Application Form

Application For Healthcare Workers

FANCY HEALTHCARE SERVICES LTD

Please complete all fields in black or blue ink and using block capitals. If you need any help, please ask.
Part one – your personal details

*Title

*Gender

* First Name

*Last Name

Address

Post Code

*Email

*Mobile Phone

*Other Phone

*Land Line

NI Number

*How did you hear about this job?

If other please specify!

Have you worked recently in a care support role?

If you answered ‘yes’, what was your standard hourly rate of pay? £ an hour

If you were told about this job by someone that works for us, please tell us their name:

Can you prove that you are legally entitled to work in the UK?

If you answered ‘YES’, what document/s will you provide to prove this?

Do any other of your close friends or relatives already work for us?

If you answered ‘YES’, please give their names here:

Part two – your availability

It is important to us that we know when you are available for work so please do your best to ensure that the information you provide in this section is correct.

*What is the earliest date you could start work with us?

Do you have the use of your own vehicle for work?

Do you have any holidays etc. already booked? IF YES - please give dates

PLEASE TICK HERE TO INDICATE WHEN YOU WOULD USUALLY BE AVAILABLE FOR WORK:

Is there anything else we should know about your availability?

ALTERNATE WEEKENDS ARE COMPULSORY AND
CAN CONSIST OF LONG DAYS

Do you have a current DBS (dated within the last 3 years)?

If Yes, is it registered online?

Certificate Number:

Surname on Certificate:

Date of Birth:

We reserve the right to check your certificates status as and when it is deemed necessary, and at least annually. You can remove this permission by contacting The Manager.

Please tell us why you would suit this position. You may continue a separate sheet if you require.

PART THREE – YOUR SKILLS AND QUALIFICATIONS

Please tell us about the languages you can speak and/or write:

Language

I can speak this language

I can write in this language

My level of skill is. Basic

Competent

Advanced

*Do you have an NVQ/QCF level 2 (or above) in Health & Social Care?

*Have you completed the Care Certificate (England only)?

If you answered ‘yes’ to either of the above, you must provide a certificate or other evidence of completion.

Upload Your CV/Certificates

Please tell us about any other relevant formal qualifications you have achieved (including any Maths or English qualifications):

When did you leave full-time education?

Part Four – your work history

We are required by law to make sure we know about the work you have done in the past, as well as the periods you may have spent out of employment. Therefore, please list your full employment history here, including any periods when you were not working (along with an explanation of what you were doing). You may email us extra sheets if you need more space.

*Present / Most Recent Employer:

*Start Date:

End Date:

*Address of Employer:

*Postcode:

Previous Employer:

Start Date:

End Date:

Contact name:

Phone Number

Address of Employer:

Postcode:

Reason for Leaving:

Previous Employer:

Start Date:

End Date:

Contact name:

Phone Number

Address of Employer:

Postcode:

Reason for Leaving:

*Do you own a UK Full Driving Licence

Add your Driver Licence No

*Do you have points on your licence

Part five – your referees

Please provide the details of four people that we can write to for a reference. The first of these people must be your current or most recent employer. The other referees will ideally also be your most recent previous employers.

If you cannot provide the details of four previous employers, you may substitute one or more of these with a referee who was a former tutor or teacher when you were in formal education. If you cannot provide details of a teacher or tutor, we may accept a personal reference from a person of professional standing (e.g., a doctor, lawyer, accountant, recognised religious leader or teacher) who knows you, either professionally or personally.

You must not give the names of friends or relatives or colleagues that are/were not senior to you as referees. All references will be verified.
First referee (should be current or most recent employer)

Please complete THE FORM BELOW.

First Reference:

*Name

Position

Name of the organisation e.g: school or college

*Address:

Postcode:

*Email

*Phone Number

Date of employment or study?

Till Date

Second Reference:

*Name

Position

Name of the organisation e.g: school or college

*Address: e.g: school or college

Postcode:

*Email

*Phone Number

Date of employment or study?

Till Date

Part six – Medical History:

*Are you receiving treatment for any medical condition?

If YES, what is the medical condition?

What is the treatment?

*Have you suffered from any illness which has or may have a lasting effect on your health or physical condition?

If YES! please explain

*Have you been ill for more than 20 consecutive days during the last 12 months?

If YES! please explain

*Have you ever suffered a nervous breakdown?

If YES! please explain

Have you suffered from the following?

*Allergy

*Epilepsy

*Typhoid

*Diabetics

*Recurring Diarrhoea

*Back Pain

*Joint Pain

*Skin Disease

*Ear Infections

*Eye problems

*Do you smoke?

