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Health Care form

Let's start with your personal details

Title

Home Address

How did you hear about us?

Emergency Contact Details

Availability to work

Do you have any holidays planned for the next 3 months? (Please note any time off will affect your work hours and your salary) 

When could you start work?

What days are you available?

Am
Pm
Both
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Do you have Care Experience?

Do you have Care Experience?
A
B

Do you have a Diploma in Health Care?

Do you have a Diploma in Health Care?
A
B

Do you have an NVQ or RQF ?

Do you have an NVQ or RQF ?
A
B

Do you have a Nursing Degree ?

Do you have a Nursing Degree ?
A
B

Education, Qualifications and Training

Name of College or Institution

Graduation or Finish Date

Qualifications, Subjects

Name of College or Institution

Graduation or Finish Date

Qualifications, Subjects

Additional Training

Employment History

Employer

Position held

Address

Start date

Contact number

End date

Responsibilities and Reason for leaving?

Employer

Position held

Address

Start date

Contact number

End date

Responsibilities and Reason for leaving?

Gaps in Employment or Education

Careworker References

Please provide details of your present and/or previous (most recent) employer(s). College leavers should give names of lecturers/tutors/professors. If not possible, provide the names of the persons (priest, lawyer, etc.). You CAN NOT give details of friends or relatives as referees.

First Professional Referee Details

Full Name

Organisation Name

Phone number

Relationship

Job Title

Address

Email

Second Professional Referee Details

Full Name

Organisation Name

Phone number

Relationship

Job Title

Address

Email

Character Reference

Full Name

Organisation Name

Phone number

Relationship

Job Title

Address

Email

If you are shortlisted, a referee may be contacted before your interview. If you are not willing to have this done, please select

If you are shortlisted, a referee may be contacted before your interview. If you are not willing to have this done, please select

Do you have any conditions affecting your ability to undertake personal care work?

Do you have any conditions affecting your ability to undertake personal care work?

Working Time Directive 1998 opt out of Maximum Hours

WTD 1998 says that you do not have to work on an Assignment with the Client in excess of the 48 hour Working Week unless you agree in writing that this limit should not apply

WTD 1998 says that you do not have to work on an Assignment with the Client in excess of the 48 hour Working Week unless you agree in writing that this limit should not apply

CRIMINAL RECORDS DECLARATION FORM

Section A: Complete only if you have no convictions either spent or unspent cautions, reprimands, and bind-over and/or final warnings.
I CONFIRM I HAVE NO CONVICTIONS, CAUTIONS, REPRIMANDS, BIND-OVERS, OR FINAL WARNINGS. I ALSO DECLARE THAT I AM NOT ON LIST 99, DISQUALIFIED FROM WORK WITH CHILDREN OR VULNERABLE ADULTS, OR SUBJECT TO ANY OTHER SANCTIONS IMPOSED BY A REGULATORY BODY.
As an applicant for the position, I confirm that the details above are an accurate record of any criminal offenses that may appear on my Criminal Records Disclosure and the discussion held with the Appointing Officer.

Signature(Applicant)

Signature

Date Signed

Section B: Record below details of any convictions, spent or unspent, cautions, reprimands, bind-overs, and/or final warnings you may have to declare.
I CONFIRM I HAVE THE FOLLOWING CONVICTIONS, CAUTIONS, REPRIMANDS, BIND-OVERS, FINAL WARNINGS, AND/OR SUBJECT TO THE FOLLOWING SANCTIONS IMPOSED BY A REGULATORY BODY
As an applicant for the position, I confirm that the details above are an accurate record of any criminal offenses that may appear on my Criminal Records Disclosure and the discussion held with the Appointing Officer.

Signature(Applicant)

Signature

Date Signed

As Appointing Officer, I have discussed with the applicant any details, as recorded above that might appear on the applicant’s DBS, in line with Alpha Care & Support Criminal Records Policy.

Full name of Appointing Officer

Email

Position

Appointing Officer Signature

Signature

Phone Number

Signature date

Why are you applying for the Home care worker position?

How long have you worked in care in the UK?

How long have you worked in care in the UK?
A
B
C
D

What health conditions do you have experience working with

What health conditions do you have experience working with

Please list any other conditions

Hobbies, Interests or Skills that could be useful in care

Hobbies, Interests or Skills that could be useful in care

Please list others*

Basic Computer Skills

Basic Computer Skills

Additional Information

Please list the languages you speak

Do you have a valid UK driving licence?

Do you have a valid UK driving licence?
A
B

Is there anything that would prevent you from doing any tasks?

Is there anything that would prevent you from doing any tasks?
A
B

Are you able to provide personal care to both male and females?

Are you able to provide personal care to both male and females?
A
B

Are you able to prepare food containing pork products?

Are you able to prepare food containing pork products?
A
B

Do have any allergies to pets?

Do have any allergies to pets?
A
B

Are you happy to provide care to clients who smoke?

Are you happy to provide care to clients who smoke?
A
B

Do you have any of the following Health Conditions?

Yes
No
A cough for 3 weeks or more?
Unexplained weight loss?
Unexplained Fever
Have you had Tuberculosis (TB) or recent contact with open TB?

Have you been Immunised or Vaccinated against the following?

Yes
No
Dont know
Hepatitis b
Hepatitis c
Polio / Tetanus
Rubella
MMR
Tuberculosis
BCG / Mantoux
Has your BCG scar been seen?
Varicella (chicken pox / shingles)

Declaration and Consent

I understand that my personal details will be handed in in accordance with the Data Protection 2018.
You are advised that the disclosed information above will be held on computer and/or manual records. It will not be disclosed to anyone outside Alpha Care & Support, CQC inspectors, Home Office and LA’S inspectors. Any nominated temporary worker who processes my information will observe the normal rules regarding confidentiality as defined within the Data Protection Act 2018
If I have willingly withheld any relevant medical details, I realize I may be subject to disciplinary action. I give my consent to Alpha Care & Support and its CQC inspectors, Home Office, and LA’S inspectors to assess my file.

Signature

Signature

Signature date

I declare that the information given in this application form is true and complete to the best of my knowledge and belief. I have read and understood the terms of the engagement booklet. I agree to comply with the current Health and Safety Work Act. I understand that my appointment is subject to the receipt of a minimum of 2 satisfactory references and is subject to disclosure. I authorize Alpha Care & Support to make any further inquiries they may feel necessary to support my application. I agree to respect the confidentiality of patients /clients and other information I may have access to.

Signature

Signature

Signature date

Your registration is now completed, please click below to submit.