Application Form Carer – Adult - Gims Care Solutions

Gims Application Form Carer Adult

Personal Details - Step 1 of 15

Title *

Name *

First

Last

Previous Names (If any):

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Have you lived in this address for less than 5 years? *

Please provide previous address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Tel

Date of Birth *

Email *

Passport No:

Are you free to remain and take up employment in the UK?

Work Permit No (if applicable):

Mobile Tel *

Place of Birth

Religion

Passport Expiry Date:

Do you have a Work Permit?

Work Permit Expiry Date:

NI Number *

Nationality *

Languages Spoken

Gender *

Please state the type of visa you have and details of endorsement/restrictions (if applicable)

Next of Kin

Next of Kin Phone

Relationship

Are you a car driver with UK driving License? *

Do you have a car? *

If you intend to use your car for business, do you have the required insurance cover?

If yes, you will be required to produce both your driving licence and motor insurance certificates. Are you willing to produce this?

EDUCATION/QUALIFICATION AND TRAINING

(Including refresher courses) Please start with the most recent.

College/Uni/Training body

Name of Course

Date From

Date To

Result/Qualification

College/Uni/Training body

Name of Course

Date From

Date To

Result/Qualification

College/Uni/Training body

Name of Course

Date From

Date To

Result/Qualification

Are you a member of Union or Professional Organisation

Please state

EMPLOYMENT HISTORY AND WORK EXPERIENCE

Please give details of your employment over the last 10 years commencing with your most recent job and including any agencies worked for.
Where applicable please explain any gaps in your employment and provide evidence e.g. maternity, looking for work, studying, unemployed
etc.

Name & Address of Employer

Positions Held Including Duties

Date From

Date To

Reason for leaving

Name & Address of Employer

Positions Held Including Duties

Date From

Date To

Reason for leaving

Name & Address of Employer

Positions Held Including Duties

Date From

Date To

Reason for leaving

You are required by law under the Care Standards Act to state, if you have worked with children in the past 10 years. Please state where you worked, in what capacity and reason for leaving (if applicable):

Please state your Current Salary:

Monthly Rate:

Hourly Rate:

OTHER SKILLS: Please give details of your skills, knowledge and experience gained in employment, voluntary or somewhere else that may be relevant for your application.

REFERENCES

Please provide at least two referees who would give reference on your character, work experience, and suitability for the post applied for. Referees must be in a senior position to you. All will be contacted, therefore please inform the referees of the fact that you have used their name. if you are unable to provide the required references, please discuss the matter with us. PLEASE NOTE: If applying to work with children; two professional references are required

Current or most recent employer

Name of Referee

Position

Company

Address Incl Post Code

Phone

Referee Email *

Length of time known (MM/YY)

Character Reference

Name of Referee

Position

Company

Address Incl Post Code

Phone

Referee Email *

Length of time known (MM/YY)

May we contact your referees before your interview?

REHABILITATION OF OFFENDERS ACT 1974 AND OTHER DISCLOSURES

In view of the nature of the work for which you are applying, the post is considered to be exempt from the provisions of the Rehabilitation of
Offenders Act 1974 as contained within the Exceptions Amendment Order 1986. Applicants are required to give details of all convictions for
criminal offences, including pending convictions and those which would otherwise be considered “spent”. Failure to provide details of
convictions could result in dismissal or disciplinary action. If there are no convictions, please state “none”. Having a criminal record will not
necessarily bar you from working with us. Gims Care Solutions complies fully with the DBS Code of Practice regarding the correct handling, use,
storage retention and disposal of Disclosures and Disclosure information. We make every subject of a DBS Check aware of the existence of the
DBS Code of Practice and make a copy available on request.

Do you have any Spent or unspent convictions either in the UK or Oversea: *

Are you currently or have you previously been the subject of an investigation alleging abuse of Vulnerable Adults or Children either in the UK or overseas? *

If yes, please give details:

Have you any pending investigation? *

If yes, please give details

Signature for Investigation Check (Enter your full name): *

Date *

DISCLOSURE AND BARRING SERVICE (DBS) CHECK

I authorise Gims Care Solutions to carry out a DBS check on my behalf as and when required, also to retain a copy of my DBS and
update service checks. I understand that before I can commence work with Gims Care Solutions, I need to have completed a DBS
Check.

In keeping with current industry standards and Government requirements, all staff members involved with the provision of Care to Children and
Adults at risk are required to complete an Enhanced Disclosure form for the Disclosure and Barring Service (DBS). No applicant will be offered
work with Anytime Recruitment Ltd prior to these DBS checks.

Do you agree to apply for Enhanced DBS checks? (a fee will be charged for these checks): *

Signature for DBS Check (Enter your full name): *

Date *

CONFIDENTIALITY

During the course of your employment you may see, hear or have access to information on matters of a confidential nature relating
to the work of the organisation, or to the health and personal affairs of clients. Under no circumstances should this information
be divulged or passed on to any unauthorised person or organisation, either during the course of your employment or any time
after. You have got a statutory obligation regarding this.

I have read and understand the above and agree that breach of such confidentiality will be regarded as gross misconduct, which
could result in disciplinary action or dismissal.

