Job Application form – Humble Health Care

Job Application

DOCUMENTS NEEDED FOR REGISTRATION

VALID WORK PERMIT

(Or if Student, College ID and Student Visa,)

BRITISH PASSPORT (or other current Home Office Document authorizing you to work in UK)
NATIONAL INSURANCE (NI) CARD

(Or P45 or P60 or letter confirming you have applied for Ni

PROOF OF ADDRESS

E.g. Driving Licence, Utility Bill, or any formal letter with your name and address

2 CURRENT PASSPORT SIZE PHOTOGRAPHS
Disclosure and Barring Service (DBS ) you apply with us.
TRAINING CERTIFICATES, e.g. Moving & Handling, Basic Aid etc. If you do not have the certificates we can provide training

Please fill the Job Application form below and submit

BIO DATA - Step 1 of 5

TITLE *

MR
MRS
MISS
MS

FIRST NAME *

MIDDLE NAME *

SURNAME *

NATIONAL INS. NO. *

DATE OF BIRTH *

MARITAL STATUS *

SINGLE
MARRIED

HOME TEL *

MOBILE *

E-MAIL *

ADDRESS LINE 1 *

CITY *

ADDRESS LINE 2

POSTAL CODE *

NEXT OF KIN *

RELATIONSHIP *

PHONE NUMBER *

ADDRESS: *

POSTCODE *

DO YOU HAVE PERMISSION TO WORK IN THE UK? *

DO YOU HAVE A VALID PASSPORT? *

YOU HAVE A VALID WORK PERMIT? *

MOBILITY

DO YOU HAVE ACCESS TO A CAR WHICH CAN BE USED FOR WORK PURPOSES? *

DO YOU HOLD A FULL UK DRIVING LICENCE? *

SUBMIT YOUR CV/ PROFILE *

MANUAL HANDLING *

CERTIFICATES DATE *

HEALTH AND SAFETY *

CERTIFICATES DATE *

BASIC FOOD HYGIENE *

CERTIFICATES DATE *

FIRST AID *

CERTIFICATES DATE *

NVQ LEVELS *

CERTIFICATES DATE *

OTHERS

(PLEASE LIST)

EMPLOYMENT HISTORY / WORK EXPERIENCE

Please record all employment in the past 5 years, including current employment by other agencies, and any other relevant experience gained within the health care field. Please start with the most recent. Please note that we shall obtain a reference from your LAST EMPLOYER

REFERENCES

1A) Must be your most recent employer (of at least 3 months duration) which must correspond with your employment history.

NAME OF EMPLOYER

ADDRESS OF EMPLOYER

TELEPHONE NUMBER

E-MAIL

1B) Another of your Employers in the last 3 years:

NAME OF EMPLOYER

ADDRESS OF EMPLOYER

TELEPHONE NUMBER

E-MAIL

2) Must be a fellow health care professional who does not live with you and is able to supply a character Reference of your personal and professional profile.

NAME OF EMPLOYER

ADDRESS OF EMPLOYER

TELEPHONE NUMBER

E-MAIL

HEALTH DECLARATION

Careers support workers are required to complete this Health Declaration. Any positive answers will not necessarily affect your application. Please list any medical conditions (past or present) which may affect your ability to do the job.

