homecare assistant application：家庭护理助理的应用.docx

homecareassistantapplication：家庭护理助理的应用MyHomecare.ieReV02HomecareAssistantApplicationThankyouforyourenquiryaboutworkingwithMyHomecare.ie/SerViSoUrCeHealthCareMyhomecare.ieincorporatingpartofServisourceHealthcareplaceHomecareAssistantswithclientsandthroughoutIreland,cover!nglong-term,mediUniandshort-termpositions.Ourcompany'spo1icyiStoprovideaconsiStentandqualityservicebVmatchingtheindividua1needsofbothorCareStaffandourClients.Ourofficeisopen7daysaweekfrom7amtol1pm,363daysoftKeyeartoprovidethebestpossibleservice.PleasefillIntherelevantdetaiIsintheapplIcationpackandsenditbacktouswithasmuchinformatiOnasyoucanprovideiminediate1y.AchecklistOfrequirementsisonthefolIowingpagetoassistyou.Pleasebeawarethatallreferencesandqualificationswillbechecked.PleaseSignanddatetheapplicatIonandreturnittoourofficesat:ServisourceOffices:DundalkOfficeUnit3,Floor2,QuaysideBusinessCentre,Dundalk,Co1.outhTel:+353429352723Fax:+353429352724GalwayOffice16aSandyfortBusinessCentre,Bohermore,GalwayTel:+35391762426/761051Fax:+35391762429CorkOffice11AngleseaStreet,CorkTel:+353214279916/4279739Fax:+35391427991DublinOfficeInternationalHouse,TaraStreet,Dublin2Tel:Ol4730474Fax:Ol6334269WaterfordOfficeWaterfordHealthPark,SlievekealeRoad,CoWaterfordTel:1800400900ContactDetaiIsServisourceRecruitmentTeamEmai1:infoervisource,iePleasealsocheckoutourwebsite:pletedwithininthelast2year8ModulesHomecareAssislantApplicationHowhearaboutourAgency?didyouNewspaperNursingMagazinesInternetFriendsOtherPersonalDetailsFirstName:ATTACHSIGNEDPASSPORTPHOTOSSurname:PreviousName:ddressMobiIeNo.HomeNo.WorkNo.EmailAddressGenderDateoCBirthPPSNumberNextofKinContactDetaiIsforNextofKinDoyouholdaGardaNationalImmigrationBureaucard?YesNoIfYespleasestatestampnumberandexpirydatePreferredHealthcareIocationsyouwishtoworkinHomecareAssistantApplicationTrainingEducationAreyouaStudentNurse?YesNoWhatdisciplineareyoustudying?IfYes,NameofTrainingHospitalPleasenotethatstudentNursesareexeniptfromFETACrequirements.FETACHaveyouconipletedorareyouinIheprocessofcompletingaFETCHealthcareSupportMajorAward?YesNoFETClevel5MajorAwardinHcaltHcarcSupportiscomposIedof8modu1cs.OutoftheseSmodules,5aremandatoryand3areeIective.PIeaseindiCatethemodu1esyouhavecomp1OtedandcncIosedcertifications:MandatoryModules:CareSkillsCareSupportSafetyHealthatWorkElectiveModules:NutritionPractIcalHomecareSkillsCareoftheIderPersonOccupationalFirstAidPalliativeCareCareProvisiOnandPracticeAnatomyandPhysiologyChildDevelopinentHumanGrowIhandDeve1opmentWordProcessingIntroductiontoNursingCustomerServiceCaringforChi1dren(06years)MaternItyCareSupportOperatingDeparUnentCareSki11sIntellectualDisabil1.tyStudiesCommunicationsWorkExperienceCaringforChi1dreninllospitalRehabilitationSupportUnderstandingMentalHealthSocialStudiesPersonalEffectivesintheWorkplaceTeamworkingHaemodialysiSCareSupportActiviticsof1.ivingPationtCareWorkp1aceStatutoryPo1iciesandProceduresTnfectiOnPreventionandContro1WorkplaceFoodSafetyandHygieneFoodSafetyHACCPOtherHomecareAssistantApplicationEmploymentHistoryRcferenccsWerequirenamesandcontactdetailsofyour3refereesfromyourcurrentandmostrecentemployment.RefereesmustbeofManagement1.evelorHigherOnereferencemustbefromyourcurrentormostrecentemployerAnyoffersofapostissubjecttosatisfactoryreferencesCurren11MostReccntEmp1oy11tmtOrganisationPositionHeldDateTo:From:MonthsinPost(1st)Referee,sNameFromCurrentPositionorMostRecentEmploymentReferee'sPositionRefereesContactDetaiIsPhone/FaxIEmailHomecareAssistantAppicationPreviousEmp1oyment:OrganisationPositionHeldDateMonthsinPostTo:From:(2nd)Referee,SNameReferee,SPositionRefereesContactDetailsPhone/FaxIEmailOrganisationPositionHeldDateTo:From:(3rd)Referee,SNameReferee,SPositionRefereesContactDetailsPhone/FaxIEmailPleasecontinueyourexperienceandemploymentonseparateCurriculumVitaeHomccareAssistantApplicationPersonalPayDetai1sPleasefillinthefolIowinginformationcarefullyandreturnitwithyourapplicationformFirstNameSurnameAddressMobiIePhoneNumberHomePhoneNumberEmailAddressDateofBirthStaffTypeHomecareAssistantBankIBANCodc:BankSWIFTCode:AccountNumber(8numbers)BankSortCode(6numbers)BankNameAddressPPSNumberHomecareAssistantpp1icationHomecareAssistant,sPleasestatecoursetitleanddurationofcourseorexperienceExperienceCourseTitleDurationCompetentlevel(1-5)AccidentEmergencyCareofElderlyClinicsComputersDrugsAlcoholHomecareInfectiousDiseasesMedicalMidwiferyPaediatricsPalativeCarePsychiatrySurgicalTheatres/RecoveryOthersSign：Date:一HoniecareAssistantApplicationHealthDeclarationIdeclarethatIunderstand,acceptandconfirmtheentitlementofMyHomccaretorejectmyapplicationorterminatemyemployment(intheeventofacontractofemploymenthavingbeenenteredinto)whereIhaveomittedtofurnishtheAgencywithanyinformationrelevanttothishealthassessmentorwhereIhavemadeanyfalsestatementormisrepresentationrelevanttothishealthassessment.PleaseanswerYESorNOandifYES,pleasegivedetailsinthespaceprovided.YesNoDetails1Doyouhave,orhaveyoueverhad,anymedicalconditions,surgery,orspecialinvestigationsi.e.cardiographinthepast5years?2Areyouatpresentattendingadoctorformedicalcare,takinganymedicationoronawaiting1istforhospitalassessmentortreatment?3HaveyoueversufferedaworkrelatediIlncss,injuryorgivenupvorkduetoi11health?4Doyouhaveimpairment/disability(physicalormental)orspecificlearningdisabi1itywhichmayaffectyourabi1itytowork?5Haveyoueversufferedfromtuberculosis(TB)?Withinthepast12monthsHasanyfamilymemberorclosecontactbeentreatedforTB?Haveyouhadacoughformorethan3weeks?Haveyoucoughedupblood?Haveyouhadanyunexplainedweightloss?Haveyousufferedfromnightsweatsorfever?HomecareAssistantAppication6Haveyoueverhadanykindofback,jointormuscleproblem?7Haveyoueverhad:Dermatitis,Eczema,Psoriasisoranyotherskincondition?8Haveyoueverhadanymentalillnesswhichmightaffectyourabilitytowork?(includinganxiety,depression,self-harm,eatingdisorders,psychologicaloremotionalproblems)9Haveyoueverhadadrugoralcoholproblem?10Doyouhaveanydifficultywithyoureyesight(includingcolourblindness)?11Doyouhavedifficultywithyourearsorhearing?12Haveyoueversufferedfromanyofthefollowing;lossofconsciousnessincludingfaintingattacks,blackouts,dizziness,epilepsy,fitsorconvulsions?13Haveyoueversufferedfromanyofthefoilowing;heartdiseaseorcirculatoryproblem;includinghighbloodpressure,varicoseveins14Haveyoueversufferedwithchestorlungproblems;Asthma,Bronchitis?15Haveyouanyallergies;includingallergiestodrugs,foodorlatex?16Haveyoueverreceivedtreatmentforbowelorgastricproblems?17Haveyoueversufferedadisorderofthebladderorkidneys?18Haveyoupreviouslyworkedinindustrywhereyouwereexposedtoany,hazards,dust,noise,chemicals?19Doyouhaveanyothermedicalconditionnotpreviouslymentionedinquestions118above?PreviousSicknessAbsencetimelostfromworkduetoillnessoverlast2years.HomecareAssistantApplicationSigned:PrintName:Date:GPNameI,engthofabsenceReasonforabsenceGPddressGPTelephoneHomecareAssistantApplicationVACCINATION/IMNflJNESTATUSHISTORYTobecompletedandstampedbyanOccupationalHealthProfessional/GeneralPractitioner.Name:_DateofBirth:Theabovepersonhasthefollowingvaccinationscarriedout.HepatitisB1STDate:2ndDate3rdDate:HepatitisBTitreDate:lu'su11：HepatitisBBoost(Date:HepatitisBTitreDate:Result:mIUmlMeasles(Serology)Date:Result:Mumps(Serology)Date:Result:Rubclla(Serology)Date:Result:Varicella(Serologv)Date:Result:HepatitisC(Serologv)Date:Result:MantouxTest2TUDate:Result:MantouxTest1OTUDate:Result:BCGScarCheckDate:1.ocation:CompletedSignature:.Title:by:Facility:DateCompleted:OFFICIA1.STAMP:HomccareAssistantApplicationIagreetothefollowing:Iconfirmthattheinformationgivenonthisapplicationformiscompleteandcorrect.IagreetoMyHomecare.ieincorporatingServisourceHealthcaretermsandconditionsofemployment.MyHomecare.ieincorporatingServisourceisauthorisedtoacquireanyinformationsoughtconcerningtheapplicationandregardingmyworkcharacterorskillsandthatthisinformationmaybeforwardedtopotentialemployers.IagreetotreatasconfidentialanyinformationreceivedconcerningthebusinessofMyHomecare.ieincorporationServisourceHealthcareoritclients.MyHomecare.ieincorporationServisourceHealthcarewillnotbeliableforprofessionalnegligence,errors,omissions,oraccidentswhilstyouareunderthehirerscustodyorcontrol.Signed:PrintName:Date:WorkingTimeReguIationTheEuropeanUnionhas1aiddownguide1inesformaximumworkingweek,whichitiSdeemedsafetowork.averagenetweek1yworkingtimeof48hoursperweekoveraperiodof16wceks.CopyofWorkingTimeRegulationActisavailabletoyouuponrequest.IconfirmthatIhavereadandunderstandtheinformationregardingtheworkingtimeregulationsanditismyresponsibilitytoadheretosame.Signed:alIworkersgoverningtheIengthoftheThecurrent1imitisamaximumPrintName:Date:HomecareAssistantAppicationHandWashingTechniqueDeclarationHandwashingisthesinglemostimportantprocedureintheimplementationofinfectioncontrol.Itisessentialtowashhandsfrequentlyandcorrectly.Al1employeesofincorporatingMyHomecare.ieareobiigedtofollowhandwashingprocedureswhilstonduty,accordingtotheHSEGuidelinesforHandWashingTechnique.CopyoftheHandWashingTechniqueisavaiIabletoyouuponyourrequest.IconfirmthatIhavereadandunderstandtheinformationregardingtheworkingtimeregulationsanditismyresponsibilitytoadheretosame.Signed:PrintNamc:Date:CriminalDeclarationPleasenotethisCriminalDeclarationmustbewitnessedbyeither:CommissionerofOalh,Solicitor,PeaceCommissioner,NotaryPublicIUnderroadtrafficIegislation),eiIherinIrclandorinanyotherstate;havencverbeenarresIedfororconviCtedofanyoffenccorcrime(otherthananoffenceofanyoffenceorcrime(otherthananoffenceunderroadtrafficlegisIationforwhichapena1tyOfimprisonmentisnotenforceable);haveneverbeenthesubjectofapardonoramnestyorothersimiIarlegalactioninrespectIhaveneverunlawfulIydistributedorsoldacontrolIedsubstance(drug)：IamnotcurrentIynorhaveIofanystateinrelationtothecommissionofacrime(otherthananoffenceunderroadtrafficIegislationforwhichapenaItyofimprisonmentiSnotenforceab1e);everbeenundcrinvestigationbyIheGardaSiochanapo1iceforceIbyanyprofessionalorstatutorybodywithresponsibiIityforregulationofthenursingormcdicalprofessions.IherebyauthorizeMyHomecare.iethere1evantHea11hcarerganisationstomakeforthepurposeofverifyinganypartofthisdecIaration,AnGardasiochanaandzorwiththeregulatorybodyofthenursingormedicalprofessionsanystate.Thisdatawi11beprocessedbytheHospitaIandthegencyinaccordanccwithDateProtectionActs,1988and2003.amnotcurrent1ynorhaveeverbeenthesubjectofdisciplinaryactionincorporatingServisourceandenquiries,withoftheSigned:Date:Witnessedby:Date:OfficialVACCINTTONIIMM1.NESTTUSHISTORYStamp:MyHomecare.ieincorporatinisanimportantdocumentthaWeneedyoutocomp1CteandreDunda1k,Co1.outh.PleaseensurewhencompIeFu11name(andanyAddressesPlease1Pleaseensurethat,NAMEinB1.OCKCAPleasewritelegiblyinbIacordermadepayabletoSerUponsuccessfulcompIetionoCHeaIthcareRecruitmentConOnceagainthankyoufortakinworkingWithyouinthenearfuKindregards,HelenStringerHomecareManagerHomecareAssistantApplicationgServisourceHealthcareseeksGardaVettingfoatneedstobecompletedasinstructedbelow,eturntheformtOusatServisource,Unit3,QuaysideBetingtheGardaformthatyouhavealIthefollowingpreviousnames)istal1addressessincebirthincludinganyfromovonthe2ndpage,underyoursignatureyoucompPITA1.Sckpenandreturnthecompletedformwith15rvisourceHealthcare.fthisapplicationformyourMyHomecare.ielServisnsultantwillarrangetomeetyou.ngthetimetocompetethisapplicationformandwcluture.orallapplicants.ThisBusinessPark,details:verseaspleteyourFU1.1.5chequepostalsourcelookforwardto