Healthcare Assistant Application Form - Open 2
Healthcare Assistant Application Form - Open 2
Healthcare Assistant Application Form - Open 2
Email: [email protected]
Website:opendoorshealthcare.com
Personal Information
Surname: Forenames:
Nationality: NI Number:
Are you eligible to work in the UK? YES NO Expiry Date (If applicable):
Preferred shifts (circle as appropriate): EARLIES LATES LONG DAYS NIGHTS Other: _____________________
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Healthcare Assistant Application
Please indicate which client groups you have experience of working with (mark as appropriate):
ELDERLY YOUNG ADULTS ACUTE MENTAL ILLNESS DEMENTIA LEARNING DISABILITIES
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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Healthcare Assistant Application
Safeguarding Adults
Food Hygiene
To:
/ /
Name: From:
Address: / /
To:
/ /
Name: From:
Address: / /
To:
/ /
MEDICAL HISTORY
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Healthcare Assistant Application
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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Healthcare Assistant Application
Name: Name:
Position: Position:
Address: Address:
Email: Email:
Name: Name:
Position: Position:
Address: Address:
Email: Email:
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Healthcare Assistant Application
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
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
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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