OCCUPATIONAL HEALTH ASSESSMENT

ARE YOU IN GOOD HEALTH? *

DETAILS

HOW MUCH TIME HAVE YOU LOST FROM WORK DUE TO ILLNESS IN THE LAST FIVE YEARS? PLEASE PROVIDE DETAILS *

HAVE YOU EVER BEEN TREATED IN HOSPITAL FOR SERIOUS ILLNESS OR SURGERY? PLEASE GIVE DATES *

HAVE YOU BEEN TREATED IN HOSPITAL DURING THE LAST 12 MONTHS? *

DO YOU HAVE ANY PHYSICAL DISABILITIES THAT COULD AFFECT YOUR ABILITY TO CARRY OUT YOUR ASSIGNMENT? *

HAVE YOU EVER LEFT, BEEN RETIRED OR DENIED A JOB ON HEALTH GROUNDS? *

HAVE YOU EVER BEEN DENIED A DRIVING LICENSE ON HEALTH GROUNDS? *

ARE YOU A REGISTERED DISABLED PERSON? *

HAVE YOU ANY DISABILITY RELATED TO YOUR PHYSICAL OR MENTAL HEALTH? *

DO YOU GET DISCOMFORT OR PAIN IN THE CHEST OR SHORTNESS OF BREATH ON EXERCISE? *

HAVE YOU EVER HAD ANY PROBLEMS WITH YOUR JOINTS, INCLUDING PAIN, SWELLING OR STIFFNESS? *

DO YOU HAVE ANY DIFFICULTY IN MOVING RAPIDLY OVER SHORT DISTANCES? *

WOULD YOU HAVE DIFFICULTY LOOKING OVER EITHER SHOULDER? *

DO YOU NEED TO WEAR GLASSES OR CONTACT LENSES? *

DO YOU HAVE ANY DIFFICULTY WITH YOUR EYESIGHT WHICH IS NOT CORRECTED BY GLASSES OR CONTACT LENSES? *

HAVE YOU ANY PROBLEMS WORKING WITH VISUAL DISPLAY UNITS? *

HAVE YOU ANY PROBLEMS WORKING IN CONFINED SPACES/USING LIFTS? *

DO YOU HAVE ANY DIFFICULTY HEARING NORMAL CONVERSATION? *

ARE YOU TAKING ANY MEDICATION THAT MAKES YOU DIZZY OR DROWSY? *

DO YOU HAVE A MEDICAL CONDITION AFFECTED BY CHANGING SLEEPING PATTERNS OR AFFECTING DAY TIME SLEEP? *

HAVE YOU SUFFERED FROM ANY ALCOHOL OR DRUG RELATED ILLNESS OR HAD AN ALCOHOL OR DRUG PROBLEM? *

ARE YOU HAVING OR AWAITING ANY TREATMENT AT THE MOMENT? *

WHAT IS THE DATE OF YOUR LAST CHEST X-RAY? *

ARE YOU RECEIVING MEDICINES, PILLS OR TABLETS FROM A DOCTOR OR ON PRESCRIPTION? *

HAVE YOU EVER SUFFERED FROM ANY OF THE FOLLOWING? *

HEART PROBLEMS/CIRCULATORY ILLNESS/HYPERTENSION *

HIGH OR LOW BLOOD PRESSURE *

DIABETES *

ASTHMA/HAY FEVER *

BRONCHITIS/PNEUMONIA/PLEURISY *

TUBERCULOSIS *

EPILEPSY/FAINTING ATTACKS/BLACKOUTS/FITS/SUDDEN COLLAPSE *

HEADACHES/MIGRAINE *

PSYCHIATRIC ILLNESS/ANXIETY/DEPRESSION *

DERMATITIS/SKIN SENSITIVITY/PSORIASIS/ECZEMA/ALLERGIES *

BACK INJURY/BACK PROBLEMS/BACK PAINS *

RECURRENT INFECTIONS E.G. SORE THROATS/EAR INFECTIONS/EYE INFECTIONS *

HEPATITIS/JAUNDICE *

HAVE YOU EVER BEEN VACCINATED, IMMUNIZED OR TESTED FOR / AGAINST ANY OF THE FOLLOWING?

