Social Care Application Form

Talisman Number Source Code

Personal Details
Surname Nl number Mobile Tel Home Tel Work Tel Email

Marsh JH 10 11 51 D 07706509876 Hayleylouise_22@hotmail.com

Driving licence

No

Full

Clean

Provisional YES

Car Owner

No

Position Required
Temporary Minimum hourly rate required Permanent Salary required

Client group (QSW, Adult residential, Adult day care, Childcare residential) Notice period

any none asap

Date available to start work Long as possible If temporary work is sought, how long are you available for? Wolverhampton- west midlands Geographical area you would like to work in

Languages and fluency

English
How did you hear about Eden Brown (if through a recommendation state who)

internet Non UK Residents Only

What kind of visa do you have that entitles you to work in the UK? Working holiday visa _____ Ancestry _____ Other (please specify) __________ Expiry Date ___________

Education & Training

Complete EDUCATION AND TRAINING and EMPLOYMENT sections School/College/Further Education From To Subject/Qualification/Grade

The Northicote school Wolverhampton college

1997 2000

1999 2001

None taken

Newly Qualified Social Workers Only

Placement address and contact From To Placement details

Education & Training

Original records must be seen and copied for file Attended First Aid Manual Handling Food Hygiene Fire Safety Health and Safety Care NVQ Level 2 Care NVQ Level 3 NVQ 4/RMA Other (basic life support, breakaway training, induction training, etc.) CHALLENGING BEHAVIOUR. DEMENTIA AWARENESS 2010 Yes Yes No No Yes Yes No No Date Certificate seen and on file

2010 2010 2010 2010

Current Employment
Employer Location you are based at Dates worked Duties/ Responsibilities

Inspirations residential wolverhampton

From oct 2010 To march 2011

Nature of Business Position Held Salary/Rate

Care home Care assistant

nmw Caring for residents who suffer from dementia, help assist with personal care, assist with food and drink. General house keeping duties were involved such as cleaning, laundry.

Reason for leaving

Contract ended

Previous Employment
Please provide details of all previous employment and gaps in employment, if any, since leaving education Employer 1 Location you are based at Dates worked Duties/ Responsibilities

Jml Dolman wolverhampton

From April 2010 To Oct. 2010

Nature of Business Position Held Salary/Rate

Nvq Care assistant training Care assistant

nmw Based in a care home whilst training to gain nvq and other certificates.

Reason for leaving

Was only a six month contract Zorbas Dance Greek restaurant Wolverhampton
From march 2009 To April 2010 Nature of Business Position Held Salary/Rate

Employer 2 Location you are based at Dates worked Duties/ Responsibilities

Restaurant Barstaff/ waitress nmw

Serving customer 18+ alcohol and assisting customers to there tables and serving their Meals.

Reason for leaving

Change of job. Zorbas Dance Greek restaurant Wolverhampton

From march 2009 To April 2010 Nature of Business Position Held Salary/Rate

Employer 3 Location you are based at Dates worked Duties/ Responsibilities

Restaurant cleaner nmw

Clean areas in the restaurant before opening nights.

Reason for leaving

Job change.

Voluntary Experience
Please outline any voluntary experience you have had within the Social Care Sector

Company name/address and telephone

Dates worked

Duties

References
Referee 1 Company Name Dates worked Company Address

Katie Lowe JML Dolman

From April 2010 To Oct 2010

Position Held Contact Telephone Numbers

01902 420820

JML Dolman 9 Roma Parva Waterloo Road Wolverhampton

Date Sent

Returned

Referee 2 Company Name Dates worked Company Address

Patricia Hayward Inspirations Residential

From Oct 2010 To March 2011

Position Held Contact Telephone Numbers

Inspirations Residential 171 Tettenhall Road Wolverhampton

Returned

Date Sent

Referee 3 Company Name Dates worked Company Address From To

Position Held Contact Telephone Numbers

Date Sent

Returned

Referee 4 Company Name Dates worked Company Address From To

Position Held Contact Telephone Numbers

Date Sent

Returned

Referee 5 Company Name Dates worked Company Address From To

Position Held Contact Telephone Numbers

Date Sent

May we contact this referee immediately?

