JotForm

Langdale Care Homes - Job Application Form

Thank you for choosing a career with Langdale Care Homes. Please answer all questions carefully.
Care Home: *
Position: *
Full Time or Part Time *
Full Name *

First Name Middle Name Last Name

Current Home Address *

Address Line 1
Address Line 2
Address Line 3	Address Line 4
Post Code	Country

Contact Telephone Number *
When did you move into your current address? *

- Day - Month Year
Date
Important

Have you lived at the current home address given above for more than five years??

For DBS requirements you MUST provide your home addresses over the last 5 years. Incomplete address history (including gaps) will delay your application process

Your previous address (if you have lived at your current address for less than 5 years)

Street Address
Street Address Line 2
City	County
Post Code	Country

From

- Day - Month Year
Date
To

- Day - Month Year
Date
Please list any other addresses where you have resided within the last 5 years. Please state from and to dates.
Email Address *
Date of Birth *

- Day - Month Year
Date
City and Country of birth *
RGN Pin number (RGN applications only)
Absence Details
How many 'single' shift absences (SSA's) have you had in the last 12 months? *
Please detail the most common reasons for any SSA's. If no SSA's please state 'None'. *
How many 'extended (3 days or more) periods of absence (ESA's) have you had in the last 18 months? *
Please detail any periods of ESA's. If no ESA's Please state 'None'. *

Medical Details
Have you ever had a major illness? *
Have you ever been in hospital / had an operation? *
Is there any serious illness in your family? *
Have you ever had any chest trouble ? (asthma / bronchitis) *
Have you ever had ulcers, stomach or bowel problems or hernia? *
Have you ever had any skin diseases, allergies or dermatitis? *
Have you ever had any mild, moderate or severe injuries? *
Have you ever left a job including the armed forces because of ill-health? *
Do you have any hearing loss or ear problems? *
Have you ever been treated for, or suffered from any psychological or mental health problems? *
Do you have a history of diabetes, tropical diseases, kidney or bladder trouble? *
Have you ever had heart trouble / problems with blood pressure? *
Do you suffer from hay fever or sinus problems? *
Have you ever worked with hazardous substances? *
Do you have any problems with vision, colour vision, headaches or eye strain? *
Do you have / have had epileptic episodes or fits, fainting or eye strain? *
Do you have any allergies? *
Have you ever had a workplace injury and/or claimed for a work-related injury? *
Do you suffer from any other medical conditions not mentioned above? *
VERY IMPORTANT ACTION:

If you answered 'Yes' to any of the medical questions above, please provide FURTHER AND FULL DETAILS OF ALL 'YES' DECLARATIONS. State 'None' if all declarations above were 'No'
Details *
Do you have any disabilities and / or injuries that affect the following questions. If you answer 'yes' to any of the questions, please provide additional details in the additional details section. Under certain circumstances you may be asked to see a doctor or nurse for further assessment prior to your employment.
Standing *
Walking *
Climbing Stairs *
Lifting *
Are you currently taking any medication? *
If you are taking any medication please provide more details here. Please state 'None' if applicable. *
Are you registered disabled? *
If you are registered disabled please provide more details here. Please state 'None' if applicable. *
Medical Declaration
Will you require your employer to make any adjustments to the job role due to pre or existing medical issues.? *
Please note if you have answered 'Yes' to the question above the Care Home Manager may need to conduct a 'Risk Assessment' form in regards to any issue(s).

Work Experience / Employment History

Please provide details of the last 5 years or the last 2 employments
Employer *
From *

- Day - Month Year
Date
To *

- Day - Month Year
Date
Position held / key responsibilities *
Employer *
From *

- Day - Month Year
Date
To *

- Day - Month Year
Date
Position held / key responsibilities *
Employer
From

- Day - Month Year
Date
To

- Day - Month Year
Date
Position held / key responsibilities
Please detail any gaps in employment over 3 months during the last 5 years. State 'none' if applicable. *

Because of the nature of the work for which you are applying, this post is exempt from the provision of sec4(2) of the Rehabilitation of Offenders Act (exempt order 1975).

Applicants are therefore not entitled to withhold information about convictions or cautions which are 'spent' under the provisions of the act and in the event of employment, any failure to disclose such convictions could result in disciplinary action or dismissal by the employer.

Any information given will be kept confidential and will only be used in consideration of the position applied for.

Please click here for more details on The Rehabilitation of Offenders Act 1974
Have you ever been convicted or cautioned of a criminal offence? *
If answered 'Yes' to the above please provide details. If no please state 'No' *
Have you ever been dismissed or suspended for any pending case? *
If answered 'Yes' to the above please provide details. If no please state 'No' *

Data Protection and Privacy Statement (in line with the GDPR Regulation guidelines 2018)

The information in this application form is requested in line with Langdale Care Homes privacy statement which can be viewed in full or on our website at www.langdalecarehomes.co.uk or in any of our homes.

If your application is unsuccessful following the interview process, all application forms are destroyed and NOT held on file.

However, if you would like to be considered for a future position within our company, please consent below to allow us to hold your personal information securely for the internal business use and for a future application made by yourself. The information you provided in this form may be used for internal statistical analysis to help with our requirement processes.

Please note that we never share any personal data that would make you identifiable to anyone outside of our organisation and for further assurance, all our employees are subject to following strict confidentiality policies and procedures implemented by our senior management team at Langdale Care Homes Group.
Please tick the box to indicate consent for us to hold your details on file.
Please add any further information in support of your application
Please note that any approval of this 'application' by Head Office is only the first stage of the application process. The homes management team still reserve the right to offer / not offer any employment.
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Langdale Care Homes - Job Application Form