Health Care Assistant/senior Carer
2 weeks ago
Application Form - Healthcare Assistant
Experience of Working with the NHS is Essential
**About You**
Surname
Title (Mr/Mrs/Miss/Ms)
First Name(s)
Male
Female
Marital status
Date of Birth
National Insurance No
Current Address
Post Code
Mobile Phone
Home Phone
E-mail
Do you drive
YES
NO
How do you usually travel to work
**Next of kin**
Name of Next of Kin
Relationship
Phone Number
Your Signature
Date
**About your work**
Job Title
Speciality 1
Speciality 2
Speciality 3
Current Place of Work
Full Time
Part-Time
Days
Nights
**Your Training, Qualifications, Appraisals and References**:
Nurses
NMC Number
RCN Number
Band
ODPS
HPC Number
**Mandatory training**
**_Please tick if you have completed the following training within the last 12 months Please enclose copies of your training certificates_**
SOVA/SOCA Level 2/3
Basic to Intermediate Life Support (in line with UK Resuscitation Council Guidelines)
Moving and Handling
Lone Worker
Countering Fraud and Bribery in the NHS
Handling Violence and Aggression
National Early Warning Score (NEWS)Training
COSHH
RIDDOR
Preventing Radicalization
Data Protection
Infection Control
Preventing Radicalisation
Equality & Inclusion
Food Safety
Mental Health 2007
Handling Violence and Aggression / Complaint Handling
Blood Component Transfusion
Mental Capacity Act 2005
Dementia Awareness
**Appraisals**_In order to work in the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser” Please give details below of the Senior Practitioner who you have made arrangements with to act as your appraiser._
**Please give the date of your last appraisal**
Name of Appraiser
Position and Grade of Appraiser
Branch Address
Post Code
Phone Number
E-mail
**References**_Please supply us with two professional referees. One must be from your present or most recent employer and must be a senior grade to yourself and you must have worked for that person for a period of not less than three months duration._
**1. Name**
Position
Work Address
Post Code
Work E-mail
Tel
Fax
**2. Name**
Position
Work Address
Post Code
Work E-mail
Tel
Fax
**Your Work History**
- Please ensure you complete this section even if you have a CV. The NHS states that “Employment history should be recorded on an Application Form which is signed” Please ensure that you leave no gaps unaccounted for and it covers full work history including your education. Please use extra paper if required._
- Full work history including your education_
- Dates to and from are shown in a mm/yy format_
- Dates are continual with NO gaps_
- Where there have been gaps in work history please state the reason for the gaps_
- Lists all relevant training undertaken_
From
To
Employer
Title of Post
Grade
From
To
Employer
Title of Post
Grade
From
To
Employer
Title of Post
Grade
From
To
Employer
Title of Post
Grade
**Your Declarations**
**1. Working time regulations**:
- For the purposes of the Working Time Regulations 1998 (as amended) I, consent to work in excess of an average of 48 hours per week, averaged over 17 weeks. I understand that I may withdraw this consent by giving Match Healthcare Ltd not less than three months’ notice at any time._
Signed
Print Name
Date
- In addition, I also consent to work in excess of the maximum number of hours permitted to work at night under the directive. Please note you are under no obligation to sign either declaration._
Signed
Print Name
Date
**2. Personal Declaration**
I understand that providing false or inaccurate information may result in the termination of any placement.
I agree that I will make best endeavours to make myself aware of the Health & Safety procedures for each client I am assigned to.
I confirm that I have read and understood the Terms of Engagement and the terms of the declaration and agree to be bound by them.
**3. Confidentiality**
I hereby declare that at no time will I divulge to any person, nor use for my own or any other person’s benefit, any confidential information in relation to the Client or the Company (Match Healthcare Ltd) or in relation to any of their employees, business affairs, transactions or finances which I may acquire during the term of my agreement with the Company (Match Healthcare Ltd) under the Terms of Engagement.
**4. Rehabilitation of Offenders Act 1974 - Please Answer All Five Questions**
Because of the nature of the work for which you are applying, Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions t
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