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Care Services
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Hospital to Home
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How We Work
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Post applying for?
Support Worker
Healthcare Assistant
Team Leader
Care Coordinator
Nurses
Manager
Deputy Manager
Risk Assessor
Safeguarding Lead
Social Media Manager/Digital Marketer
Full Name
Phone Number
Email
Address
City
Country
Postal Code
Country
National Insurance Details:
Do you have the right to work in The UK?
Yes
No
Please provide details of your visa and any restrictions in the space provided below (if applicable)
Do you drive a car?
Yes
No
Are you happy to drive to work?
Yes
No
Next of Kin.( For emergency contact)
Relationship
Next of Kin Address
Next of Kin Email
Next of Kin Mobile
Full Employment History
References
Contact Name
Job Title
Email
Address
Tel
Relationship to you
Number of years known
EQUAL OPPORTUNITY MONITORING FORM
ETHNICITY
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Mixed
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Chinese
Other
OTHER ETHNICITY (Please state)
GENDER
Male
Female
Other
PLEASE INDICATE YOUR AGE RANGE BY TICKING ONE OF THE BOXES BELOW
18-21
22-25
26-30
31-35
36-40
41-45
46-50
51-60
60-65
DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY OF SOME KIND?
Yes
No
If yes, give details
Disclosure of criminal record information
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE, OR BEEN SUBJECT TO ANY CONFIDENTIAL DISCHARGE, BIND-OVERS OR CAUTIONS?
Yes
No
If yes, give details
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENCE?
Yes
No
If yes to question above, please give details.
HAVE YOU EVER RECEIVED ANY OFFICIAL CAUTIONS, REPRIMANDS OR WARNINGS?
Yes
No
If yes to question above, please give details.
ARE YOU CURRENTLY THE SUBJECT OF ANY CRIMINAL PROCEEDINGS OR ANY POLICE INVESTIGATION?
Yes
No
If yes to the question above, please give details.
I declare that I do not possess, nor have I ever possessed a criminal conviction, nor have I been subject to any conditional discharges, bind-overs or cautions
ANY INFORMATION CONTAINED IN THIS FORM WILL BE TREATED IN CONFIDENCE. FAILURE TO DISCLOSE ANY RELEVANT INFORMATION OR PROVIDING FALSE OR INACCURATE INFORMATION MAY BE REGARDED AS A BREACH OF ANY SUBSEQUENT CONTRACT OF EMPLOYMENT, RESULTING IN DISCIPLINARY ACTION AND / OR DISMISSAL.
HEALTH CHECK QUESTIONNAIRE GP Contact Details
PLEASE ANSWER THE FOLLOWING QUESTIONS BY GIVING RELEVANT DETAILS
Have you ever suffered from any of the following:
DEPRESSION, ANXIETY STATE, NERVOUS ILLNESS OR BREAKDOWN
Yes
No
If Yes
EPILEPSY OR DISEASE OF THE NERVOUS SYSTEM
Yes
No
If Yes
AILMENT OF LUNGS OR CHEST
Yes
No
If Yes
SPINAL PROBLEM (BACKACHE)
Yes
No
If Yes
ARTHRITIS, RHEUMATISM OR GOUT ETC
Yes
No
If Yes
ANY HEART OR CIRCULATORY, INCLUDING BLOOD PROBLEMS
Yes
No
If Yes
ILLNESS OF THE KIDNEYS, BLADDER, LIVER OR GLANDS
Yes
No
If Yes
DIABETES
Yes
No
If Yes
SKIN DISORDER
Yes
No
If Yes
Are you presently taking medication or undergoing treatment. If so give details.
ARE YOU A REGISTERED DISABLED PERSON?
Yes
No
How many working days have you been absent from working during the last 12 months (apart from holidays)
Additional Details: (if necessary)
Notes
Data Protection:
THE HEALTHCARE RECRUITMENT PRIVACY STATEMENT IS AVAILABLE ON OUR WEBSITE (WWW.DWCSLTD.CO.UK) OR A COPY CAN BE REQUESTED FROM THE HUMAN RESOURCES DEPARTMENT. PLEASE SIGN BELOW TO CONFIRM YOU HAVE ACCESSED THE DRITEWISE CARE AND SUPPORT LIMITED HEALTHCARE RECRUITMENT PRIVACY STATEMENT AND YOU HAVE READ, UNDERSTOOD AND AGREE TO ALL THE TERMS STATED.
Data
Name
DECLARATION
I DECLARE THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TO THE BEST OF MY KNOWLEDGE, COMPLETE AND CORRECT. I ACCEPT THAT SHOULD ANY STATEMENT MADE BY ME IN CONNECTION WITH THIS APPLICATION BE FOUND TO BE FALSE, INCOMPLETE OR MISLEADING THEN THE APPLICATION SHALL BE VOID AND CONSEQUENTLY, DRITEWISE CARE AND SUPPORT LIMITED MAY TERMINATE ANY CONTRACT ARISING AT ANY TIME. BECAUSE OF THE SENSITIVE NATURE OF THE DUTIES THE POSTHOLDER WILL BE EXPECTED TO UNDERTAKE, I UNDERSTAND THAT THE DECLARATION WILL INCLUDE DETAILS OF ANY CRIMINAL CONVICTIONS, CAUTIONS, REPRIMANDS AND FINAL WARNINGS THAT ARE NOT ‘PROTECTED’ AS DEFINED BY THE REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS) ORDER 1975 (2013) AND ANY OTHER INFORMATION THAT MAY HAVE A BEARING ON MY SUITABILITY FOR THE POST. I ALSO UNDERSTAND THAT THE RELEVANT LEVEL OF DBS CHECK WILL BE SOUGHT IN THE EVENT OF A SUCCESSFUL APPLICATION
Name
Date
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