TUBERCULOSIS INCL BCG, HEAF, MANTOUX OR TINE *

DETAILS

RUBELLA (GERMAN MEASLES) *

DETAILS

POLIOMYELITIS *

DETAILS

HEPATITIS B *

DETAILS

HEPATITIS B ANTIBODIES DATE AND RESULT *

DETAILS

HIV *

DETAILS

TETANUS *

DETAILS

TYPHOID *

DETAILS

ANY OTHER *

DETAILS

DOCTOR INFORMATION

GP NAME

ADDRESS

POSTCODE

PHONE:

WORK PREFERENCE

To assist us in finding suitable work for you, please place a tick next to all specialties 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
HOSPITALS
NURSING/RESIDENTIAL HOMES
MORNING / DAY / EVENING / NIGHT SLEEPER DUTY

LIVE-IN CARE

Please state if you are able to work as a 24-hour Residential (live-in) Carer.

If YES, would you like

LONG ASSIGNMENTS
SHORT ASSIGNMENTS

Would you accept a live-in assignment some distance from your home?

If NO, please specify preferred areas:

CARE/SUPPORT ASSISTANT ABILITY SCHEDULE

Please select the areas you have had previous experience.

PERSONAL HYGIENE

BATH/SHOWER/STRIP WASH
BED BATH
USE OF BATH AIDS
SHAVING
MOUTH CARE(INC. DENTURES
CARE OF HAIR
CARE OF FEET(EXC.TOE NAILS)
CARE OF FINGER NAILS
DRESSING/UNDRESSING

CARE DUTIES

PRESSURE AREA CARE
SIMPLE DRESSING PROCEDURE
ASSISTING WITH MEDICATION
TERMINAL CARE

PRACTICAL TASKS

LIGHT HOUSE WORK
WASHING PERSONAL LAUNDRY
SHOPPING
BED MAKING/CHANGING BED LINEN
COLLECTING BENEFITS

TOILETING

CONTINENCE CARE
BEDPANS/COMMODES ETC.
CHANGING A CATHETER BAG
EMPTING CATHETER BAG

ADMIN. ABILITIES

CONFIDENTIALITY
REPORT WRITING
RECORDING INSTRUCTIONS FROM GP/DISTRICT NURSE
OBSERVING/RECORDING
CHANGES IN CLIENTS CONDITION

MOBILITY

MANEUVERING AND HANDLING COURSE
USE OF HOISTS(MAN./ELEC)
USE OF WALKING AIDS

PREVIOUS EXP.

PRIVATE HOUSE
NURSING/RESIDENTIAL HOME

EQUAL OPPORTUNITIES MONITORING

Humble Healthcare Care Ltd aims to be an equal opportunities employer. Employees are therefore put forward for work / shift irrespective of race, ethnic origin, disability, age and gender. In order to monitor the effectiveness of our policy, we request all candidates to provide the following information.

Age Group *

16 – 20
21 – 35
36 – 50
50+

Fitness *

Registered disability
Unregistered disability
No disability

Please tick appropriately which best describes your Ethnic Origin. *

White European
White Other
Black African
Black Caribbean
Black Other
Indian
Pakistani
Chinese
Other

Are you related or do you know any member of staff at Humble Healthcare Care Ltd *

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 Humble Healthcare Care 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)

Declaration *

I declare All the information I have given is true

Job Application

DOCUMENTS NEEDED FOR REGISTRATION

Please fill the Job Application form below and submit

MOBILITY

EMPLOYMENT HISTORY / WORK EXPERIENCE

REFERENCES

1A) Must be your most recent employer (of at least 3 months duration) which must correspond with your employment history.

1B) Another of your Employers in the last 3 years:

2) Must be a fellow health care professional who does not live with you and is able to supply a character Reference of your personal and professional profile.

HEALTH DECLARATION

OCCUPATIONAL HEALTH ASSESSMENT

HAVE YOU EVER BEEN VACCINATED, IMMUNIZED OR TESTED FOR / AGAINST ANY OF THE FOLLOWING?

DOCTOR INFORMATION

WORK PREFERENCE

WORK PREFERENCE: (Please tick)

LIVE-IN CARE

CARE/SUPPORT ASSISTANT ABILITY SCHEDULE

EQUAL OPPORTUNITIES MONITORING

REHABILITATION OF OFFENDERS ACT 1974

Where We Are

Write To Us

Call Us Today