Best for Care Services Ltd - Home Health Care in Bradford

Surname

Title

First Name

MaleFemale

Date of Birth

NI Number

Current Address

Mobile Phone

Home Phone

Postcode

Email:

Nationality:

Passport No:

Do you drive?

YesNo

Driver License No.

Next of Kin (To be notified in case of Emergency)

Name

Address

Relationship
to You

Mobile Phone

Home Phone

Current Education

Name of Institute

Qualifications currently studying

From

To

Education History

Group 1

Name of Institute

Grade obtained

From

To

Group 2

Name of Institute

Grade obtained

From

To

Group 3

Name of Institute

Grade obtained

From

To

Please ensure you complete this section even if you have a Curriculum Vitae. The NHS requires 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 10 years, or up to you education. Please use a continuation sheet if necessary.

Work History

Job 1

Job Duration
(From - To):

Employer:

Position Title:

Grade:

Main Responsibilities:

Work Address:

Reason for Leaving:

Job 2

Job Duration
(From - To):

Employer:

Position Title:

Grade:

Main Responsibilities:

Work Address:

Reason for Leaving:

Job 3

Job Duration
(From - To):

Employer:

Position Title:

Grade:

Main Responsibilities:

Work Address:

Reason for Leaving:

Please explain any gaps you had in your employment? The above is true to the best of my knowledge.

Please give the names and addresses of two employment references. One of these must be your present and most recent employer or agency whom we may approach for a reference, excluding relatives. Please remember that the two references must cover the last 3 year period.

Referee 1

Name:

Position / Grade:

Work Address:

How Long Have
Known This Person:

Phone Number:

Email:

Is This Referee
Senior to You:

YesNo

Can we contact
this person prior
to interview?:

YesNo

Referee 2

Name:

Position / Grade:

Work Address:

How Long Have
Known This Person:

Phone Number:

Email:

Is This Referee
Senior to You:

YesNo

Can we contact
this person prior
to interview?:

YesNo

Character Referee 1

Name:

Address:

Phone Number:

Email:

How Long Have
Known This Person:

Can we contact
this person prior
to interview?:

YesNo

Character Referee 2

Name:

Address:

Phone Number:

Email:

How Long Have
Known This Person:

Can we contact
this person prior
to interview?:

YesNo

Date available to commence

Please sate the specialized areas in which you feel competent and confident to work:

1st Choice

2nd Choice

3rd Choice

Would you be willing to work at short notice?

YesNo

Do you have any commitments that reduce your flexibility to work?

YesNo

Please state:

Please list any other agencies you are currently register and work for:

General Competencies

Level of the competency of the English language
Have you passed each of the academic modules of the IELTS test? YesNo

Please provide copies of all IELTS certificates held by you.

Personal Hygiene

Bath/shower/strip washBed bathUse bath aidsShavingMouth care (including dentures)Care of feedCare of hairCare of fingernails (excluding toenails)Dress/undressing of patientsCare of eyes

Toileting

Use of bedpans/commodes etc.Recoding fluid balanceCare of bladder and bowelsChanging a colostomy bag

Mobility

Lifting and transferring of patientsUse of hoistsLifting and handling courseUse of walking aids

Mobility

TemperaturePulseRespirationUrine testing

Nutrition

Experience with dementiaFeeding a helpless patientEnsuring pressure is healthyReport writing/givingEnsuring medication has been takenWashing of personal laundryLight houseworkShoppingBed makingExperience in a hospiceChanging a bed/draw sheet with patient in/on itExperience in first aidObserving client confidentialitySitting with a terminal patient

Simple dressing procedure

Record instruction from GP/District Nurse

Observe changes in patient/clients conditions and report to the person in charge of their care

Disclosure and barring services (DBS)

The disclosure and Barring Services (DBS – formerly Criminal Records Bureau CRB) is the executive agency of the Home Office responsible for the conducting checks on criminal records. We are registered body for receipt of DBS disclosure information. NHS Trust and Private Sector hospitals and nursing homes insist on agencies making information recruitment decisions which require DBS check to be made on all staff. It is a condition of proceeding with your application that you apply for a DBS disclosure check. The disclosure will be compared with the information given below and any inconsistencies could invalidate your application or lead to the cancellation of your registration with us.

Rehabilitation of Offenders Act 1974 and Criminal Records

By the virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986 the provision of 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 a 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 there force list all offences below even if you believe them to be “spent” or “out of date” for some other reason.

Have you been convicted for a criminal offence? NoYes

Have you ever been cautioned or issued with a formal warning for a criminal offence? NoYes

Right to work

It is a legal requirement that before any offer of work can be made all candidates provide the company with confirmation of their eligibility to work in the UK by providing one of the original documents detailed below.

A passport which describes the holder as a British Citizen or as having a right of abode in the United Kingdom or a passport or other travel document to show that the holder has IDENFINITE LEAVE TO REMAIN in the United Kingdom and is not precluded from taking the work in question. A passport or identity card issued by a State which is party to the European Union and EEA Agreement and which describes the holder as a national or a state which is arty to that agreement. A letter issued by the Home Office or the Department of Education and Employment indicating that the person named in the letter has permission to take agency work in question or a biometric residence permit.

Work Time Directives

The European Union has laid down guidelines for all workers, governing the length of the maximum working week that is safe to work. The current limit is 48 hours per week. You are under no obligation to accept work offered to, therefore you will never be compelled to work more than 48 hours per week but you may choose to do so. Please confirm that you have read and understood their information by indication your preference below.

I DO NOT wish to work more than 48 hours per weekI DO wish to work more than 48 hours per week

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Want to know more? Give us a call on 01274 925011

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