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Job Application (NEW – DRAFT)

1. Personal 2. Next of kin & Employment 3. Gaps 4. References 5. Health 6. Review

Please complete all fields. If a field does not apply, enter N/A.

PERSONAL INFORMATION

Branch Name Preferred Title First Name Surname Previous Surname Address Postcode Date you moved to this address Landline Number Mobile Number National Insurance No. Date of Birth Email Address Place of Birth (Town / Country)

Do you hold a clean driving licence?

Yes No

Do you have a car?

Yes No

Are you eligible to work in the UK?

Yes No

Can you work alone with male service users?

Yes No

Pet allergies or fear of pets?

Yes No

When can you start? Have you planned any holiday? If yes, please put the dates

Please complete all fields. If a field does not apply, enter N/A.

NEXT OF KIN

(A family member or friend we can contact in an emergency)

Name

Relationship

Address

Telephone

PRESENT OR LAST EMPLOYMENT

(Use present or last education if you have no employment history) If you do not wish us to send a reference before interview, tick this box

Job / Course Title

Employer / School Name

Referee Name

Email Address

Address

Post Code

Telephone

Start Date

End Date

Reason for Leaving

PREVIOUS EMPLOYMENT HISTORY

(Last five years – add up to 3)

Employer Name, Address & Telephone

Title of Post Held

Name of Immediate Supervisor

Main Duties / Responsibilities Salary

From

Reason for Leaving

Please complete all fields. Use N/A where not applicable.

EDUCATION AND EMPLOYMENT GAP

(Please explain in detail the gaps in your education and employment history if any)

From

Reason for the Gap

EDUCATION / TRAINING HISTORY

School / College / University

Course Title

Qualification Received

From

Part Time or Full Time Qualification Received

RELEVANT CARE TRAINING

Course Title / Subject

Year

Length

Qualification Received

Organising Body Name & Address

LANGUAGES

DO YOU SPEAK ANY OTHER LANGUAGES BESIDES ENGLISH? IF YES, PLEASE STATE:

Language

REFERENCES

Please provide names and addresses of two (2) people we can contact for reference, including one from your last employer or college. Referees should not be a relative or friend. Your referees should know you for at least six (6) months. Please write in capital letters.

WORK RELATED REFERENCES

1ST REFEREE – WORK RELATED

Contact Name (MR / MS)

His / Her Position

Organisation Address

Postcode

Daytime Telephone

Fax No

Your Position

Dates Worked – From

Dates Worked – To

CHARACTER REFERENCES

1ST REFEREE – CHARACTER

Contact Name (MR / MS)

His / Her Position

Organisation Address

Postcode

Daytime Telephone

Fax No

Your Position

Dates Worked – From

Dates Worked – To

ADDRESSES (Please list your addresses in the past 5 years)

Address 1

Full Address

Date From

Date To

REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work involved, the post for which you are applying is exempt from section 4(2) of the Rehabilitation of Offenders Act 1974. You are not entitled to withhold information relating to any conviction you may have had.

Have You Committed Any Criminal Offence?

Yes No

Do You Have Any Conviction?

Yes No

Have You Been Given Any Warning Before?

Yes No

If you answered YES to any of the above questions, please give details below.

DECLARATION

Declare any investigation, enquiry, or reason you may be considered unsuitable to work with children or vulnerable adults. If none, write N/A.

ASYLUM & IMMIGRATION ACT 1996

Please tick the document you will provide to confirm your eligibility to work in the UK:

A birth certificate issued in the United Kingdom or in the Republic of Ireland or a certificate of registration or Naturalisation as a British citizen.
A passport which described the holder as a British citizen or as having a right abode in the United Kingdom or a passport or other travel document endorsed to show that the holder has indefinite leave to remain in the United Kingdom and is not precluded from taking the employment in question.
EEA A passport or an identity card issued by a state which is a party of the European Economic Area agreement and which describes the holder as a national of a state which is a party to that agreement
A letter issued by the home office or the department of education and employment indicating that the person named in the letter has permission to take the employment in question.

