Employee Application Form - Care Staff

Please read all instructions, job description and person specification prior to completing this form.

Post Applied For:

Preferred Region:

Where/how did you hear about the vacancy? If you were referred please state who.

R.E.S.P.E.C.T
- we are Reliable, Efficient, Supportive, Professional, Evolving, Caring and Trusted

We work within a core set of Values and Behaviours; based on R.E.S.P.E.C.T., these were developed in collaboration with our staff. Our Values and Behaviours are embedded into the culture of our organisation and form the basis of all we do.


Personal Details

Title:

First Name(s):

Surname:

Address:

Post Code:

Home Telephone Number:

Mobile Telephone Number:

Email:

National Insurance Number:

Are you entitled to work in the UK?

Do you need a Visa to work in the UK? (Provide details):

Do any of your family members currently work for Care Visions?

Do you hold a current full driving licence?

Does your licence have penalty points or endorsements?

If yes, please give details:


Education

Name of School Attended:

Date Attended:

Qualifications Gained At School (Subject, Grade):

Have you completed further education? YesNo

If yes, please provide details below:
(Name College/University, Any courses for which a certificate, e.g. SVQ, HNC, HND, degree or diploma was awarded. Name of Institute/College Qualification Subject Date Gained)

Are you currently in full or part time education? YesNo

If yes, please provide details below:
(Name College/University, Course Studying, Expected Date of Completion)


Membership of Professional Bodies

Are you currently a Membership of any Professional Bodies? YesNo

If yes, please provide details below:
(Name of Awarding Body/Institution, Class of Membership, Date of Re-registration)


Employment

Present or Most Recent Employment

Company Name:

Full Address & Contact Details:

Job Title:

Date Started:

Date Left (if applicable):

Salary & Other Benefits:

Notice period:

Main Duties & Responsibilities:

Reasons For Leaving:


Clinical and non-Clinical skills and Experience

Working Environments:

Community Care ResidentialRespiteEMI NursingGeneral NursingHospice Day CareHospital

Clinical and Non-Clinical Experience:

End of Life Care Palliative CareUse of Ventilation EquipmentOxygen Saturation Measurement / MonitoringOxygen TherapyUse of GlucometerDiabetes ManagementAdministration of MedicationMedication PromptsAdministering SuppositoriesAdministering EnemasAdministering Eye DropsUse of Nasal SprayNaso Gastric Tubing careColostomy CareCatheter CareSkin Integrity care and managementPressure Sore CareTracheostomy CareUse of Suctioning EquipmentPEG FeedingIncontinence Pad Changes – double/ singlePhysiotherapy TechniquesMouth CareBlood PressureTilt TableHandling Equipment


Values Based Questions
The following questions must be answered. Please think about our company Values and Behaviours when providing each answer.

Question 1: Why do you want to work for Care Visions at Home?

Question 2: Time keeping is an important element in any job, why do you think it is particularly important within care?

Question 3: What qualities or personality traits do you have that you would bring to the role of carer?


Please be aware the role for which you are applying requires DBS Clearance and is exempt from the Rehabilitation of Offenders Act; you must therefore disclose all offences and convictions.

Have you been convicted or any criminal offence(s) and / or driving offence(s), including warnings, reprimands and cautions? These include spent and unspent convictions.

YesNo

If yes, please give details:

Are you presently the subject of a criminal investigation?

YesNo

If yes, please give details:

Are you presently or ever been the subject of a safeguarding investigation?

YesNo

If yes, please give details:

The disclosure of a criminal record will not debar you from appointment unless the selection panel considers that the conviction renders you unsuitable for appointment. However, this post is exempted employment within the terms of the Rehabilitation of Offenders Act 1974 (Exemptions) Order, as amended. You are therefore required to declare any convictions, whether or not they would, in terms of the Act, be classed as spent.

The amendments to the Exception order 1975 (2014) provide that certain spent convictions and cautions are ‘protected’ and are not subject to disclosure to employers, and cannot be taken into account. Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and Barring Service website.

Failure to disclose important information may disqualify you from appointment or lead to summary dismissal.

If selected for the position, we will check your details against criminal records held by the Police, prior to an offer of employment.


Referee
References must be from a person who has line-managed/supervised you. We do not accept character references or references from friends. References may be requested prior to interview, please indicate if you would prefer that we did not contact a referee prior to an interview being held.

Name:

Job Title:

Relationship to You:

Email:

Phone Number:

May we contact this person now?

YesNo

If no, please detail why: