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1、homecareassistantapplication：家庭护理助理的应用MyHomecare.ieReV02HomecareAssistantApplicationThankyouforyourenquiryaboutworkingwithMyHomecare.ie/SerViSoUrCeHealthCareMyhomecare.ieincorporatingpartofServisourceHealthcareplaceHomecareAssistantswithclientsandthroughoutIreland,cover!nglong-term,mediUniandshort-t
2、ermpositions.Ourcompanyspo1icyiStoprovideaconsiStentandqualityservicebVmatchingtheindividua1needsofbothorCareStaffandourClients.Ourofficeisopen7daysaweekfrom7amtol1pm,363daysoftKeyeartoprovidethebestpossibleservice.PleasefillIntherelevantdetaiIsintheapplIcationpackandsenditbacktouswithasmuchinformat
3、iOnasyoucanprovideiminediate1y.AchecklistOfrequirementsisonthefolIowingpagetoassistyou.Pleasebeawarethatallreferencesandqualificationswillbechecked.PleaseSignanddatetheapplicatIonandreturnittoourofficesat:ServisourceOffices:DundalkOfficeUnit3,Floor2,QuaysideBusinessCentre,Dundalk,Co1.outhTel:+353429
4、352723Fax:+353429352724GalwayOffice16aSandyfortBusinessCentre,Bohermore,GalwayTel:+35391762426/761051Fax:+35391762429CorkOffice11AngleseaStreet,CorkTel:+353214279916/4279739Fax:+35391427991DublinOfficeInternationalHouse,TaraStreet,Dublin2Tel:Ol4730474Fax:Ol6334269WaterfordOfficeWaterfordHealthPark,S
5、lievekealeRoad,CoWaterfordTel:1800400900ContactDetaiIsServisourceRecruitmentTeamEmai1:infoervisource,iePleasealsocheckoutourwebsite:pletedwithininthelast2year8ModulesHomecareAssislantApplicationHowhearaboutourAgency?didyouNewspaperNursingMagazinesInternetFriendsOtherPersonalDetailsFirstName:ATTACHSI
6、GNEDPASSPORTPHOTOSSurname:PreviousName:ddressMobiIeNo.HomeNo.WorkNo.EmailAddressGenderDateoCBirthPPSNumberNextofKinContactDetaiIsforNextofKinDoyouholdaGardaNationalImmigrationBureaucard?YesNoIfYespleasestatestampnumberandexpirydatePreferredHealthcareIocationsyouwishtoworkinHomecareAssistantApplicati
7、onTrainingEducationAreyouaStudentNurse?YesNoWhatdisciplineareyoustudying?IfYes,NameofTrainingHospitalPleasenotethatstudentNursesareexeniptfromFETACrequirements.FETACHaveyouconipletedorareyouinIheprocessofcompletingaFETCHealthcareSupportMajorAward?YesNoFETClevel5MajorAwardinHcaltHcarcSupportiscomposI
8、edof8modu1cs.OutoftheseSmodules,5aremandatoryand3areeIective.PIeaseindiCatethemodu1esyouhavecomp1OtedandcncIosedcertifications:MandatoryModules:CareSkillsCareSupportSafetyHealthatWorkElectiveModules:NutritionPractIcalHomecareSkillsCareoftheIderPersonOccupationalFirstAidPalliativeCareCareProvisiOnand
9、PracticeAnatomyandPhysiologyChildDevelopinentHumanGrowIhandDeve1opmentWordProcessingIntroductiontoNursingCustomerServiceCaringforChi1dren(06years)MaternItyCareSupportOperatingDeparUnentCareSki11sIntellectualDisabil1.tyStudiesCommunicationsWorkExperienceCaringforChi1dreninllospitalRehabilitationSuppo
10、rtUnderstandingMentalHealthSocialStudiesPersonalEffectivesintheWorkplaceTeamworkingHaemodialysiSCareSupportActiviticsof1.ivingPationtCareWorkp1aceStatutoryPo1iciesandProceduresTnfectiOnPreventionandContro1WorkplaceFoodSafetyandHygieneFoodSafetyHACCPOtherHomecareAssistantApplicationEmploymentHistoryR
11、cferenccsWerequirenamesandcontactdetailsofyour3refereesfromyourcurrentandmostrecentemployment.RefereesmustbeofManagement1.evelorHigherOnereferencemustbefromyourcurrentormostrecentemployerAnyoffersofapostissubjecttosatisfactoryreferencesCurren11MostReccntEmp1oy11tmtOrganisationPositionHeldDateTo:From
12、:MonthsinPost(1st)Referee,sNameFromCurrentPositionorMostRecentEmploymentRefereesPositionRefereesContactDetaiIsPhone/FaxIEmailHomecareAssistantAppicationPreviousEmp1oyment:OrganisationPositionHeldDateMonthsinPostTo:From:(2nd)Referee,SNameReferee,SPositionRefereesContactDetailsPhone/FaxIEmailOrganisat
