Crystal Support - Full Personnel Application

POSITION APPLIED FOR

Date Of Application

1. PERSONAL DETAILS:

Surname:

First Name:

Address:

Previous Name:

Home Telephone:

Work Telephone:

National Insurance Number?

Mobile Number:

Immigration Details:

Are You A Citizen Of The EU:

Yes No

Do You Need A Work Permit:

Yes No

Current Driving License:

Yes No

Do You Have A Car For Work Use:

Yes No

3. PREVIOUS EMPLOYMENT

A full employment history must be detailed beginning with your current employment and covering all reasons for gaps in any given year.

Date (From - To)		Employer's Name	Position Held	Salary & Benefits	Reasons for Leaving
From	To	Employer's Name	Position Held	Salary & Benefits	Reasons for Leaving

4. REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work involved, the post for which you are applying is exempt from section 4(2) of the rehabilitation of offenders act 1974. You are not entitled to withhold information relating to any conviction.

Do you have any convictions to disclose?

YES NO

Signature:

Date:

5. ADDITIONAL PERSONAL DETAILS

6. REFERENCES

Ref 1 Name:

Status:

Address/Telephone:

Ref 2 Name:

Status:

Address/Telephone:

Holiday dates booked:

Period of notice required:

Earliest start date:

I declare that to the best of my knowledge, all information contained and documented here is complete and truthful.

Signature:

Date:

FOR OFFICE USE ONLY

Shortlisted:

Yes No

Interview Date:

Ref Requested:

Verbal Check:

Yes No

Additional Notes:

App Completed:

Yes No

Full Emp Hist:

Yes No

Completed By:

Date:

EQUAL OPPORTUNITIES MONITORING

This section of the application will be detached and used for monitoring purposes only. Our organization recognize and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation religion or belief. We welcome applications from all sections of the community.

Date of Birth:

Gender:

Male Female I do not wish to disclose this

Ethnic Origin (Race Relations Amendment 2000):

Religion & Sexuality (Employment Equality Regs 2003):

Christianity

Islam

Hinduism

Sikhism

Judaism

Buddhism

Atheism

Do not wish to disclose

Heterosexual

Gay

Lesbian

Bisexual

Do not wish to disclose

HEALTH QUESTIONNAIRE

Epilepsy / Blackouts	Yes No
Nervous / Mental Disorders	Yes No
Migraine / Headaches	Yes No
Sensory Impairment	Yes No
Skin Allergies	Yes No
Back Pain / Previous Injury	Yes No
Heart Condition	Yes No
Asthmatic / Respiratory	Yes No
Recurring Illness	Yes No
Registered Disabled?	Yes No

If registered disabled, please detail:

Periods spent outside UK as resident:

Vaccinations / Immunizations (Date - Immunization - Expiry):

Declaration (fitness to undertake post): I declare I am fit physically and mentally to undertake this post.

Signature:

Date:

CRYSTAL SUPPORT

INTERVIEW ASSESSMENT EVIDENCE

Questions

1. Please detail relevant experience and your reason for applying for this particular post

2. If you've had no formal experience, what skills do you consider you could bring to the post?

3. Why is confidentiality so important for this type of work?

4. Are there any circumstances where you think you would have to break confidentiality?

5. Define the types of abuse which you might come across when caring for vulnerable adults

6. Where do you think you find information about the service users in your care?

7. What would you do if you were asked to carry out tasks which were not detailed in the care plan?

8. How would you ensure that the correct dosage and types of medication are given to the service user and where would you expect to record that information?

9. If a service user was distressed and anxious after a visit from a relative, A: would you think this was your business? And B: what would you do with the information?

10. What would you do if you felt that the service user was deteriorating and becoming more vulnerable?

Scenarios

Scenario 1: You have been visiting a client for quite some time, but this particular morning you cannot gain access, what would you do?

Scenario 2: A service user with a known drink problem asks you to buy alcohol, what would you do?

Scenario 3: You are going to assist another carer and the other carer asks you to complete a manoeuvre that you know is not safe, what would you do?

Scenario 4: Whilst escorting a service user with dementia, you become separated, what steps would you take immediately?

Scenario 5: What would you do if you had a difference of opinion with a service user?

CRYSTAL SUPPORT

BANK PAYMENT DETAILS

Personal Information (For Bank Mandate)

Title:

Name:

Address:

Post Code:

NI Number:

Phone:

Email:

PAYE or Contractor:

Sign/Date:

Bank Details

NAME OF BANK / BUILDING SOCIETY
BANK ADDRESS
BRANCH NAME
ACCOUNT NAME
SORT CODE
ACCOUNT NUMBER

CRYSTAL SUPPORT

NEXT OF KIN DETAILS

NAME:
RELATIONSHIP:
TELEPHONE:
ADDRESS:
POSTCODE:

IMMUNIZATION & FINAL DECLARATION

Immunization

Expiry

Date Received

Immunization

Expiry

Date Received

I declare that the information given is correct to the best of my knowledge. I am fit physically and mentally to undertake this post. I understand that omissions or false statement may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.

Final Signature:

Date: