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Care Worker Application Form
ProCare believes that the Service User should be at the heart of everything we do
Care Worker Application Form
Please answer all the questions in full to the best of your ability - any difficulties should be discussed with a member of the ProCare Management Staff. Your application form may be subject to scrutiny by Local Authority Accreditation Bodies and the Care & Social Services Inspectorate Wales.
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SECTION A: PERSONAL DETAILS
Surname
*
Mr/Mrs/Miss/Ms
*
First Name(s)
*
Address & Postcode
*
Email
*
Home Telephone
*
Mobile Tel. No.
*
National Insurance No
*
Date of Birth
*
Languages Spoken
*
Nationality
*
What is your Marital Status?
*
(Married/Single/Widowed/With Partner)
Do you have a Full UK Driving License
*
Do you own a car?
*
Are you a Student?
*
If Yes, Full-time or Part-time?
Name of Emergency Contact
*
Relationship to You
*
Contact's Telephone No.
*
Alternative No.
Contacts Address & Postcode
*
Availability
(Please tick which days, nights and weekends you will be available to work, and write the number of hours per day)
Monday
Day
Monday
Night
Max Hours Per Day
Tuesday
Day
Tuesday
Night
Max Hours Per Day
Wednesday
Day
Wednesday
Night
Max Hours Per Day
Wednesday
Day
Wednesday
Night
Max Hours Per Day
Thursday
Day
Thursday
Night
Max Hours Per Day
Friday
Day
Friday
Night
Max Hours Per Day
Weekends
Saturday
Day
Saturday
Night
Max Hours Per Day
Sunday
Day
Sunday
Night
Max Hours Per Day
Section B: EDUCATION & TRAINING
If you have an up-to-date C.V. please submit the file in the box below, otherwise complete Section B in full. Your C.V. must contain the following information:
> All secondary schools, colleges or other training institutions attended
> All qualifications gained (including any obtained through work or other bodies)
> Name and address of ALL employers since leaving full-time education, stating the reason for leaving each position
> Please account for ALL gaps in your employment history, however short
Upload C.V.
Section Break
School from
To
Name of School
School from
To
Name of School
School from
To
Name of School
School from
To
Name of School
School from
To
Name of School
Section Break
College or University from
To
Name of College or University
College or University from
To
Name of College or University
College or University from
To
Name of College or University
Section Break
Training course from
To
Name of Training Center
Training course from
To
Name of Training Center
Section Break
(List all qualifications & certificates gained, including any obtained through work or other bodies)
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
Date
Qualifications (eg o levels, GCSE's or NVQ's with grades
SECTION C: EMPLOYMENT HISTORY
Please supply the names and addresses of ALL employers since leaving full-time education, stating the reason for leaving each position. Start with your CURRENT EMPLOYER FIRST and work your way down to the earliest. Please also account for any gaps in your employment history in the space provided.
Name
Full Address & postcode
Telephone No
Email
Person to Contact
Your Job Title
Employed From
To
Reason for Leaving
Previous Employment
Name
Full Address & postcode
Telephone No
Email
Person to Contact
Your Job Title
Employed From
To
Reason for Leaving
Section Break
Name
Full Address & postcode
Telephone No
Email
Person to Contact
Your Job Title
Employed From
To
Reason for Leaving
Section Break
Name
Full Address & postcode
Telephone No
Email
Person to Contact
Your Job Title
Employed From
To
Reason for Leaving
Section Break
Name
Full Address & postcode
Telephone No
Email
Person to Contact
Your Job Title
Employed From
To
Reason for Leaving
Explanation of Gaps in Employment
From
To
Explanation
From
To
Explanation
From
To
Explanation
From
To
Explanation
SECTION D - PERSONAL STATEMENT
Please tell us in as much detail as possible what you could bring to the role of support worker if you were successful and why you are applying for this position.
What can you bring to this Role?
*
Why are you applying for this Position?
*
SECTION E: EMPLOYMENT & CHARACTER REFERENCES
We require a minimum of 2 references. Your first reference MUST be from your previous employer (unless there are extenuating reasons why such a reference cannot be obtained). You may not use a relative as a referee.
