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application form 3
FirstCare Application form
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Indicates required field
Position applied for
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PERSONAL INFORMATION
Title
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Mr
Mrs
Miss
Ms
Name
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First
Last
Any other surnames you have been known by
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Date of birth
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Nationality
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National Insurance Number
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Full Address
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Post code
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Phone Number (home)
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Phone Number (mobile/ daytime)
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Email
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Next of kin Name
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First
Last
Next of kin address
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Phone Number
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Relationship
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EXPERIENCE AND QUALIFICATIONS
To enable us to place you, please tick what experience you have
Choose Any
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Bath/shower/strip wash
Use of bath aids
Mouth care / denture care
Feet care
Dressing/ undressing
Bed bath
Shaving
Hair care
Fingernails care
Eye care
Bowel and bladder care
Bedpan and commode use
Moving and handling
Use of hoist
Choose Any
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Preparation of meals
Feeding
Pressure area care
Ensuring medication has been taken
Observing and reporting
Simple dressing
Care for terminally ill
Answering telephone, taking and conveying messages
Bed making
Changing bed with patient on it
Light housework
Shopping/ collecting pensions
Experience with dementia
Any other experience that you feel may be relevant. Please state below
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Please give details and provide copies of any certificates that may be relevant to the position you are applying for
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EDUCATION
Name and address of secondary school/colleges attended
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Dates taken
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Grade/Mark (eg. GECE, Diploma etc)
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WORK EXPERIENCE
Name and Address of employer
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position held
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Date from - date to
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Reason for leaving
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WORK PREFERENCES
Choose Any
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Full time
Part time
Weekends
Weekdays
Nights
Occasional work
When are you available to work?
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Do you hold a current full driving licence?
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Yes
No
Do you have the use of your own transport?
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Yes
No
Do you speak any other language as well as English? If yes please specify
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TRAINING
Moving and handling date
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Please leave blank if you haven't done it
Fire precaution date
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Please leave blank if you haven't done it
Health and safety
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Please leave blank if you haven't done it
Infection control date
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Please leave blank if you haven't done it
CPR date
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Please leave blank if you haven't done it
Other
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Please leave blank if not applicable
Date of update required
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Please leave blank if you don't know
Record of Immunisations
Please specify if you have had these immunisations and date/result
Tetanus
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Diphtheria Schick test
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Rubella
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Poliomyelitis
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Tuberculosis BCG
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Hepatitis B
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Antibodies
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DECLARATION OF HEALTH
Have you ever suffered from any of the following?
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Tuberculosis
Chest pain
Heart condition
Bronchitis
High/low blood pressure
German measles
Epilepsy
Typhoid
Fits/ fainting
Mental illness/ depression
Migraine
Diabetes
Dermatitis/ sensitive skin
Back or neck problems
Jaundice/ Hepatitis
Polio
Dysentry
Chicken pox/ shingles
Please tick
Have you any reason to believe you may be infected with any communicable disease?
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Yes
No
Any other current condition or treatment which might affect your performance at work?
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yes
no
Please give details of any relevant or ongoing medication you are taking
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Any illness, condition or surgical operation that prevented you from work for more than a week during the past year?
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Yes
No
Any physical abilities including defect of sight or hearing
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Yes
No
Have you recently been resident outside the UK?
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Yes
No
Are you registered under the disabled person act?
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Yes
No
Have you ever knowingly been in contact with anyone suffering from MRSA or worked in an MRSA environment?
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Yes
No
Are you or have you ever been infected with tuberculosis (TB)
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Yes
No
Are you aware of the need to understand and be screened for MRSA?
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Yes
No
Rehabilitation of Offenders Act 1974 and Criminal Records
By virtue of the Rehabilitation of Offenders Act 1974 (exceptions) (amendments) order 1986, the provision of a section 4.2 of the Rehabilitation of Offenders Act 1974
do not apply
to any employment which is concerned with the provision of health services and which is of such kind to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. You should therefore list all offences on a separate sheet even if you believe them to be “spent” or “out of date” for some other reason.
CRB. The Criminal Records Bureau is the executive agency of the home office responsible for conducting checks on criminal records. We are a registered body for receipt of CRB disclosure information. NHS Trust and Private Sector hospitals and nursing homes insist on agencies making informed recruitment decisions, which require criminal record checks to be made on all staff. It is a condition of proceeding with your application hat you apply for a CRB disclosure (or that you produce an acceptable original disclosure which you have already obtained). The Disclosure will be compared with the information given above and any inconsistencies could invalidate your application or lead to the cancellation of your registration with us.
Have you ever been convicted of a criminal offence?
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Yes
No
(if you have answered “Yes” please attach details including dates on a separate sheet.)
Have you ever been cautioned or issued with a formal warning for any criminal offence
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Yes
No
(if you have answered “Yes” please attach details including dates on a separate sheet.)
Signature (Please tick to sign)
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Option 1
Option 2
Option 3
Date
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Today's date
Do you require a work permit or other permission to take employment in the U.K?
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Yes
No
(if yes please complete below)
Work permit
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Yes
No
Expiry date
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Passport nationality
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Place of issue
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Passport number
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Date of issue
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Expiry date
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Working Time Directives
The European Union has laid down guidelines for all workers, governing the length of maximum working week that is safe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will never be compelled to work more than 48 hours per week but you may choose to do so.
Please would you sign below to confirm that you have read and understood this information, indicating your preference by ticking the most appropriate statement
Please tick
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I DO NOT wish to work more than 48 hours per week. ٱ
I DO wish to work more than 48 hours per week. ٱ
Please tick to sign
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Option 1
Option 2
Option 3
Data Protection Act 1998 and Inspection
Part of the care standards commission inspection process involves checking that we maintain certain information on staff e.g. address, qualifications, a mechanism for checking health and fitness including records of immunisation, record of training, annual leave and sickness, two written references and rehabilitation or Offenders information. Inspectors will need to know that the company in maintaining the information as we should; please be assured that they will not wish to read personal information such as supervision notes.
We would be grateful if you would complete and sign the declaration below. If you have any concerns about this or want to discuss it further, please contact FirstCare (GB) Ltd.
Please select one
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I consent
I do not consent
Name
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Tick to sign
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Option 1
Option 2
Option 3
Date
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References
Please give the names of two professional people or senior/grade position to you, including your present or most recent employer whom we may approach for a nursing reference (not relatives or friends). They must be able t provide a credible comment on your ability to undertake the duties of the post applied for.
Home addresses of referees are not acceptable.
Name
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Position
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Work address
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Telephone number
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Fax
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Leave blank if not applicable
How long have you known this person and in what capacity?
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Reference 2 Name
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Position
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Work address
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Telephone number
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Fax
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Leave blank if not applicable
How long have you known this person and in what capacity?
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DECLARATION
The information that I have given in this registration form is to the best of my knowledge, complete and accurate in all respects. I understand that knowingly giving false information will disqualify me from registration with this agency. I also agree to keep FirstCare (GB) advised of any changes to any information
Name
*
Date
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Tick to sign
*
Option 1
Option 2
Option 3
Please ensure you supply
original
and
photocopies
of the following:
Two passport sized photographs ٱ
Proof of identity (birth/marriage cert. New style driving licence/passport) ٱ
Copy of work permit, visa stamp, entry stamp (overseas applicants) ٱ
Completed Equal Opportunities form ٱ
Relevant certificate of training ٱ
Proof of National Insurance Number
Copy of Driving License (if applying as a driver) ٱ
Submit