PRIVACY NOTICE

We process personal data relating to those who apply for job vacancies with us or who send speculative job applications to us. We do this for employment purposes, to assist us in the selection of candidates for employment, and to assist in the running of the business. The personal data may include identifiers such as name, date of birth, personal characteristics such as gender, qualifications and previous employment history.
We will not share any identifiable information about you with third parties without your consent unless the law allows or requires us to do so. The personal data provided during an application process will be retained for a period of at least six months or, if required by law, for as long as is required.
This privacy notice does not form part of an employment offer or contract between us. If we make an employment offer to you, we will provide further information about our handling of your personal information in an employment context separately. If you would like to find out more about our data retention policy and how we use your personal data, you want to see a copy of the information about you that we hold or have any questions or issues regarding data protection, please email us with the Subject “Data Protection Request”.

I confirm that I have read and understood all the questions and statements on this form. The answers I have furnished are true and correct to the best of my knowledge and belief. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references and process my personal data according to the GDPR regulation.

Please Print Your Name Signed Date

CARE EXPERIENCE

Name

Position

Health & Social Care Qualification Level 1

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 2

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 3

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 4

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 5

Good Fair Poor Don’t Know

Experience

Brain Injury

Good Fair Poor Don’t Know

Care of Person with Substance Abuse

Good Fair Poor Don’t Know

Children and Family

Good Fair Poor Don’t Know

Domiciliary Care

Good Fair Poor Don’t Know

Live-in Care

Good Fair Poor Don’t Know

Mental Health Care

Good Fair Poor Don’t Know

Older Adults Care

Good Fair Poor Don’t Know

Pressure Care

Good Fair Poor Don’t Know

Reablement Care

Good Fair Poor Don’t Know

Care of Person with Sensory Impairment

Good Fair Poor Don’t Know

Physical Disability

Good Fair Poor Don’t Know

Catheter Care

Good Fair Poor Don’t Know

Challenging Behaviour

Good Fair Poor Don’t Know

Changing a Colostomy Bag / Stoma Bag

Good Fair Poor Don’t Know

Dementia & Parkinson’s Disease

Good Fair Poor Don’t Know

End of Life Care / Palliative Care

Good Fair Poor Don’t Know

Learning Disability

Good Fair Poor Don’t Know

Blood Level Test

Good Fair Poor Don’t Know

PEG Feeding

Good Fair Poor Don’t Know

Tracheostomy Care

Good Fair Poor Don’t Know

Use of Equipment / Manual Handling Tasks

Standing Hoist

Good Fair Poor Don’t Know

Transferring Service Users

Good Fair Poor Don’t Know

Use of Commodes / Bed Pans

Good Fair Poor Don’t Know

Use of Hoists and Bath Lifts

Good Fair Poor Don’t Know

Use of Sliding Sheets

Good Fair Poor Don’t Know

Wheelchair

Good Fair Poor Don’t Know

Dressing and Undressing Patients

Good Fair Poor Don’t Know

Giving Bed Baths / Strip Wash

Good Fair Poor Don’t Know

Mouth Care (Including Dentures)

Good Fair Poor Don’t Know

Use of Bath Aids

Good Fair Poor Don’t Know

Light Domestic

Good Fair Poor Don’t Know

Feeding Service Users

Good Fair Poor Don’t Know

Food Preparation / Shopping

Good Fair Poor Don’t Know

Shopping / Paying Bills

Good Fair Poor Don’t Know

DIVERSITY MONITORING

Name

Position

Please Tick

Your Gender Male
Female

Sexual Orientation Heterosexual
Bisexual
Homosexual
Transgender

Your Age Band 16 – 18
18 – 24
25 – 35
36 – 46
47 – 54
55 – 64
65 – 74

Disability

Do you consider yourself to have a disability as defined by the Disability Discrimination Act 1995? e.g. a physical and/or mental impairment, which has a substantial and long-term adverse effect on your ability to undertake day to day activities.

Yes
No

If yes, do you need any help during the interview? Yes
No

Are there any reasonable adjustments that would assist you in attending an interview?

What is your ethnic group? Please only tick ONE of the four groups below

Our ethnic background describes how we think of ourselves. Ethnic background is not the same as nationality or country of birth.

1) White
White British
White Irish

Any other White background – please specify.

2) Asian or Asian British
Asian British
Indian
Pakistani
Bangladeshi
Chinese

Any other Asian background – please specify.

3) Mixed
White and Black Caribbean
White and Black African
White and Asian

Any other Mixed background – please specify.

4) Black or Black British
Black British
Caribbean
African

Any other Black background – please specify.

5) Religion
Christian
Muslim
Buddhist
Hindu

Any other Religion – please specify.

Nationality

Where did you see this post advertised?

QUESTIONNAIRE

Name

Date

Do you have history of

Back injury / problems / pain

Yes No

Diabetes

Yes No

Headaches / Migraine

Yes No

Gastro-enteritis

Yes No

Skin disorder

Yes No

Ulcers / Ruptures

Yes No

Any illness not mentioned above

Yes No

Bronchitis / Asthma / Hay Fever

Yes No

Disease of nervous system

Yes No

Heart Disease

Yes No

Psychiatric

Yes No

Tuberculosis

Yes No

Anxiety / Depression

Yes No

Chest Pain / Problem

Yes No

Epilepsy / Blackout

Yes No

High Blood Pressure

Yes No

Rheumatism or Arthritis

Yes No

Typhoid / Dysentery

Yes No

Please specify (if YES to any above)

Have you been vaccinated against

If yes, please enter the date of vaccination.

Hepatitis B

Yes No

Tuberculosis (BCG)

Yes No

German Measles (Rubella)

Yes No

Tetanus

Yes No

COVID-19

Yes No

any other illness

1. Personal 2. Next of kin & Employment 3. Gaps 4. References 5. Health 6. Review

Please complete all fields. If a field does not apply, enter N/A.

PERSONAL INFORMATION

Do you hold a clean driving licence?

Yes No

Do you have a car?

Yes No

Are you eligible to work in the UK?

Yes No

Can you work alone with male service users?

Yes No

Pet allergies or fear of pets?

Yes No

When can you start? Have you planned any holiday? If yes, please put the dates

Please complete all fields. If a field does not apply, enter N/A.

NEXT OF KIN

(A family member or friend we can contact in an emergency)

Name

Relationship

Address

Telephone

PRESENT OR LAST EMPLOYMENT

(Use present or last education if you have no employment history) If you do not wish us to send a reference before interview, tick this box

Job / Course Title

Employer / School Name

Referee Name

Email Address

Address

Post Code

Telephone

Start Date

End Date

Reason for Leaving

PREVIOUS EMPLOYMENT HISTORY

(Last five years – add up to 3)

Employer Name, Address & Telephone

Title of Post Held

Name of Immediate Supervisor

Main Duties / Responsibilities Salary

From

Reason for Leaving

Please complete all fields. Use N/A where not applicable.

EDUCATION AND EMPLOYMENT GAP

(Please explain in detail the gaps in your education and employment history if any)

From

Reason for the Gap

EDUCATION / TRAINING HISTORY

School / College / University

Course Title

Qualification Received

From

Part Time or Full Time Qualification Received

RELEVANT CARE TRAINING

Course Title / Subject

Year

Length

Qualification Received

Organising Body Name & Address

LANGUAGES

DO YOU SPEAK ANY OTHER LANGUAGES BESIDES ENGLISH? IF YES, PLEASE STATE:

Language

REFERENCES

WORK RELATED REFERENCES

1ST REFEREE – WORK RELATED

Contact Name (MR / MS)

His / Her Position

Organisation Address

Postcode

Daytime Telephone

Fax No

Your Position

Dates Worked – From

Dates Worked – To

CHARACTER REFERENCES

1ST REFEREE – CHARACTER

Contact Name (MR / MS)

His / Her Position

Organisation Address

Postcode

Daytime Telephone

Fax No

Your Position

Dates Worked – From

Dates Worked – To

ADDRESSES (Please list your addresses in the past 5 years)

Address 1

Full Address

Date From

Date To

REHABILITATION OF OFFENDERS ACT 1974

Have You Committed Any Criminal Offence?

Yes No

Do You Have Any Conviction?

Yes No

Have You Been Given Any Warning Before?

Yes No

If you answered YES to any of the above questions, please give details below.

DECLARATION

Declare any investigation, enquiry, or reason you may be considered unsuitable to work with children or vulnerable adults. If none, write N/A.

