BetaCare Birmingham Application Form

Job Application Form

Vacancy Title:

Please Tell Us How You Heard About This Vacancy:

1. Personal Details

First Name

Last Name

Date of Birthof appointment

Marital Status

Nationality

Country of Birth

National Insurance No.

Address:

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Postcode:

Home Telephone No.

E-mail Address:

Bank Details

Account Number

Sort Code

Bank Name

Address

City

Country

Postcode

All details are held in the strictest confidence under the Data Protection Act 1998. I authorise W4U SOLUTIONS LTD to make payments to this account for work done

Agree

Application Date

IDENTIFICATION

Residential Address

City

PostCode

County

Home Tel. No.

Office Tel. No.

Email

Fax No.

Correspondence Address (If different from above)

City

County

PostCode

3. Professional Qualifications

Qualifications

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3. Education/Qualifications

Qualifications

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4. Employment History

Name and Address of Employer and Nature of Business

Job Title: job Functions/Responsibilities

Dates To and From employed

Final Salary and Reason for Leaving

Name and Address of Employer and Nature of Business

Job Title: job Functions/Responsibilities

Final Salary and Reason for Leaving

Dates To and From employed

5. Proficiency In Languages

Native Language

Second Language (optional)

Third Language (optional)

Do You Hold a Full Uk Driving License Or Equivalent

YesNo

Do You Have A Car?

YesNo

Details Of Any Endorsement

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6. Skills

Skills (Nursing)

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Skills (Others)

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7. References

Name of references

Address Of References

Position Of Reference

Telephone/Fax No of Reference

Name of references 2

Address Of References 2

Position Of Reference 2

Telephone/Fax No of Reference 2

8. Health Questionnaire

An answer must be provided for all questions. The information will be treated in confidence.

General Practitioner InformationName of the medical pratice

GP Address

County

PostCode

Paralysis or other neurological disorder

YesNo

Tel Number

GP Tel Number

9. Medical History

Please complete the following questions by ticking the appropriate box. If the answer is ‘yes’, give details including (a) date, (b) amount of time lost from work/school, (c) treatment, as appropriate.

Have you ever suffered from any of the following illnesses?

Visual defects/eye conditions (including colour-blindness)

YesNo

If yes please provide details

0 /

Hearing defects/ear conditions

YesNo

If yes please provide details

0 /

Severe anxiety, depression, other psychiatric disorder

YesNo

If yes please provide details

0 /

Paralysis or other neurological disorder

YesNo

If yes please provide details

0 /

Fainting attacks, blackouts, epilepsy or fits

YesNo

If yes please provide details

0 /

Recurrent headaches, migraine

YesNo

If yes please provide details

0 /

Vertigo, giddiness or tinnitus

YesNo

If yes please provide details

0 /

Heart disease, high blood pressure

YesNo

If yes please provide details

0 /

Asthma, bronchitis, tuberculosis or other chest disease

YesNo

If yes please provide details

0 /

Peptic ulcer or other digestive or bowel disorder

YesNo

If yes please provide details

0 /

Liver disorder

YesNo

If yes please provide details

0 /

Paralysis or other neurological disorder

YesNo

If yes please provide details

0 /

Kidney of bladder problems

YesNo

If yes please provide details

0 /

Gynecological problems

YesNo

If yes please provide details

0 /

Recurrent backache, arthritis, rheumatism

YesNo

If yes please provide details

0 /

Any blood disorder

YesNo

If yes please provide details

0 /

Eczema, dermatitis, other skin conditions

YesNo

If yes please provide details

0 /

Diabetes, thyroid or other gland problems

YesNo

If yes please provide details

0 /

Hayfever, allergies to drugs, animals etc

YesNo

If yes please provide details

0 /

Any recurrent infections

YesNo

If yes please provide details

0 /

Any impairment of immunity to infection

YesNo

If yes please provide details

0 /

Any alcohol or drug related problems or illness

YesNo

If yes please provide details

0 /

Hernia

YesNo

If yes please provide details

0 /

Varicose veins causing trouble

YesNo

If yes please provide details

0 /

Any other medical condition, physical or mental, not mentioned above

YesNo

If yes please provide details

0 /

Have You Ever

Ever undergone a surgical operation or been admitted to hospital for any reason?

