101 First Floor Knightrider House, Knightrider Street, Maidstone, ME156 LU

Email: [email protected]
Website:opendoorshealthcare.com

HEALTHCARE ASSISTANT APPLICATION FORM

Personal Information
Surname: Forenames:

Maiden Name (if applicable): Date of Birth:

Nationality: NI Number:

Passport Number : Passport Expiry Date:

Mobile Number: Email:

Marital Status: Driver’s License: Yes No

Home Address: Gender: MALE FEMALE OTHER

Next of Kin Name:

Relationship: Address:

Postcode: Home Tel:

Mobile: Postcode:
Email: Telephone Number:

Enhanced DBS Disclosure Number (if applicable):

Are you eligible to work in the UK? YES NO Expiry Date (If applicable):

Do you have your own transport? YES NO

Please confirm your immunisation status against the following:

Hepatitis B: YES NO Tuberculosis/ BCG: YES NO Measles: YES NO

Varicella: YES NO Rubella: YES NO Other: _____________________________

Preferred shifts (circle as appropriate): EARLIES LATES LONG DAYS NIGHTS Other: _____________________

Do you have an NVQ qualification in Health and Social Care? YES NO

If yes, at what level? 2 3 4

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If no, are you currently studying towards one? YES NO

Do you have a Moving & Handling certificate? YES NO

If Yes, Expiry Date:

Do you have a Basic Life Support certificate? YES NO

If Yes, Expiry Date:

Please indicate which client groups you have experience of working with (mark as appropriate):
ELDERLY YOUNG ADULTS ACUTE MENTAL ILLNESS DEMENTIA LEARNING DISABILITIES

Do you have a minimum of 6 months work experience within the following?

Residential Homes: YES NO Nursing Homes: YES NO

Qualifications (Relevant to Healthcare / Nursing only)

Date To
Qualification Where Completed Date From (MM/YY)
(MM/YY)

Only include below additional training you have a valid certificate of attendance for:
Date Completed Date Expires
Course Where Completed (DD/MM/YY) (DD/MM/YY)

Drug Administration

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Safeguarding Adults

Equality & Diversity

Food Hygiene

Current and Previous Employment History

(Work history required starting with the most recent first)
Dates (DD/MM/YY) Position/ Job Title Reason for
Name & Address of Employer Salary
Leaving
Name: From:
Address: / /

To:
/ /

Name: From:
Address: / /
To:
/ /
Name: From:
Address: / /
To:
/ /

NOTES (eg. gaps in work history):

MEDICAL HISTORY

Have you ever suffered from any of the following?

Heart/Circulatory Illness/Hypertension YES NO
Diabetes YES NO
Asthma/Hay fever YES NO
Bronchitis/Pneumonia/Pleurisy YES NO
Epilepsy YES NO
Headaches/Migraine YES NO

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Tuberculosis YES NO
Psychiatric Illness/Anxiety/Depression YES NO
Dermatitis/Psoriasis/Eczema YES NO
Back problems YES NO
Recurrent infections YES NO
Hepatitis/Jaundice YES NO
Are you taking any prescription drugs? YES NO

If you have answered yes to any of the above questions, please give details below:

Do you have any health issues or disabilities that will prevent you from carrying out your duties as a Healthcare Professional to a
satisfactory standard? YES NO

If yes, what are your needs in terms of reasonable adjustments to enable you to carry out your duties to a satisfactory standard?
Please specify:

Have you been dismissed or had disciplinary action taken against you in the last 3 years?
YES NO

Details:

References
(We can only accept work references from Line Managers, not work colleagues. Please use work contact details only, ensuring
one reference is from your current or most recent employer. We do not accept personal references. Please note; references must
cover a 3-year period where applicable).

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Name: Name:

Position: Position:

Company Name: Company Name:

Address: Address:

Telephone No: Telephone No:

Email: Email:

Name: Name:

Position: Position:

Company Name: Company Name:

Address: Address:

Telephone No: Telephone No:

Email: Email:

Rehabilitation Of Offenders Act 1974

In view of the nature of the work for which you are applying, this post is exempt from the provision of 2.4(2) of the Rehabilitation of
Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act (Exceptions) Order 1975. Applicants are, therefore, not entitled
to withhold information about convictions, which for other purposes are “spent” under the provision of the Act and, in the event of

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employment, any failure to disclose such convictions would result in dismissal. Any information given will be completely confidential
and will be considered only in relation to this application.

Have you ever been convicted of a criminal offence by a Court of Law (please indicate)? YES NO

IF YOU HAVE A CONVICTION/CAUTION RELATING TO A VIOLENCE OR THEFT OFFENCE, WE WILL BE

UNABLE TO PROGRESS WITH YOUR APPLICATION.

Equal Opportunities
Open Doors Healthcare is fully committed to the principle of Equal Opportunities in recruitment irrespective of colour, race, sex,
marital status, sexual orientation, ethnic origin, nationality, religion, disability or age.

Declaration
I confirm that I have received the Open Doors Healthcare Services Pvt Ltd conditions and terms and will adhere to the conditions
and guidance enclosed.

By signing this application, I declare that all information given by me is accurate and in no way misleading or false.

Signature:_______________________________ Date:_________________________

I consent to Open Doors Healthcare Services checking the details I have provided against the various data sources in order to verify
my identity and process the application. These details may be recorded and used to assist other organisations for identity verification
purposes such as the CRB/DBS, regulatory bodies such as NMC or GSCC

Signature: _______________________________________ Date:___________________________

Our agency retains the right to hold this application and any other data required to process this application (whether in the UK, or
elsewhere) and keep for as long as necessary in line with the data protection act.

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