:(Required)

Address:(Required)

Post Code:(Required)

Tel no:(Required)

Email:(Required)

How long has this person known you?(Required)

3rd Reference:

Name:(Required)

Position:(Required)

Address:(Required)

Post Code:(Required)

Tel no:(Required)

Email:(Required)

How long has this person known you?(Required)

4th Reference:

Name:(Required)

Position:(Required)

Address:(Required)

Post Code:(Required)

Tel no:(Required)

Email:(Required)

How long has this person known you?(Required)

SECTION 10: Confidentiality Declaration

Registration implies acceptance of our code of confidentiality.

In the course of your duties you may have access to confidential information about your clients. On no account must information relating to identifiable clients be divulged to anyone other than your branch manager or his/ her assistant.

You should not disclose any information to your family, friends, or neighbours. If you are worried by any information you have obtained and consider that you should talk about it to someone else, make an appointment to speak in private with your manager.

Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register.

I have read and I understand the above and agree to abide by the contents therein.

Signed

Date

SECTION 11: Passport and Work Permit Details (for care workers from overseas only)

Work permit/visa

Yes

No

Proof of ID (passport & visa):

Max. file size: 256 MB.

Passport Nationality:

Place of Issue:

Passport Number:

Date of Issue:

Expiry Date:

Known restrictions in use:

Yes

No

SECTION 12: Declaration

The information that I have given in this application form, is to the best of my knowledge, complete and accurate in all respects, and I am not aware of any reason why I am not for for this work. I understand that knowingly giving false information will disqualify me from registration with this agency.

Signed

Date

Name

Position applied for

Location

Healthcare & Locum Recruitment aims to be an equal opportunities provider of work and select solely on merit irrespective of race, sex, disability etc... In order to monitor the effectiveness of our equal opportunities policy, we request all applicants to provide the information indicated.

Please note:

Ethnic minority questions are not about nationality, place of birth or citizenship. They are about colour and broad ethnic groups. UK citizens can belong to any of the groups indicated.

Please tick the appropriate category.

Please select the appropriate category:

Indian

White

Chinese

Black/Caribbean

Black/African

Black/Other

Pakistani

Bangladeshi

Other

Name

This field is for validation purposes and should be left unchanged.

HLR Privacy Policy and Data Protection

Mon-Fri 9am-5pm: 020 8274 8625 | Out-of-hours: 07956 956 358

All Rights Reserved Copyright © Healthcare & Locum Recruitment, 2022

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