PPH Application

Philip Parkinson Homecare Job Application Form
Which post are you applying for?
Please now complete all sections of the form (1-6)
1. Personal details
Title

Mr Mrs Miss Ms
Forename(s)
Surname
Former name(s)
Address
Telephone (home)
Telephone (work)
Mobile
E-mail
National Insurance No
Current driving licence?

Yes No
Do you have a car?

Yes No
2. Present/recent employment
Post held (job title)
Job title
Address
Date from

Day Month Year Hour Minutes AM/PM Option
Date to

Day Month Year Hour Minutes AM/PM Option
Days sickness/absence
Reason for leaving
3. Experience (tick all that apply)
Personal care

Supporting clients dressing/undressing Bathing/showering/strip washing Bed bathing Care of feet (excluding toenails) Mouth care (including dentures) Shaving Care of hair Care of eyes (including spectacles) Cleaning of hearing aids Changing incontinence pads Care of bladder and bowels Use of bedpans and commodes Emptying catheter bags Ensuring pressure areas are healthy Prompting medication has been taken Assisting with medication Administering medication Changing bottom sheet (client in bed)
Mobility

Transferring clients Use of hoists (manual) Use of hoists (electric) Use of walking aids Use of bathing aids
Nutritition

Preparing meals for clients Following dietary guidelines Supporting clients in eating their meals
General

Washing laundry Bed making Light housework Shopping Report writing/giving Observing a client’s well-being Reporting problems to correct person Recording GP/Nurse instructions
Experience with Client Group

Dementia Learning difficulties Challenging behaviour Elderly people Mental health problems Physical disabilities Sensory disabilities Adults/children complex care needs Spinal injuries Tracheostomy Long term ventilation Terminal illness Healthy children Disabled children
Qualifications and Courses

NVQ2 In Health & Social Care NVQ3 In Health & Social Care Medication – Prompt Medication – Assist Medication – Administer Safeguarding Adults Moving and handling First Aid Infection Control Health and Safety Fire Safety Food Hygiene Other
If other please state
Date course completed

Day Month Year Hour Minutes AM/PM Option
Any other relevant information
4. Availability for work (tick all that apply)
When would you prefer to work?

Early mornings Days Evenings Nights Weekends
Number of hours wanted
When can you start?

Day Month Year Hour Minutes AM/PM Option
Do you have any other work commitments?
5. References (two required)
Reference 1
Present/recent employer
Position held
Address
Telephone
Fax
Email
Reference 2
Another employer/suitable reference
Address
Telephone
Fax
Email
How person is known to you?
6. Declaration
I declare that I am physically fit to undertake the post in which I am applying. I confirm that all the information on the application is correct and that any false or misleading information will give my employer the right to terminate any employment contract that has been offered. I accept that the information given will be used in the process of this application.Philip Parkinson Homecare will ensure that any information disclosed is kept confidential, and not disclosed to any third parties except when required by law, or when we retain the services of a third party to act on your behalf.
I have read and agree with *

The Data Protection Notification Criminal Convictions Disclosure UK Residency Terms of Employment
Please note, information on the Data Protection Notification, Criminal Convictions Disclosure and UK Residency Terms of Employment are provided as part of our online Word application form.
Name
Date

Day Month Year Hour Minutes AM/PM Option
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E-mail
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Philip Parkinson Homecare Job Application Form

1. Personal details

2. Present/recent employment

3. Experience (tick all that apply)

4. Availability for work (tick all that apply)

5. References (two required)

6. Declaration