Home Care Assistant Application Form - Worcestershire County ...

Home Care Assistant Application FormPlease give us some information about you:Surname/Family name:Previous surname (if relevant):Forename(s):Mr, Mrs, Miss, Ms:Date of birth:NI Number:Telephones: Home: Mobile: Work:Address:Postcode:Please tell us about all your employment, volunteering, caring or other lifeexperiences (start with your most recent experience – use additional sheet if required).Employer’s ororganisation’s name(if relevant)Your job title or experienceStartdateMon/YearFinishdateMon/YearWhy did you leavethis job or finish thisactivity?What is the period of notice for your current job? _________________________________

Please tell us about training you have done or qualifications you have gained thatyou think will help you to do the job.Title of trainingWhen did you do this(year only)?Where did you dothis?Qualification (ifany)You will need to travel between people’s homes (please tick):Do you hold a current, valid full driving licence? Yes ❏ No ❏Do you own a car or motorcycle? Yes ❏ No ❏Do you have access to one? Yes ❏ No ❏If you have said no, how will you get about?_______________________________________________Convictions/DisqualificationsBecause you will work with vulnerable people we have to check with the Criminal Records Bureau tosee if you have any criminal convictions. You must tell us if you have any convictions (failure todisclose may result in the withdrawal of your application or dismissal from the job):I do not have any criminal convictions, bind-overs or cautionsI have a criminal conviction or a bind-over or a caution,even if this was a long time ago, and I give the details below.(Please note that if you tick this box it does not mean that youwill be automatically rejected)ٱٱYou must tick oneof these boxes.

Please tell us about the sort of work pattern you would like to do (please tick):Working flexibly on a rota covering all 365 days of the year working:mornings onlyevenings onlyboth mornings and evenings❏❏❏Working on weekends and bank holidays mornings only ❏evenings only❏both mornings and evenings ❏Working on a relief basis to cover sickness and holidays❏Please tell us about your recent health record:How many days have you been off work or study for health reasons in the past year?How may separate periods of absence do those days cover?Home Care is a physically demanding job. If there is anything about your health that you think mayaffect your ability to do the job please tell us here.ReferencesPlease give details of two people who are able and willing to comment on your suitability for this job(if you have worked in the last 5 years one of these people should be your current or most recentemployer). Referees must not be related to you.Name:Address:Name:Address:Telephone number:Relationship to you:Do you want to be asked before this person iscontacted?Yes ❏No ❏Telephone number:Relationship to you:Do you want to be asked before this person iscontacted?Yes ❏No ❏

DisabilityThe County Council undertakes to interview people with disabilities who meet theminimum/essential criteria detailed on the person specification. For these purposes, disability isdefined as any physical or mental impairment which has a substantial and long term (over 12months) adverse effect on your ability to carry out normal day to day activities.Please confirm therefore whether you have a disability Yes ❏ No ❏In the space below please tell us why you want to work as a Home Care Assistantand why you think you would be good at the job.Please check that you have completed all parts of this form and then sign thefollowing declaration.I have read the information given to me about this job. I confirm that I do not have any physical ormental impairment, which without reasonable adjustment would prevent me from carrying out theduties of this job. I declare that all the information given in this application is correct and complete. Iunderstand that if any information I have provided is found to be untrue any offer may bewithdrawn or my contract of employment terminated.Signature:Date:

Please return the completed form to CRT, Human Resources County Hall, Spetchely Rd, Worcester,WR5 2NPName:Employer’s ororganisation’sname(if relevant)Your job title or experienceStartdateMon/YearFinishdateMon/YearWhy did you leavethis job or finish thisactivity?

Equal Opportunities Monitoring FormWorcestershire County Council is committed to the elimination of all forms of unjustifiablediscrimination. The County Council will actively pursue equality of opportunity for all by seekingto ensure that all prospective and existing employees are treated fairly. Personal circumstancesand characteristics will only be taken into account when they can be justified as being relevant toemployment. To enable the County Council to constantly monitor itself to ensure thiscommitment is fulfilled, we would ask all applicants to complete the questions detailed below.This information will be treated as completely confidential and will be used for monitoringpurposes only. This information will be detached from the application form on receipt and willnot be considered during the selection process.Please tick as appropriate:1. Which of the following do you consider to be your ethnic origin?(tick only one box), see below for explanatory notes.❏ White British (AWB) ❏ White and Black Caribbean (BWBC) ❏ Indian (CIN)❏ White Irish (AWI) ❏ White and Black African (BWBA) ❏ Pakistani (CP)❏ White Other (AWO) ❏ White and Asian (BWA) ❏ Bangladeshi (CB)❏ Mixed Other (BMO ❏ Asian Other (CAO) ❏ Caribbean (DBC)❏ African (DBA) ❏ Chinese (ECH) ❏ Black Other (DBO)❏ Other Ethnic Group (EOE) (Please describe)_________________2. Are you ❏ Male ❏ Female3. Do you have a disability? ❏ Yes ❏ NoFor these purposes, disability is defined as any physical or mental impairment that has a substantialand long-term (over 12 months) adverse effect on your ability to carry out normal day to dayactivities.4. Please tick the age band currently Monitoring applicable Form Explanatory you Notes❏ i. Up to 19 ❏ ii. 20-29 ❏ iii. 30-39 ❏ iv. 40-49 ❏ v. 50-65 ❏ vi. Over 65The ethnic groups set out above are those recommended by the Commission for Racial Equalityand used in the 2001 Census. Ethnic origin questions are not about nationality, place of birth orcitizenship, they are about colour and broad ethnic group. UK citizens can belong to any of thegroups indicated. If you are descended from more than one ethnic group, please tick the group towhich you consider you belong or tick the ‘other ethnic group’ box and give details in the spaceprovided above.Where did you see this post advertised?…………………………………………………………………………………………………………………