Job Application
Thank you for your interest in joining PFMDINC Home Care Services, where professionalism, compassion, and dedication to quality care define our team.
Position Applying For
Personal Particulars
Prefix
*
Mr.
Ms
Mrs.
Miss
Full Name
*
First Name
Middle Name
Last Name
Marital Status
*
Single
Married
Divorced
Widowed
Date Of Birth
*
-
Day
-
Month
Year
Date
Country Of Birth
*
Nationality
*
National Insurance Number
*
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Bank Details
Bank Name
Address
Street Address
City
State / Province
Postal / Zip Code
Sort Code
Account Number
All details are held in the strictest confidence under the Data Protection Act 1998. I authorise XYZ Care to make payments to this account for work done
*
I Agree
Date
-
Month
-
Day
Year
Date
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Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Tel. No.
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Tel. No.
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Correspondence Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Educational Qualifications
Professional Qualifications
Name and Address of Employer and Nature of Business:
Dates To and From employed
Job Title: job Functions/Responsibilities
Final Salary and Reason for Leaving
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Proficiency In Languages
Native Language
Second Language (optional)
Proficiency In Speaking Second Language
Please Select
High
Moderate
Low
Proficiency In Writing Second Language
Please Select
High
Moderate
Low
Proficiency In Reading Second Language
Please Select
High
Moderate
Low
Third Language (optional)
Proficiency In Speaking Third Language
Please Select
High
Moderate
Low
Proficiency In Writing Third Language
Please Select
High
Moderate
Low
Proficiency In Reading Third Language
Please Select
High
Moderate
Low
Do You Hold a Full Uk Driving License Or Equivalent
Yes
No
Details Of Any Endorsement
Do you have a car?
Yes
No
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Skills related to the position you are applying for!
Skills (Others)
References
Name of references
Address Of References
Position Of Reference
Telephone/Fax No of Reference
Type a question
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Health Questionnaire
An answer must be provided for all questions. The information will be treated in confidence.
GP Name:
First Name
Last Name
GP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GP Tel Number
Please enter a valid phone number.
Format: (000) 000-0000.
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)
Yes
No
If yes please provide details
Hearing defects/ear conditions
Yes
No
If yes please provide details
Severe anxiety, depression, other psychiatric disorder
Yes
No
If yes please provide details
Paralysis or other neurological disorder
Yes
No
If yes please provide details
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Fainting attacks, blackouts, epilepsy or fits
Yes
No
If yes please provide details
Fainting attacks, blackouts, epilepsy or fits
Yes
No
If yes please provide details
Recurrent headaches, migraine
Yes
No
If yes please provide details
Vertigo, giddiness or tinnitus
Yes
No
If yes please provide details
Heart disease, high blood pressure
Yes
No
If yes please provide details
Asthma, bronchitis, tuberculosis or other chest disease
Yes
No
If yes please provide details
Peptic ulcer or other digestive or bowel disorder
Yes
No
If yes please provide details
Liver disorder
Yes
No
If yes please provide details
Kidney of bladder problems
Yes
No
If yes please provide details
Gynecological problems
Yes
No
If yes please provide details
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Recurrent backache, arthritis, rheumatism
Yes
No
If yes please provide details
Any blood disorder
Yes
No
If yes please provide details
Any blood disorder
Yes
No
If yes please provide details
Eczema, dermatitis, other skin conditions
Yes
No
If yes please provide details
Diabetes, thyroid or other gland problems
Yes
No
If yes please provide details
Hayfever, allergies to drugs, animals etc
Yes
No
If yes please provide details
Any recurrent infections
Yes
No
If yes please provide details
Any impairment of immunity to infection
Yes
No
If yes please provide details
Varicose veins causing trouble
Yes
No
If yes please provide details
Hernia
Yes
No
If yes please provide details
Any alcohol or drug related problems or illness
Yes
No
If yes please provide details
Any other medical condition, physical or mental, not mentioned above
Yes
No
If yes please provide details
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Have You Ever
Ever undergone a surgical operation or been admitted to hospital for any reason?
Yes
No
If yes please provide details
Had more than 20 days sickness absence in the past 2 years?
Yes
No
If yes please provide details
Ever been, or are a Registered Disabled Person?
Yes
No
If yes please provide details
Received a Disability Pension?
Yes
No
If yes please provide details
Suffered from an Industrial Disease/Accident?
Yes
No
If yes please provide details
Had a chest X-ray in the past 12 months – If so state place / date / result
Yes
No
If yes please provide details
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PRESENT HEALTH STATUS
Had a chest X-ray in the past 12 months – If so state place / date / result
Yes
No
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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)?
Yes
No
Are you subject to any restrictions from previous employers which may restrict your working activities?
Yes
No
Have you ever been employed by this company or its affiliates before?
Yes
No
Have you applied for employment with this company before?
Yes
No
Are you related to any employee working at this company?
Yes
No
Do you have any physical impairment or health problem?
Yes
No
Have you been dismissed or suspended from the service of any employer?
Yes
No
Are you bound by any bond to serve the government, or any organisation?
Yes
No
If yes to any of the above, please give details here
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Interview Questionnaire
Full Names
*
First Name
Last Name
Position Applied For
What are your strengths?
What are your weaknesses?
What are your goals?
What makes you a good candidate for this job?
If you encountered a service user who was upset what would you do?
If you encountered a service user who was being aggressive towards you or another resident how would you deal with it?
How would you transfer a resident from a bed to a wheelchair?
What is a care plan? Why should it be kept up-to-date?
What is the purpose of a hand-over?
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Describe what you would do if a service user were to have an accident? Who would you report this to?
What does 'Promoting Independence' means?
How would you promote infection control?
What items do you use to prevent the spread of infection?
How would you dispose of clinical waste?
What would you do if you witnessed another employee stealing?
What would you do if witnessed another employee being aggressive with a service user?
What would you do if you witnessed another employee not abiding by health, safety and infection control policies?
What would you do if you were uncertain of what to do on a shift?
What would you do if you did not understand or felt you didn't have enough training in certain areas of mandatory expectations?
You confirm that everything completed in this section is correct and attest to your character?
*
Yes, I agree
Date
*
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Month
-
Day
Year
Date
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Terms Of Engagement
Contract For Services
Temporary Worker's Full Names
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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