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
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Year
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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
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Year
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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?
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Day
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Month
Year
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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.
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E-mail
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