In order to guide the interview process, we would like you to indicate your personal philosophy of care by completing the following statement:
I believe that the purpose of care from a care service is:
If I were Service User in The Agency I would like:
I believe that the Service User’s family and relatives would like from The Agency:
I believe that I can support a Service User in The Agency because:
As a member of The Agency care team I feel valued when:
I believe that a good relationship between me and the Service User depends on:
I believe that I learn best when:
I believe that a good working team is made by:
I believe that my role in relation to the Service User is:
My other beliefs and values of relevance to my job are:
The recruitment process within this organization has a minimum of two stages.
The completion of this application form is part of stage one. This application will be reviewed and a decision made as to whether to proceed to stage two, the interview, based on this information. PLEASE COMPLETE FULLY AND IN CAPITALS.
Position applied for:
Approx. no. of hours wanted
Full-time / part-time
Days/Nights/Mornings/Afternoons/Evenings/ Weekends only
Sur name:
First name(s):
Previous surnames (Supply documentary evidence e.g. marriage certificate, deed of name change etc):
Current address:
Post code:
Moved to this address on (date):
Previous addressNote: For Criminal Record check purposes, addresses covering the five years up to the application date must be supplied. If necessary, use another sheet of paper.
Telephone number (home):
Telephone number
Own Transport (Yes/No):
How long has your licence been held?
Clean current driving licence:
Endorsements:
Details:
School/College/University
Examinations Passed/Qualifications gained
Date of Graduation/Qualification
Location/Details
Notes
Subjects
Current/ most recent first. Information must cover the whole of your working life to date. State the reasons for any breaks in employment. Use a separate attached sheet if required; please sign that sheet(s).
Name and address of your most recent/last employer:
Date employed:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Name and address of Employer prior to the employer listed above:
Other roles(use additional sheet):
Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home. Please use separate sheet if insufficient space is available.
Do you have any mental or physical disability or illness (currently or recurring) which is relevant to the post for which you are applying?
If yes, please give details:
What adjustments (if any) need to be made to the working environment to accommodate your disability?
Please give details of all absences from work in the last 12 months, except holidays:
Please give details of any illnesses/accidents/injuries in the last 2 years:
GP’s name:
Tel no:
Address:
Full name:
Relationship:
Nursing and Midwifery Council PIN number:
National Insurance Number:
Are there any restrictions to your residence in the UK which might affect your right to take up employment in the UK?
If yes, please provide details.
If you are successful in the application, would you require a work permit prior to taking up employment?
Note: Minimum age legislation dictates that care workers in general must be 16 years old or older. Please inform your interviewer immediately if you do not meet these specifications.
You must provide references from your two most recent employers. Please provide an additional character referee. All will be contacted, therefore please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.
Name:
Tel No:
Job title:
This questionnaire is intended to identify whether you may have any medical conditions which affect your suitability to work in catering. It is not mandatory; if you complete this questionnaire, and it indicates a potential medical problem in working in a catering setting, you will be offered a full, free, health assessment.
Complete only if you are applying for catering work, and wish to complete it. However, all applicants for catering work MUST sign the declaration on this page.
Have you ever suffered from:
Delete as appropriate
Date
Details
Food poisoning
Dysentery
Typhoid or Paratyphoid
Tuberculosis
Parasitic infections
Has any close family contact suffered from any of the above?
Diarrhea or vomiting
Skin rash
Recurring boils
Discharge from ear, eye or nose
Do you suffer from any other medical problems which may affect your employment as a food handler?
Have you been abroad within the last two years?
Should it be necessary, will you agree to provide such specimens as may be required by the Doctor to ensure you are not a carrier of any organism which may infect food?
Signed: Date: Print name:
Further investigation or action required:
Employer’s initial assessment (no further action required?):
Specify investigation or action required:
This questionnaire is intended to assess your suitability for night work. It is not mandatory; if you complete this questionnaire, and it indicates a potential medical problem in working nights, you will be offered a full, free, health assessment.
Complete only if you are applying for night work, and wish to complete it.
However, all applicants for night workers MUST sign the declaration on this page.
OPTIONAL SECTION – Do you suffer from any of the following conditions, which may be made worse by night work?
Diabetes, requiring insulin injections to a strict timetable?
A heart or circulatory disorder which affects your physical stamina?
Stomach or intestinal disorder, such as ulcers?
Any other condition which makes the timing of meals of particular importance?
A medical condition affecting sleep?
A chronic chest condition?
Any medical condition requiring medication to a strict timetable?
Any other medical condition in which the symptoms get worse at night?
Please give further details for any questions for which you have answered Yes above
Workers in this establishment are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.
You will not be eligible for work in a care setting if you are on the ISA Register(s).
Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions in the space provided below.
SIGNATURE and DECLARATION – IMPORTANT – READ BEFORE SIGNING
I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately. I understand that I cannot be offered a post until a satisfactory response has been received with respect to my ISA Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise the organisation to request an ISA Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my ISA Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status.
INTERVIEWER – DETACHES THIS FORM FROM THE PACK AND HAND IT TO THE CANDIDATE, TOGETHER WITH A STAMPED ADDRESSED ENVELOPE. NO MARKS TO IDENTIFY THE CANDIDATE MAY BE MADE – THE REPLY IS ANONYMOUS AND CONFIDENTIAL.
The organisation is committed to promoting equal opportunities for all its employees and all prospective employees.
To ensure that all applicants are dealt with equally, we wish to monitor your recruitment process and would ask for your help by completing the details below by placing a v in the appropriate box. This will allow the organisation to monitor its policies.
You do not have to complete this form. The information is given on a voluntary basis and the information provided will only be used for the monitoring purpose. Please do not enter any identifying marks on this form, so that your information remains confidential. This information will be stored on a computer.
Gender
Registered Disabled?
Marital Status:
Children?
Please indicate your ethnic background:
Age
Account Name:
Account Number:
Sort Code:
B/S Roll No.:
NI Number:
NI Category:
Tax Code:
Month/Week 1:
Gross Pay TD:
Tax Paid TD:
This employee receives Info from:
Employee:
Administration:
Registered Provider:
In accordance with money laundering regulations, where an employee requires payment of wages into a bank account which is not in their own name as recorded in the personnel file, their explanation and authority is required. The Manager must assess whether the request and the explanation is reasonable, and does not appear to be connected with money laundering (concealment of sources of income).
Accounts with the same surname but different initials (e.g. husband/wife situations) do not require certification/explanation.
Any explanation recorded below will be kept fully confidential.
Date:
Bank details (sort code)
Bank details (account number):
Bank details (name on account):
Explanation for name on account differing from my name:
Signed:
Approved by (Manager):