ASYLUM & IMMIGRATION ACT 1996

Please tick the document you will provide to confirm your eligibility to work in the UK:

PRIVACY NOTICE

Please Print Your Name Signed Date

CARE EXPERIENCE

Name

Position

Health & Social Care Qualification Level 1

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 2

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 3

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 4

Good Fair Poor Don’t Know

Health & Social Care Qualification Level 5

Good Fair Poor Don’t Know

Experience

Brain Injury

Good Fair Poor Don’t Know

Care of Person with Substance Abuse

Good Fair Poor Don’t Know

Children and Family

Good Fair Poor Don’t Know

Domiciliary Care

Good Fair Poor Don’t Know

Live-in Care

Good Fair Poor Don’t Know

Mental Health Care

Good Fair Poor Don’t Know

Older Adults Care

Good Fair Poor Don’t Know

Pressure Care

Good Fair Poor Don’t Know

Reablement Care

Good Fair Poor Don’t Know

Care of Person with Sensory Impairment

Good Fair Poor Don’t Know

Physical Disability

Good Fair Poor Don’t Know

Catheter Care

Good Fair Poor Don’t Know

Challenging Behaviour

Good Fair Poor Don’t Know

Changing a Colostomy Bag / Stoma Bag

Good Fair Poor Don’t Know

Dementia & Parkinson’s Disease

Good Fair Poor Don’t Know

End of Life Care / Palliative Care

Good Fair Poor Don’t Know

Learning Disability

Good Fair Poor Don’t Know

Blood Level Test

Good Fair Poor Don’t Know

PEG Feeding

Good Fair Poor Don’t Know

Tracheostomy Care

Good Fair Poor Don’t Know

Use of Equipment / Manual Handling Tasks

Standing Hoist

Good Fair Poor Don’t Know

Transferring Service Users

Good Fair Poor Don’t Know

Use of Commodes / Bed Pans

Good Fair Poor Don’t Know

Use of Hoists and Bath Lifts

Good Fair Poor Don’t Know

Use of Sliding Sheets

Good Fair Poor Don’t Know

Wheelchair

Good Fair Poor Don’t Know

Dressing and Undressing Patients

Good Fair Poor Don’t Know

Giving Bed Baths / Strip Wash

Good Fair Poor Don’t Know

Mouth Care (Including Dentures)

Good Fair Poor Don’t Know

Use of Bath Aids

Good Fair Poor Don’t Know

Light Domestic

Good Fair Poor Don’t Know

Feeding Service Users

Good Fair Poor Don’t Know

Food Preparation / Shopping

Good Fair Poor Don’t Know

Shopping / Paying Bills

Good Fair Poor Don’t Know

DIVERSITY MONITORING

Name

Position

Please Tick

Your Gender Male
Female

Sexual Orientation Heterosexual
Bisexual
Homosexual
Transgender

Your Age Band 16 – 18
18 – 24
25 – 35
36 – 46
47 – 54
55 – 64
65 – 74

Disability

Yes
No

If yes, do you need any help during the interview? Yes
No

Are there any reasonable adjustments that would assist you in attending an interview?

What is your ethnic group? Please only tick ONE of the four groups below

Our ethnic background describes how we think of ourselves. Ethnic background is not the same as nationality or country of birth.

1) White
White British
White Irish

Any other White background – please specify.

2) Asian or Asian British
Asian British
Indian
Pakistani
Bangladeshi
Chinese

Any other Asian background – please specify.

3) Mixed
White and Black Caribbean
White and Black African
White and Asian

Any other Mixed background – please specify.

4) Black or Black British
Black British
Caribbean
African

Any other Black background – please specify.

5) Religion
Christian
Muslim
Buddhist
Hindu

Any other Religion – please specify.

Nationality

Where did you see this post advertised?

QUESTIONNAIRE

Name

Date

Do you have history of

Back injury / problems / pain

Yes No

Diabetes

Yes No

Headaches / Migraine

Yes No

Gastro-enteritis

Yes No

Skin disorder

Yes No

Ulcers / Ruptures

Yes No

Any illness not mentioned above

Yes No

Bronchitis / Asthma / Hay Fever

Yes No

Disease of nervous system

Yes No

Heart Disease

Yes No

Psychiatric

Yes No

Tuberculosis

Yes No

Anxiety / Depression

Yes No

Chest Pain / Problem

Yes No

Epilepsy / Blackout

Yes No

High Blood Pressure

Yes No

Rheumatism or Arthritis

Yes No

Typhoid / Dysentery

Yes No

Please specify (if YES to any above)

Have you been vaccinated against

If yes, please enter the date of vaccination.

Hepatitis B

Yes No

Tuberculosis (BCG)

Yes No

German Measles (Rubella)

Yes No

Tetanus

Yes No

COVID-19

Yes No

any other illness