If YES in any of the above please state nature.

How would you describe your present state of health?

Who should be contacted in an emergency?

*Name

Address

*Phone Number

Relationship:

Upload all Immunisation Certificates

Part seven – Criminal Record

Care workers work with vulnerable people and we take our responsibility to protect them very seriously. Your appointment will depend on the satisfactory completion of a criminal records disclosure (see policy statement below), but at this stage, we need you to answer the following questions truthfully and honestly:

*Have you received any convictions, cautions, reprimands or final warnings that are not ‘protected’ as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013 by SI 210 1198)?

*To your knowledge, are you currently the subject of any criminal proceedings (for example, charged or summoned but not yet dealt with) or any police investigation?

If you answered ‘yes’ to either of the two previous questions, please provide details:

*Do you consent to our applying for an enhanced criminal records disclosure on you and to our retaining a copy of your disclosure certificate during the period of your employment or until a new disclosure is completed (whichever occurs first)? Note that if, once a criminal records disclosure has been completed, it is discovered that you have failed to accurately disclose the information requested above, the company reserves the right to terminate your employment without notice. Please be aware, however, that you’re having a criminal record will not necessarily mean we cannot employ you – if you would like to know more about our policy on the recruitment of ex-offenders, please ask.

Criminal records disclosures – our policy

As an organisation assessing applicants’ suitability for positions which are included in the Rehabilitation of Offenders Act 1974 (Exceptions) Order using criminal record checks processed through the Disclosure and Barring Service (DBS), we comply fully with the Code of Practice and undertake to treat all applicants for positions fairly. We will not discriminate unfairly against any subject of a criminal record check on the basis of a conviction or other information revealed.

We can only ask an individual to provide details of convictions and cautions that we are legally entitled to know about. Where a DBS certificate at either standard or enhanced level can legally be requested (where the position is one that is included in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended) and where appropriate Police Act Regulations (as amended), we can only ask an individual about convictions and cautions that are not protected.

Part Eight – suitability for the job

Please read the care worker job description and answer the following questions.

*Have you read and understood the care worker job description?

The position for which you are applying requires physical effort (including sitting, standing, carrying, walking, moving and handling people), mental effort (including dealing with emergencies and short-notice changes to work in a fast-paced environment) and possible emotional/psychological effort (including dealing with bereavement and challenging behaviour in a potentially stressful environment)

*Do you have any health conditions that would prevent you from meeting these intrinsic requirements for which the company might need to make reasonable adjustments?If yes, please be aware that we may need to discuss these with you at your interview)

If you answered ‘YES’, please provide brief details:

Part Nine – Declarations

Please read the following statements carefully. If there is anything you do not understand, please ask before you sign at the bottom of the page.

The job applicant named on the front of this form, confirm that the information I have given in this application is accurate and true to the best of my knowledge. I also understand and agree that:

The company may make checks to verify the information I have provided.

Providing misleading or false information in this form or at any other time during the application process may disqualify me from appointment or, if I have already been appointed, may result in my dismissal.

The personal information I have provided in this form (and any other personal information that I or my referees may provide) is confidential and will be handled in line with the Data Protection Act 1998.

The company will use the personal information I have provided to decide if I am suitable for the job, I have applied for;

Until I am employed, the company will not use my personal information for any purpose other than monitoring its own recruitment processes and that if the company does use my personal information for statistical analysis, it will be anonymised.

If my application is unsuccessful, the company will keep only basic information about me and destroy the rest.

If my application is successful, my personal information will be used for legitimate purposes in relation to my work (my contract of employment, which I will sign before I start work, will include further detail on how my information may be used).

The company may process my personal information for the purposes described above or as otherwise permitted or required by law in line with its registration with the Information Commissioner.

Any offer of employment will depend on the receipt of satisfactory employment references and the satisfactory completion of a criminal records disclosure (see part six above).

I will be liable for the cost of my initial criminal records disclosure but that the company will bear the cost of any future disclosures that need to be made.

I will be required to complete a pre-employment induction training programme prior to my starting work with the company.

My attendance on the induction training programme will not indicate any offer (on the part of the company) or acceptance (on my part) of employment and that the time I spend on the induction programme will therefore not count as working time for the purposes of calculating the company’s compliance with National Minimum Wage regulations.

I will be liable for the cost of my induction training (£85) and any uniform given to me (£15) if I leave the company’s employment within six months and that this sum may be deducted from my wages.

Your Signature

*Dated

Follow Us On:

Application Form

Application For Healthcare Workers

Application Form

Criminal records disclosures – our policy