YesNo

If yes please provide details

0 /

Had more than 20 days sickness absence in the past 2 years?

YesNo

If yes please provide details

0 /

Received a Disability Pension?

YesNo

If yes please provide details

0 /

Ever been, or are a Registered Disabled Person?

YesNo

If yes please provide details

0 /

Suffered from an Industrial Disease/Accident?

YesNo

If yes please provide details

0 /

Had a chest X-ray in the past 12 months – If so state place / date / result

YesNo

If yes please provide details

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10. Supporting Statement

Please state why you believe you are a suitable candidate for this post by explaininghow you meet the requirements of the job description and the experience youhave gained which is relevant. Please give examples of particular achievements

Additional Information

Earliest Date Available If Appointed

Have you had any criminal convictions (including spent convictions under the rehabilitation of offenders Act 1974)?

YesNo

Are you subject to any restrictions from previous employers which may restrict your working activities?

YesNo

Have you ever been employed by this company or its affiliates before?

YesNo

Have you applied for employment with this company before?

YesNo

Are you related to any employee working at this company?

YesNo

Do you have any physical impairment or health problem?

YesNo

Have you been dismissed or suspended from the service of any employer?

YesNo

Have you been dismissed or suspended from the service of any employer?

YesNo

If yes to any of the above, please give details here

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11. Interview Questionnaire

First Name

Last Name

Position Applied For

If yes to any of the above, please give details here

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What are your weaknesses?

0 /

What are your goals?

0 /

If you encountered a service user who was upset what would you do?

0 /

If you encountered a service user who was being aggressive towards you or another resident how would you deal with it?

0 /

How would you transfer a resident from a bed to a wheelchair?

0 /

How would you transfer a resident from a bed to a wheelchair?

0 /

What is the purpose of a hand-over?

0 /

Describe what you would do if a service user were to have an accident? Who would you report this to?

0 /

Describe what you would do if a service user were to have an accident? Who would you report this to?

0 /

How would you promote infection control?

0 /

What items do you use to prevent the spread of infection?

0 /

How would you dispose of clinical waste?

0 /

What would you do if you witnessed another employee stealing?

0 /

What would you do if witnessed another employee being aggressive with a service user?

0 /

What would you do if you witnessed another employee not abiding by health, safety and infection control policies?

0 /

You confirm that everything completed in this section is correct and attest to your character?

YesNo

Todays Date

12. Terms Of Engagement

Thank you for applying to the Work4U website (the "Site"). These terms & conditions ("Terms and Conditions") apply to the Site and its application service which reference these Terms and Conditions. Kindly review the Terms and Conditions listed below diligently prior to submitting this form as your submission on this website indicates your agreement to be wholly bound by its Terms and Conditions without modification. You agree that if you are unsure of the meaning of any part of these Terms and Conditions or have any questions regarding the Terms and Conditions, you will not hesitate to contact us for clarification.

Temporary Worker's Full Names

Todays Date

You acknowledge that you have read and agreed to the terms and conditions of the contract attached herewith?

YesNo

Declaration

Thank you for applying to the Work4U website (the "Site"). These terms & conditions ("Terms and Conditions") apply to the Site and its application service which reference these Terms and Conditions. Kindly review the Terms and Conditions listed below diligently prior to submitting this form as your submission on this website indicates your agreement to be wholly bound by its Terms and Conditions without modification. You agree that if you are unsure of the meaning of any part of these Terms and Conditions or have any questions regarding the Terms and Conditions, you will not hesitate to contact us for clarification.

Todays Date

BetaCare Application Form

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