Mental Wellbeing Officer
2 weeks ago
**APPLICATION FOR EMPLOYMENT**
**Position applied for**:
**Full/Part-time /Casual**:
**Surname & Title**
**Forenames**
N.I. Number
Address
Tel: Home
Tel: Mobile
**Vaccination Status**
As per the Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) Regulations 2021, it is mandatory for anyone working in care homes from 11 November 2021 to have received a full course of Covid-19 Vaccinations. Please confirm your vaccination / exemption status.
Do Not Vaccinated Yes ❒ No ❒
Do Fully Vaccinated Yes ❒ No ❒
Have Medically exempt (must be evidenced) Yes ❒ No ❒
Vaccinated with 1 dose and 2nddose booked before 11 November 2021 Yes ❒ No ❒
**Education and Training**
Have you ever been convicted of a criminal offence? Yes ❒ No ❒
Please tell us if:
- There are any reasonable adjustments we can make to the job itself to help you carry it out
Do you have the right to work in the UK? Yes ❒ No ❒
Do you hold a current driving licence? Yes ❒ No ❒
Have you applied to Durbia Healthcare in the last 12 month? Yes ❒ No ❒
Have you ever been employed by Durbia Healthcare? If yes state where you worked
**FULL EMPLOYMENT HISTORY - **_You must provide your _**_FULL_** _employment history with no gaps_
**Dates**
**From To**
**Employers name and address**
**Job title**
**Reason for leaving**
**REFERENCES - **_Please provide details of two appropriate referees from previous employment; one must be your current or last employer. The referees should be your line manager, supervisor or HR Department and must be able to provide a company reference. If you are without two previous jobs you should provide the name of your senior school and college along with one personal referee from a member of the community (though not ones who are related to you)_
**1. Name**
**2. Name**
Position
Position
Address
Address
Tel No.
Tel No.
- Please indicate how these people know you and about your work abilities, please state whether they are your current supervisor, manager, etc._
1
2
**SUITABILITY TO WORK WITH VULNERABLE ADULTS - **_Your answers below will be checked via a criminal records check with the relevant governing body._
Has your name been referred to the Secretary of State under any of sections 82, 83 and 84 of the Health and Social Care Act 2008 and Regulated Activities - Northern Ireland Care Council for inclusion in the list maintained by the Secretary of State of individuals who are unsuitable for work with vulnerable adults (“the list”)
Yes ❒ No ❒
If yes has the Secretary of State:
- Confirmed the inclusion of your name on the list ❒
- Removed your name from the list ❒
- Not yet completed their consideration of referral ❒
**DECLARATION**
**I CONFIRM THAT THE INFORMATION CONTAINED IN THIS APPLICATION FORM IS TRUE, COMPLETE AND NOT MISLEADING. I UNDERSTAND THAT THE PROVISION OF UNTRUE, INCOMPLETE OR MISLEADING INFORMATION ON THIS APPLICATION IS GROSS MISCONDUCT AND IF I AM OFFERED AND ACCEPT THE POSITION AND AT ANY TIME DURING THE COURSE OF MY EMPLOYMENT IT COMES TO LIGHT THAT I HAVE PROVIDED FALSE OR MISLEADING INFORMATION I WILL BE SUBJECT TO THE COMPANY’S DISCIPLINARY PROCEDURE AND SUMMARY DISMISSAL.**
**I UNDERSTAND THAT MY SIGNATURE ON THIS FORM CONSTITUTES MY CONSENT FOR THE PURPOSE OF THE DATA PROTECTION ACT 1998 AS REFERRED TO ABOVE.**
Signature
Dated
- Please return this form to:_
**This is controlled document. It should not be altered in anyway without the express permission of the author or their representative. On receipt of a new version, please destroy all previous versions**
**Salary**: £22,500.00-£26,500.00 per year
**Benefits**:
- Discounted or free food
- Health & wellbeing programme
- On-site parking
- Work from home
Schedule:
- Flexitime
- Monday to Friday
Ability to commute/relocate:
- Castleford, West Yorkshire: reliably commute or plan to relocate before starting work (required)
Work Location: In person
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