Referee's Name
*
Relationship to You (e.g. Manager)
*
Address & Postcode
*
Telephone No.
*
Email Address
Referee's Name
*
Relationship to You (e.g. Manager)
*
Address & Postcode
*
Telephone No.
*
Email Address
Referee's Name
Relationship to You (e.g. Manager)
Address & Postcode
Telephone No.
Email Address
Applications from ex-offenders are welcome and will be considered on their merit. Convictions or cautions that are irrelevant to the job will not be taken into consideration but you are required to disclose ALL convictions or cautions (including 'spent' convictions) by virtue of the rehabilitation of offenders act (Exceptions) Order 1975. Successful applicants will be required to undergo an enhanced DBS check.
Do you have a Criminal Record? (includes cautions, Reprimands & Final Warnings)
*
Are you currently subject to any investigation or disciplinary procedure at work?
*
If you have answered 'Yes' to either of these questions please give an outline of the details. (You may offer a fuller explanation at interview.)
SECTION F: MEDICAL HISTORY
If you have answered 'yes' to either of these questions please give an outline of the details. (you may offer a fuller explanation at interview.)
Do you have any physical disability or condition that might affect your work? (YES or NO)
*
Comments if 'Yes'
Do you have any mental disability or condition that might affect your work? (YES or NO)
*
Comments if 'Yes'
Do you require any specific assistance to enable you to work? (YES or NO)
*
Comments if 'Yes'
Immunisations or Vaccinations:
Rubella (German Measles) (YES or NO)
*
Dates
Comments
Tetanus (YES or NO)
*
Dates
Comments
Diphtheria (YES or NO)
*
Dates
Comments
Tuberculosis (YES or NO)
*
Dates
Comments
Hepatitis (YES or NO)
*
Dates
Comments
X-Ray - Date of last X-Ray (if applicable) (YES or NO)
*
Dates
Comments
Other Information
Your GP's Name
*
Surgery Address & Telephone No.
*
How many days/week's sickness have you had in the last 12 months?
*
In the interests of your health & safety, you should tell us if you are pregnant.
*
Will you be working for any other Agency?
*
Will this be your only job?
*
SECTION G: DECLARATION & SIGNATURE
To the best of my knowledge I declare that the information given above is true:
Applicants Signature*
Date*
* If you are unable to sign electronically, please leave blank and sign at interview.
On the basis of the information provided above, and at interview, I am satisfied that the Applicant is fit for the purpose of work
Managers Signature
Managers Signature
Date
Managers Date
TRAINING & EXPERIENCE CHECKLIST
Please click or tick the boxes below to indicate which duties, if any, you have had training/experience in a professional capacity:
Mobility
Movement & Transferring
Use of Walking Aids (e.g. Zimmer Frame)
Use of Hoist
Movement & Handling Course (Objects)
Movement & Handling Course (People)
General Duties
Washing Personal Laundry
Making Beds
Light Housework
Shopping
Administration & Record-Keeping
Observing Confidentiality
Writing Simple Reports (e.g. Log Sheets)
Observation of Client's Condition
Reporting Accidents or Incidents
Prompting Medication
Administration of Medication Course
Relevant Experience or Training
Nursing Home(s)
Homecare
Hospital or Hospice
Dementia Awareness Training
Emergency Responses (First Aid)
Management of Aggression
Physical Restraint Training
Other (please specify):
Other Experience or Training(Please Specify)
Personal Care:
Dressing/Undressing of Clients
Showering
Bathing
Use of Bath Board/Seat
Strip Wash
Bed Bath
Shaving
Oral Hygiene (Cleaningteeth etc.)
Care of Feet
Personal Care:
Care of Hair
Changing Incontinence Garments
Toileting
Use & Cleaning of Commodes
Use of Bedpans/Urine Bottles
Use of Urinary Sheath (Conveen)
Emptying/Changing Catheter Bag
Changing Colostomy Bag
Recording of Fluids
Nutrition
Preperation of Meals
Serving Meals
Assisting to Feed Disabled Clients
Basic Food Hygiene Course
Section Break
Applicants Signature & Date (Day/Month/Year)
Interviewer's Signature & Date (Day/Month/Year)
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