KENYLINK SERVICES LTD.

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1 APPLICATION FORM Post: Care-Assistant Please complete this form fully using black ink or type and return to the above address. THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE. PERSONAL DETAILS Surname: First Name: Postcode: Date of Birth: Phone : Mobile Other address: Next of Kin {NOK} Contact {NOK} National Insurance No: SSSC Registration Yes No Do you need a work permit to work in the UK? Yes No Do you hold a current full UK Driving Licence? Yes No Do you have own car transport? Yes No How many hours per week do you intend to work? < >30

2 EMPLOYMENT HISTORY Should there be any gap in employment, please state reason: Present or Most Recent Employment Current pay:( pa or pm or per hr) Name of Employer: Postcode: Post Held: Period of Employment: From: Brief description of duties: To: Continue on a separate sheet if necessary Period of Notice: Last day of service: (if no longer employed): Reason for leaving

3 Previous Employment: 1. Name of Employer: KENYLINK SERVICES LTD. Postcode Post Title: Period of Employment: From: Summary of duties: To: Reason for leaving: 2. Name of Employer: Postcode Position Held: Period of Employment: From: Summary of duties: To: Reason for leaving: 3.Other employers Continue on a separate sheet if necessary

4 EDUCATION Qualifications obtained from Schools, Colleges and Universities/ SVQ, Nursing etc. 1. College or University Course Qualifications/ grades/year 2. College or University Course Qualifications/ grades/year Continue on a separate sheet if necessary COURSES ATTENDED Please tick attended courses Course Tick if Attended 1. Manual Handling 2. Health & Safety 3. Infection Control 4. Dementia Awareness 5. Incontinence Awareness & Catheter Care. 6. Adult Support and Protection 7. First Aid Awareness 8. Violence at work/challenging behaviour at Work. 9. Medication Administration Training. Other Courses REHABILITATION OF OFFENDERS Act (1974) Do you have any convictions that are unspent under the rehabilitation of offender s act 1974? Yes No If yes, please give details / dates of offence(s) and sentence: Continue on a separate sheet if necessary

5 CONVICTIONS/OFFENCES The following information will be required before any appointment can be confirmed. Have you ever been convicted of any criminal offence? Yes No Are you currently the subject of police investigation or do you have any prosecutions pending? Yes No List below details of ALL charges, prosecution, convictions, cautions, even if they happened a long time ago.. Please note that disclosure of a conviction does not necessarily debar any applicant from obtaining employment. Failure to disclose a conviction can lead to failure to obtain employment or could lead to dismissal CONSENT TO FOR DISCLOSURE/PVG CHECK I understand that a criminal check must be carried out before my appointment can be confirmed. I am aware that spent convictions may be disclosed. I declare that the information I have given is accurate and I consent to the check being made. Signature: Date: DISABILITY DISCRIMINATION ACT The Disability Discrimination Act defines a disabled person as someone who has a physical or mental impairment which has a substantial and adverse long term effect on his or her ability to carry out normal day to day activities. Do you have a disability which is relevant to your application? Yes If yes, please give details: No

6 REFEREES Please give the names and addresses of your three most recent employers (if applicable). If you are unable to do this, please clearly outline who your references are. Reference 1 Name: Work Relationship: Position (job title): Postcode Organisation: Telephone No Reference 2 Name: Work Relationship: Position (job title): Postcode Organisation: Telephone No Reference 3 Name: Work Relationship: Position (job title): Postcode Organisation: Telephone No

7 DECLARATION I hereby certify that: All the information given by me on this form is correct All questions relating to me have been accurately and fully answered Print Name: Signed: Date:

8 Equal Opportunities Monitoring We want to ensure that our job opportunities are open to all. The only way we can ensure there is equal opportunity is to measure applications we receive. Therefore this form asks you for your ethnic origin, gender, disability, religion, sexuality and age.. 1. You are: Female Male 2. Do you consider yourself to work: Full time 1 Part time 1 3. Do you consider yourself, or have you ever considered yourself as transgender? This could include considering or intending to undergo gender reassignment surgery or not identifying with your assigned birth gender. No Yes Prefer not to say 4. What is your date of birth? 5. Do you have a physical or mental health condition or disability that has a substantial effect on your ability to carry out day to day activities or is expected to last 12 months or more? No Yes If Yes, please describe here the nature of the disability and any special arrangements for interview / work location: Again, if Yes please tick if it is either of the following: Learning disability Long standing illness Mental Health Condition Physical Impairment Sensory Impairment Other (please describe): 6. What is your ethnic group? Choose one section from A to F, then tick the appropriate box to indicate your cultural background A) White Scottish Irish Other British Other White Background B) Mixed Any mixed background C) Asian; Asian Scottish; Asian English; Asian.British: Pakistani Indian Chinese Bangladeshi Other Asian background D) Black; Black Scottish; Black British Caribbean African Other Black background E) other ethnic background Any other background

9 F) Prefer not to answer KENYLINK SERVICES LTD. 7. What is your religion? A) Buddhism B) Christianity - Church of Scotland C) Hinduism D) Judaism E) Islam F) Christianity - Roman Catholic G) Christianity (other) G) Sikhism H) Other faith / belief I) Prefer not to answer 8. What is your sexual orientation? A) Bi Sexual B) Lesbian/Gay Woman C) Heterosexual (straight) D) Gay Man E) Other F) Prefer not to answer 9. What is your marital status? A) Married B) Single C) Widowed D) Not married E) Other F) Separated G) Prefer not to answer

10 JOB DESCRIPTION JOB TITLE: Care Assistant Overview of key tasks for the service users 1. To provide a responsive, effective, high quality, support service in the community. 2. To support service users to use local services and facilities, in order to achieve their personal goals as agreed in their support plans. 3. To be aware of the wellbeing, safety and state of health of service users, reporting any concerns 4. To provide support that is appropriate to the age, gender, disability, race, religion and sexuality of the resident to enhance their quality of life. 5. Personal Care Provision a. Assist Service Users in/out of bed, chairs, etc., using agreed procedures. b. Assist Service Users in dressing, care of aids and personal equipment (hearing aids, glasses, etc). c. Assist Service Users in all aspects of personal hygiene, i.e. washing, shaving, showering etc. d. Assist Service Users to access toilet facilities, emptying commodes and disposal of incontinence materials, using agreed health and safety procedures. e. Encourage Service Users to maximise their own abilities and skills 6. Domestic Services Delivery a. Maintain cleanliness of Service Users home. b. Where appropriate home facilities are available, launder and iron clothes and/or bed linen. PERSON SPECIFICATION Key experience and qualifications required ESSENTIAL Qualifications 1. Good Standard of Education DESIRABLE 1. SVQ/NVQ level 2 Willing to learn 1. Experience working in 2. Health Care Sector or 3. Domiciliary Care / Social Care setting 4. An understanding of the health and social care sector 5. Provision of person centred care in the community. Personal Attributes 1. Able to listen 2. Concern for others 3. Determined to make a positive difference 4. Flexible 5. Good people-skills/friendly 6. Good team player 7. Patient 8. Reliable 9. Respectful 10. Sensitive 11. Understanding

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