Care Worker Application Form

Gaps in Your Employment History

Please account for all gaps in your employment. For any period of unemployment, include dates and — where applicable — the address of the Department of Employment where you registered.

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Training Achieved

Please provide information on any training courses completed. If none, type “N/A” in the first row. Include relevant certificates such as Manual Handling, First Aid, Safeguarding, Medication Administration, etc.

Please provide the names of at least two referees, one of whom MUST be your present or last employer. In line with CQC requirements, all previous employers in health, social care, or work with children or vulnerable adults should be listed (with no time limit). All applications for references will be made in the strictest confidence, after first having obtained your permission. Please inform your referees that you have used their name.

Reference 1

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Reference 2

Disability

Rania Support Care has a policy of interviewing applicants who have a disability and who meet the essential short-listing criteria. The Equality Act 2010 defines disability as a physical or mental impairment which has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities.

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Rehabilitation of Offenders Act (1974) Declaration

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Signature

By signing below you confirm that the information provided in this section is accurate to the best of your knowledge.

Your GP Details

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Vaccination & Immunisation Record

Please indicate whether you have been vaccinated or tested. Include dates where known.

Vaccination / Test	Yes	No	Details & Dates (if Yes)
Hepatitis B	Yes	No	Details
Hepatitis B Antibodies	Yes	No	Details
HIV Test	Yes	No	Details
Tetanus	Yes	No	Details
Tuberculosis (TB) & BCG	Yes	No	Details
Rubella (German Measles)	Yes	No	Details
Poliomyelitis	Yes	No	Details
Typhoid	Yes	No	Details
Varicella (Chickenpox)	Yes	No	Details
Mantoux / Tine / Heave Test	Yes	No	Details
Covid-19	Yes	No	Details
Last Chest X-Ray	Yes	No	Details
Others (please specify)	Yes	No	Details

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Health Conditions

Please indicate if you have ever suffered from any of the following. If ‘Yes’, please provide details in the box provided. This information is kept completely confidential.

Condition	Yes	No	Details (if Yes)
Skin complaints (dermatitis, psoriasis, eczema)	Yes	No	Details
Diabetes or glandular complaints	Yes	No	Details
Headaches or migraine	Yes	No	Details
Hypertension / heart problems / similar illness	Yes	No	Details
Back pain / back injury or problems	Yes	No	Details
Jaundice / Hepatitis	Yes	No	Details
Epilepsy or fainting attacks	Yes	No	Details
Pleurisy / Bronchitis / Pneumonia	Yes	No	Details
Asthma	Yes	No	Details
Infections — ear / sore throat (recurrent)	Yes	No	Details
Psychiatric illness / mental health / depression	Yes	No	Details
Currently receiving injections or taking medication	Yes	No	Details
Under treatment for any condition	Yes	No	Details
Major operations (past)	Yes	No	Details
Physical disabilities	Yes	No	Details

Supporting Statement

Please add your reasons for applying. You should refer to the job description and person specification. It would also be of value to describe particular strengths and talents that set you apart from others, including skills gained from work, home and other activities.

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Values Based Screening Questions

Please complete the questions below before attending any interview. Your answers will be discussed as part of the interview process. There are no right or wrong answers — we are looking to understand your values and approach to care.

Personal Details

This section is held separately from your main application and is not seen by the shortlisting panel.

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Gender

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Marital Status

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Age

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Ethnicity

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group you feel you belong to. Please select the option that best describes you.

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Disability or Health Condition

The Equality Act 2010 defines disability as a physical or mental impairment that has a substantial and long-term effect on the ability to carry out normal day-to-day activities.

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Sexual Orientation

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Working Pattern

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Flexible Working

Please tick all that apply to your current or most recent role. If you are not currently working, please tick “None”.

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Caring Responsibilities

Do you have caring responsibilities? Please tick all that apply.

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