Join the EmpressCare Team Start your journey with us today Support Worker Application Form Download This Form Download Form Upload CV CV * Accepted: PDF, DOC, DOCX. Max 10MB. Section 1 – Personal Details Title *—Please choose an option—MrMrsMsOther Full Name * Date of Birth * Previous Names (if any) Nationality * Address * National Insurance Number * Email * Telephone Number * Marital Status *—Please choose an option—SingleMarriedDivorcedWidowedSeparatedCo-habitingOther Section 2 – Passport and Work Permit Details Do you have a work permit? YesNo Work Permit Expiry Date Passport Nationality Place of Issue Passport Number Date of Issue Expiry Date Section 3 – Next of Kin Details Title *—Please choose an option—MrMrsMsOther Name(s) * Relationship * Address * Contact Telephone Number * Section 4 – General Information Do you hold a UK driving licence? YesNo How did you first hear about City Support Limited? Section 5 – Training & Skills Personal HygieneBath/Shower/Strip washBed BathUse of Bath aidsGeneral personal careToiletingContinence careBed pans/commode etcChanging catheter bagAttaching night bagEmptying a catheter bagStoma care MobilityMoving & handling coursesUse of hoists (manual/electric)Use of walking aidsMoving & Handling clients Administrative AbilitiesConfidentialityReport writingRecording instructionsObserving/recording changes in client’s condition Care DutiesPressure area careSimple dressing proceduresPerson centred approachAssisting with medicationRecovery modelTerminal carePOVA proceduresPractical tasks Clinical MeasurementsRecording blood pressureRecording temperatureMeasure respiration Previous Experience (Settings)Private hospitalNursing/residential homeHospital Other Skills Section 6 – Work Experience Employment #1 Employer Name & Address Position(s) held & duties Date From Date Left Reason for leaving Vocational Qualifications / Courses Attended Institution Dates Qualification Section 7 – References Name * Position * Post Code * Address * Tel No(s) * Email * Section 8 – Work Preferences PositionsPart-timeFull-time Type of workNHSPrivate HospitalsNursing HomeResidentialClients in their own homeLive-InDaysNights Do you have any other work commitments? YesNo If Yes, please specify Other (please specify) Available start date Length of time available Section 9 – Health Declaration Height (cm) Weight (kg) Attended hospital in past 5 years?YesNo If Yes, please give details Current Health Physical disability? YesNo Taking medication? YesNo Refused employment for health reasons? YesNo Do you smoke?YesNo Cigarettes per day Do you drink alcohol?YesNo Units per day Medical HistoryAllergiesAnaemiaAnxietyArthritisAsthma/BronchitisBack pain/operationCancer/TumourChest painConvulsion/EpilepsyDiabetesDermatitis/skin problemsDentalEarsEyesFainting spellsGlandsGall Bladder/JaundiceHeadaches/MigrainesHeart diseaseHepatitis AHepatitis BHepatitis CHerniaInsomniaHigh blood pressureKidney/UrineNeck painPolioPregnancyPsychiatric treatmentRheumatic feverRheumatismSalmonella/Food poisoningStomach/Intestine diseaseTuberculosis (TB)Weight loss/gain Immunisations / VaccinationsGerman measles (Rubella)TuberculosisHepatitis BTetanusCOVID-19 VaccinationPolioOther HIV test?YesNo Result Section 10 – Pay (BACS) Name on account * Bank/Building Society Name * Bank Sort Code * Account Number * Bank/Building Society Address * Equal Opportunities Monitoring Category —Please choose an option—White: English/Scottish/Welsh/IrishAny other white backgroundMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianAsian: IndianAsian: PakistaniAsian: BangladeshAny other Asian backgroundBlack: AfricanBlack: CaribbeanAny other black background This information is optional and used for monitoring only. Section 11 – Confidential Declaration I have read, understood, and agree to abide by the confidentiality rules. Signed * Date * Enhanced Criminal Records Disclosure Information I declare the information in this application is true and complete; I consent to processing for recruitment, employment, and management purposes, and give permission for reference checking. Signed * Date *