I agree that at the discretion of the designated signatory copies of my references may be sent to third parties in accordance with legislation Signature Print Name HAYLEY MARSH Date 23/02/2012

Personal Health Declaration

Family doctor Address Health and Safety Declaration Whilst working as a contractor for Eden Brown, I will (a) not use any machinery unless experienced and able, (b) not work on a dangerous machine (e.g. hoist) unless 18+ years of age and supervised or experienced in the use of machinery. I will ensure that at all times I will take every precaution to (a) avoid injury to myself and others, (b) prevent damage to any equipment/machinery. Do you or have you had any problem with the under noted. If YES please give details on separate sheet A. Please detail any illness, which have led to absence from work in the last three years B. Please detail any disabilities Nervous or psychiatric illness Tonsillitis / sinusitis / ear infection / deafness Asthma / hay fever / pleurisy / chest infections Tuberculosis Heart / circulation / high blood pressure problems Bladder / Kidney problems Back problems / strain-causing time of work Blackouts / epilepsy / giddiness / fainting attacks Skin rashes / allergies to food or drugs Thyroid / diabetes / other glandular illness Gastro-intestinal / jaundice Migraine / headache / varicose veins / painful periods Hernia Foot problems Have you ever left employment for health reasons? Nervous or psychiatric illness Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No Are you receiving any medical treatment Do you have any persistent coughs? Have you ever attended hospital at any time? Have you been off work in the last twelve weeks? Have you had a Mantoux test? Eye trouble or detective vision not corrected by glasses Other muscle or joint trouble Have you any disabilities affecting: Standing Walking Stair climbing Lifting Use of hands Working at heights on ladders. Staging Ability to drive a motor vehicle Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No Telephone Number

Are you receiving any medical treatment

Date and place of the last chest X-Ray

_________________________________________________________________ ______________________________________________ Yes No Date Certificate seen

Please give us details of childhood illnesses e.g. chicken pox, measles Type TB Rubella Yes No Date Certificate seen Type HepB Varicella

In the last 2 years have you been off work because of illness or injury? If yes, give number of working days lost: Have you now made full recovery from your illness or injury If no, a doctor's certificate is required stating you are safe to return to work Are you at present having any treatment or medicine prescribed by a doctor? If yes, please detail: Do you consider yourself fit to carry out night work

Yes Yes Yes

No No No

Yes

No

I declare that all the foregoing statements are true and complete to the best of my knowledge. Should the situation Change whilst I am either: (a) engaged on a temporary assignment by Eden Brown, or (b) in between assignments for Eden Brown, I will immediately notify Eden Brown and, If appropriate, the client company where I am working.

Signature Print Name

Date

Home Office Circular

Dear Applicant The post, which is exempt from the rehabilitation of offenders Act 1974, you are being interviewed for requires registration with the Criminal Records Bureau and the National Care Standards Commission. In order to ascertain suitability for this registration, please complete the following questionnaire. If you require a more detailed explanation why Eden Brown requires you to complete the questionnaire, please ask the recruiting officer who will arrange for a member of the senior staff to contact you. Thank you very much for your co-operation. Please indicate below whether you have ever been: 1. Charged, cautioned or convicted of any offence, or been subjected to an investigation by police 2. Subject to any form of complaint, dismissal or disciplinary proceedings, (including disqualification for caring for children under the disqualification caring for children regulations 1991) 3. Employed by, or in any way associated with, an establishment/agency which been the subject of: a. Police investigation b. Inspection unit (DOH or NCSC) investigation c. Child protection investigation d. Adult protection investigation e. Proceedings under the registered Homes Act 1984, The resident Care Home regulations 1989, Care Standards Act 2000 f. Proceedings under the: Children Act 1989 The children's homes regulations 2001 or fostering or adoption regulations 2002 g. Proceeding under the Nursing Homes and mental Nursing Home Regulations 1984 1. Charged, cautioned or convicted of any offence, or been subjected to an investigation by police If your answer is YES to any of the above, please give details including dates: Yes Yes No No

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No

Should Eden Brown not offer you a position within the organisation, this completed questionnaire will be confidentially destroyed within six months. I hereby declare that the information detailed above is accurate to the best of my knowledge at this time. I understand that a false declaration may lead to refusal of this application. If, while I am working through Eden Brown, any of the above in this Home Office circular changes, I agree to notify Eden Brown in writing immediately. Signature Print Name Date

Declaration
I affirm that the information set out in this application form is true and correct, is not misleading and that no material information has been omitted. I understand and agree that if I submit any false or misleading information or omit any material information, this may result in an offer of employment/ registration being withdrawn or, if I have already been employed/ registered, in my removal from the register. I agree the information given on this form may be used for registered purposes under data protection legislation. Signature Print Name Date

FOR OFFICE USE ONLY - DO NOT MARK BELOW

Comments

Consultant Name Consultant Signature

Date

RTW Checklist
Check All periods of employment covered Tick and sign Tick and sign

Refs for last 3 years received NOTE some clients require 5 years

2 signed passport size photos received

2 forms of ID and proof of address i.e. Passport & birth certificate

Right to work letter/passport stamp (if applicable)

Health declaration fully completed

Relevant certificates on file

CRB sent and received

QSW only GSCC registered

GP letter and/or sick note if reqd

Bank details submitted

ID card issued

TOE signed and received

Application form fully completed and signed

Date file signed as RTW Consultant signature Manager signature