Care Assistant Application Form

Please complete the form with all your details and we will get back to you shortly. (* Represents Required Fields)

Position Applied For
Date Available
* Surname
* Address
* Post Code
* E-mail
Date of Application
* First Name
Second Name
Maiden Name
Home Phone
* Mobile

5 Year Work History (we will need full explanation of the past five years including unemployment etc, please continue on a separate sheet if necessary)

Date From
to
Address
Post Code
Position
Grade / Level (if app.)
Employer Name
Why Joined
Why Left / Leaving
Key Roles
Date From
to
Address
Post Code
Position
Grade / Level (if app.)
Employer Name
Why Joined
Why Left / Leaving
Key Roles
Date From
to
Address
Post Code
Position
Grade / Level (if app.)
Employer Name
Why Joined
Why Left / Leaving
Key Roles

Competence Check List

Please tick all boxes that apply to you (all courses require a copy of your certificate to be validated)

I have completed the following professional training

NVQ Level in Date
Induction / Health Date

All staff members must fill in the supplementary questionnaire pertaining to their chosen work area

I have received the following mandatory training

Moving & Handling
         Date
Food Hygiene
         Date
Emergency Procedures
         Date
Health & Safety
         Date

I have attained the following academic qualifications

Subject Level Date
Subject Level Date
Subject Level Date
Subject Level Date
Subject Level Date
Subject Level Date

(Please note you will be required to attend an induction prior to beginning work for Care Support Leicester where you will be given Moving and Handling Training. You will also be required to attend an annual Mandatory Training Session.)

Supplementary Skills Check List – Care Assistant

To ensure quality provision and to assess learning needs please tick those skills that you acquired through practice in the work place:

Personal cleansing & dressing

Bath / shower / strip wash
Bed Bath
Bed making
Getting group of clients
ready for certain time
Hoisting client in / out bath
Simple dressings

Elimination

Continence Care (bowel and
bladder)
The use of bedpans and
commodes
Changing / emptying a catheter
bag
Applying a convene
Stoma care

Mobility

Use of hoists
Use of walking aids
Transferring clients from bed to
chair
Transferring clients from
wheelchair to commode
Pressure area care

Reporting

Hand over to other staff members
Care planning
Report writing
Dialing 999 / Dr

Communication

Deaf clients
Mute clients
Non-English speaking clients (including fluency in other languages)

Observations

Blood Pressure via
Equipment
Temperature via
Equipment
Pulse via
Method

Eating & Drinking

Assisting with medication
……to what extent?
……trained to
……trained by
Preparing meals
Feeding

Death

Care of the dying client
Care of the bereaved relatives

Learning Contract

I confirm that I am independently able to perform the above skills through previous experience and only feel I need help in the areas not ticked.

I accept that learning is an ongoing process and agree to take part in any new or developmental Learning when arranged for my benefit or / and that of the client or / and as legislation dictates.

I also agree to take part in all mandatory training and accept I can only negotiate out of this if I have valid certification from alternative sources.

Failure to comply with this learning contract may lead to disciplinary proceedings and possible dismissal.

Please tick this box to show that you will abide by Learning Contract
Date

Flexible Working (Let us know what your desired working week will consist of and your transport details)

Desired hours per week
Day or Night shifts preferred
Weekend work

Note: Hours are not actually guaranteed or contracted and to enable Care Support Leicester to facilitate the required amount of hours, your flexibility in the above is essential unless agreed otherwise by your local manager i.e. there is enough work in your chosen area for restrictive availability.

City       Radius Miles
Full D/Licence             Access to Car

References

One must be your current employer and senior to yourself, the others being from your previous or current employers. Please name as many referees as possible which will enable us to gain a minimum of two references. Please be advised that we will approach referees for a verbal reference.

Company Name
First Name      Surname      Position
Address
Tel No.      Fax      Approach prior Interview
Company Name
First Name      Surname      Position
Address
Tel No.      Fax      Approach prior Interview
Company Name
First Name      Surname      Position
Address
Tel No.      Fax      Approach prior Interview
Company Name
First Name      Surname      Position
Address
Tel No.      Fax      Approach prior Interview

Recruitment Media

Please help us to record our recruitment results by telling us how and where you heard about Care Support Leicester which led to this application

Immigration, Asylum and Nationality Act 2006 (sections 15-25)

Within the United Kingdom it is a criminal offence for anyone to work who does not have the right to do so. We reserve the right to undertake any checks required to ensure that applicants are eligible to work for this agency. As an agency/employment business we can only offer work to EU citizens and only non EU citizens that are in a receipt of a student visa to a maximum of 20 hours per week.

I can confirm that I am over the age of 18
Are you registered with the Vetting and Barring Scheme?
I can confirm that I have answered all the questions as accurately as possible
Date
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