Signature for Confidentiality (Enter your full name): *

Date *

WORKING TIME DIRECTIVE

The Working Times regulations 1998 (“The Regulations”) require Gims Care Solutions (“The Company”) to limit your average
weekly working time to 48 hours unless you agree with The Company that the limit shall not apply to you. The Company wished
to have an agreement with you. It proposes an agreement (which will apply until terminated by notice) on the basis that:

a. The 48-hour limit on average weekly time will not apply to you.
b. You may terminate the agreement (so that the 48-hour time limit would apply to you) by giving the person at The Company
to whom you usually report 4 weeks’ written notice. Under the Regulations, The Company must keep records relating to
your working time. This is the case whether or not you reach an agreement with The Company about waiving working time
limits.

If, however, you do wish to agree to this opt-out, then please sign where indicated on the statement below. You may withdraw
your agreement by a 4 weeks’ notice in writing, and you will not be subjected to any detriment if you do not give your agreement.

Signature for Working Time Directive (Enter your full name): *

Date *

BANK DETAILS

(Complete all sections accurately – your money will be paid directly into your
bank account)

Account Holders Name: *

Account Number: *

Bank Name: *

Sort Code: *

AREAS OF EXPERIENCE

(Enter the Length of Experience)

Hospitals

Dementia

Nursing Homes

Mental Health

Residential Homes

Palliative Care

Learning Disability

Care of the Elderly

Domiciliary Care

SKILLS EVALUATION

Please tick the box to indicate your level of competence:

Assisting with washing, Shaving *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Mouth Care *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Eye Care *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Stoma Care *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Continence Care *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Use of Commode, Bed pan *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Catheter Care *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Recording fluid balance sheets *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Blood Sugar Testing *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

TPR Recording *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

B/P Recording *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Urinalysis *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Feeding Patient *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Meal preparation *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Use of Hoist *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Transferring, Mobilising a Patient *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Report Writing *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

Pressure Area Care *

I am experienced and competent in this.
I am familiar with this procedure but do not have experience.
No Knowledge of this procedure

MANDATORY TRAINING UPDATES

Choose courses attended and enter dates below:

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

Course

Date Attended

Expiry Date

YOUR AVAILABILITY FOR WORK

Please indicate the times and days you would be available for work

Monday

Friday

Tuesday

Saturday

Wednesday

Sunday

Thursday

How many hours would you like to work each week

Do you have any other work commitments which may impair your ability to carry out your duties for Gims Care Solutions? *

Please give details

Please tick the area you would be able to work in: *

Barking and Dagenham
Redbridge
Havering
Newham
Tower Hamlets
Thurrock
Essex

EQUAL OPPORTUNITIES MONITORING

Nationality

Age Group

Ethnicity (please indicate which best describes your ethnic origin)

Are you related to or do you know any member of staff at Gims Care Solutions?

How did you hear about this job post?

Language Spoken

Disabilities

Specify Ethnicity

Please give details

THIRD PARTY DECLARATION

I hereby allow any information relating to my registration with Gims Care Solutions to be shared with relevant third parties, including
external audits and frameworks. This will be overseen by the governance lead for Gims Care Solutions.

Signature for Third Party Declaration (Enter your full name): *

Date *

DECLARATION (ALL CANDIDATES)

I declare that the information on this application form is to the best of my knowledge accurate and correct. I certify that I am at
present in good physical and mental health and will, if engaged, be liable to disciplinary action or immediate dismissal from Gims
Care Solutions Ltd for any incorrect or misleading information given in this form.
I hereby give permission for Gims Care Solutions Ltd to allow access to my file information only as part of an official audit or client
compliance purposes, carried out by but not limited to CQC, NHS, GPS or other official regulatory bodies. Access will only be granted
in terms of the Data Protection Act.
If, during a temporary assignment, the Client wishes to employ me direct, I acknowledge that Gims Care Solutions will be entitled
either to charge the client an introduction/transfer fee, or to agree an extension of the hiring period with the Client (after which I
may be employed by the Client without further charge being applicable to the Client).
I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body (e.g. NMC/HPC)
or being investigated by my current or previous employer. I will inform Gims Care Solutions if I am under investigation or suspended
by my professional regulatory body or employer at any point whilst working for Gims Care Solutions.

I agree to inform Gims Care Solutions immediately if I am the subject of any pending prosecution, work related investigation,
Disciplinary action/professional misconduct. Also, any changes to my personal circumstances that could affect my fitness to practise
as a healthcare professional.
I give Gims Care Solutions permission to carry out all relevant Employment checks necessary for my registration including any
external bodies.
I confirm that I am aware that the trust/organisation where I attend assignments have the right to carry out any physical searches
of me, my possessions and my vehicle while on the premises. All security checks must comply with the Human Rights Act 1998.
I confirm I have received, read and understood the Gims Care Solutions handbook and agreed to abide by its terms at all times.
I confirm Gims Care Solutions can complete annual updates in relation to my compliance documentation in line with the
framework/ contract.

By signing this document, you are confirming all the above agreements and all the company’s proposals.
This document will then be a record of agreement.

Signature for Declaration (Enter your full name): *

Date *