13、ionPositionHeldDateTo:From:(3rd)Referee,SNameReferee,SPositionRefereesContactDetailsPhone/FaxIEmailPleasecontinueyourexperienceandemploymentonseparateCurriculumVitaeHomccareAssistantApplicationPersonalPayDetai1sPleasefillinthefolIowinginformationcarefullyandreturnitwithyourapplicationformFirstNameSu
14、rnameAddressMobiIePhoneNumberHomePhoneNumberEmailAddressDateofBirthStaffTypeHomecareAssistantBankIBANCodc:BankSWIFTCode:AccountNumber(8numbers)BankSortCode(6numbers)BankNameAddressPPSNumberHomecareAssistantpp1icationHomecareAssistant,sPleasestatecoursetitleanddurationofcourseorexperienceExperienceCo
15、urseTitleDurationCompetentlevel(1-5)AccidentEmergencyCareofElderlyClinicsComputersDrugsAlcoholHomecareInfectiousDiseasesMedicalMidwiferyPaediatricsPalativeCarePsychiatrySurgicalTheatres/RecoveryOthersSign：Date:一HoniecareAssistantApplicationHealthDeclarationIdeclarethatIunderstand,acceptandconfirmthe
16、entitlementofMyHomccaretorejectmyapplicationorterminatemyemployment(intheeventofacontractofemploymenthavingbeenenteredinto)whereIhaveomittedtofurnishtheAgencywithanyinformationrelevanttothishealthassessmentorwhereIhavemadeanyfalsestatementormisrepresentationrelevanttothishealthassessment.Pleaseanswe
17、rYESorNOandifYES,pleasegivedetailsinthespaceprovided.YesNoDetails1Doyouhave,orhaveyoueverhad,anymedicalconditions,surgery,orspecialinvestigationsi.e.cardiographinthepast5years?2Areyouatpresentattendingadoctorformedicalcare,takinganymedicationoronawaiting1istforhospitalassessmentortreatment?3Haveyoue
18、versufferedaworkrelatediIlncss,injuryorgivenupvorkduetoi11health?4Doyouhaveimpairment/disability(physicalormental)orspecificlearningdisabi1itywhichmayaffectyourabi1itytowork?5Haveyoueversufferedfromtuberculosis(TB)?Withinthepast12monthsHasanyfamilymemberorclosecontactbeentreatedforTB?Haveyouhadacoug
19、hformorethan3weeks?Haveyoucoughedupblood?Haveyouhadanyunexplainedweightloss?Haveyousufferedfromnightsweatsorfever?HomecareAssistantAppication6Haveyoueverhadanykindofback,jointormuscleproblem?7Haveyoueverhad:Dermatitis,Eczema,Psoriasisoranyotherskincondition?8Haveyoueverhadanymentalillnesswhichmighta
20、ffectyourabilitytowork?(includinganxiety,depression,self-harm,eatingdisorders,psychologicaloremotionalproblems)9Haveyoueverhadadrugoralcoholproblem?10Doyouhaveanydifficultywithyoureyesight(includingcolourblindness)?11Doyouhavedifficultywithyourearsorhearing?12Haveyoueversufferedfromanyofthefollowing
21、;lossofconsciousnessincludingfaintingattacks,blackouts,dizziness,epilepsy,fitsorconvulsions?13Haveyoueversufferedfromanyofthefoilowing;heartdiseaseorcirculatoryproblem;includinghighbloodpressure,varicoseveins14Haveyoueversufferedwithchestorlungproblems;Asthma,Bronchitis?15Haveyouanyallergies;includi
22、ngallergiestodrugs,foodorlatex?16Haveyoueverreceivedtreatmentforbowelorgastricproblems?17Haveyoueversufferedadisorderofthebladderorkidneys?18Haveyoupreviouslyworkedinindustrywhereyouwereexposedtoany,hazards,dust,noise,chemicals?19Doyouhaveanyothermedicalconditionnotpreviouslymentionedinquestions118a
23、bove?PreviousSicknessAbsencetimelostfromworkduetoillnessoverlast2years.HomecareAssistantApplicationSigned:PrintName:Date:GPNameI,engthofabsenceReasonforabsenceGPddressGPTelephoneHomecareAssistantApplicationVACCINATION/IMNflJNESTATUSHISTORYTobecompletedandstampedbyanOccupationalHealthProfessional/Gen
24、eralPractitioner.Name:_DateofBirth:Theabovepersonhasthefollowingvaccinationscarriedout.HepatitisB1STDate:2ndDate3rdDate:HepatitisBTitreDate:lusu11：HepatitisBBoost(Date:HepatitisBTitreDate:Result:mIUmlMeasles(Serology)Date:Result:Mumps(Serology)Date:Result:Rubclla(Serology)Date:Result:Varicella(Serol
25、ogv)Date:Result:HepatitisC(Serologv)Date:Result:MantouxTest2TUDate:Result:MantouxTest1OTUDate:Result:BCGScarCheckDate:1.ocation:CompletedSignature:.Title:by:Facility:DateCompleted:OFFICIA1.STAMP:HomccareAssistantApplicationIagreetothefollowing:Iconfirmthattheinformationgivenonthisapplicationformisco
26、mpleteandcorrect.IagreetoMyHomecare.ieincorporatingServisourceHealthcaretermsandconditionsofemployment.MyHomecare.ieincorporatingServisourceisauthorisedtoacquireanyinformationsoughtconcerningtheapplicationandregardingmyworkcharacterorskillsandthatthisinformationmaybeforwardedtopotentialemployers.Iag
27、reetotreatasconfidentialanyinformationreceivedconcerningthebusinessofMyHomecare.ieincorporationServisourceHealthcareoritclients.MyHomecare.ieincorporationServisourceHealthcarewillnotbeliableforprofessionalnegligence,errors,omissions,oraccidentswhilstyouareunderthehirerscustodyorcontrol.Signed:PrintN
28、ame:Date:WorkingTimeReguIationTheEuropeanUnionhas1aiddownguide1inesformaximumworkingweek,whichitiSdeemedsafetowork.averagenetweek1yworkingtimeof48hoursperweekoveraperiodof16wceks.CopyofWorkingTimeRegulationActisavailabletoyouuponrequest.IconfirmthatIhavereadandunderstandtheinformationregardingthewor
29、kingtimeregulationsanditismyresponsibilitytoadheretosame.Signed:alIworkersgoverningtheIengthoftheThecurrent1imitisamaximumPrintName:Date:HomecareAssistantAppicationHandWashingTechniqueDeclarationHandwashingisthesinglemostimportantprocedureintheimplementationofinfectioncontrol.Itisessentialtowashhand
30、sfrequentlyandcorrectly.Al1employeesofincorporatingMyHomecare.ieareobiigedtofollowhandwashingprocedureswhilstonduty,accordingtotheHSEGuidelinesforHandWashingTechnique.CopyoftheHandWashingTechniqueisavaiIabletoyouuponyourrequest.IconfirmthatIhavereadandunderstandtheinformationregardingtheworkingtimer
31、egulationsanditismyresponsibilitytoadheretosame.Signed:PrintNamc:Date:CriminalDeclarationPleasenotethisCriminalDeclarationmustbewitnessedbyeither:CommissionerofOalh,Solicitor,PeaceCommissioner,NotaryPublicIUnderroadtrafficIegislation),eiIherinIrclandorinanyotherstate;havencverbeenarresIedfororconviC
32、tedofanyoffenccorcrime(otherthananoffenceofanyoffenceorcrime(otherthananoffenceunderroadtrafficlegisIationforwhichapena1tyOfimprisonmentisnotenforceable);haveneverbeenthesubjectofapardonoramnestyorothersimiIarlegalactioninrespectIhaveneverunlawfulIydistributedorsoldacontrolIedsubstance(drug)：Iamnotc
33、urrentIynorhaveIofanystateinrelationtothecommissionofacrime(otherthananoffenceunderroadtrafficIegislationforwhichapenaItyofimprisonmentiSnotenforceab1e);everbeenundcrinvestigationbyIheGardaSiochanapo1iceforceIbyanyprofessionalorstatutorybodywithresponsibiIityforregulationofthenursingormcdicalprofess
34、ions.IherebyauthorizeMyHomecare.iethere1evantHea11hcarerganisationstomakeforthepurposeofverifyinganypartofthisdecIaration,AnGardasiochanaandzorwiththeregulatorybodyofthenursingormedicalprofessionsanystate.Thisdatawi11beprocessedbytheHospitaIandthegencyinaccordanccwithDateProtectionActs,1988and2003.a
35、mnotcurrent1ynorhaveeverbeenthesubjectofdisciplinaryactionincorporatingServisourceandenquiries,withoftheSigned:Date:Witnessedby:Date:OfficialVACCINTTONIIMM1.NESTTUSHISTORYStamp:MyHomecare.ieincorporatinisanimportantdocumentthaWeneedyoutocomp1CteandreDunda1k,Co1.outh.PleaseensurewhencompIeFu11name(an
36、danyAddressesPlease1Pleaseensurethat,NAMEinB1.OCKCAPleasewritelegiblyinbIacordermadepayabletoSerUponsuccessfulcompIetionoCHeaIthcareRecruitmentConOnceagainthankyoufortakinworkingWithyouinthenearfuKindregards,HelenStringerHomecareManagerHomecareAssistantApplicationgServisourceHealthcareseeksGardaVett
37、ingfoatneedstobecompletedasinstructedbelow,eturntheformtOusatServisource,Unit3,QuaysideBetingtheGardaformthatyouhavealIthefollowingpreviousnames)istal1addressessincebirthincludinganyfromovonthe2ndpage,underyoursignatureyoucompPITA1.Sckpenandreturnthecompletedformwith15rvisourceHealthcare.fthisapplicationformyourMyHomecare.ielServisnsultantwillarrangetomeetyou.ngthetimetocompetethisapplicationformandwcluture.orallapplicants.ThisBusinessPark,details:verseaspleteyourFU1.1.5chequepostalsourcelookforwardto
