CONFIDENTIALAPPLICATION FOR EMPLOYMENT

Thank you for taking the time to complete this form. It is an important source of information which will form part of your personnel record. If you are employed, the information collected will be retained as part of Christchurch Eye Surgery’s HR records. You will have the right to access and request correction of this information. The information will be stored accordance with the Privacy Act 1993 and Health Information Privacy Code 1994.

If you are not employed by Christchurch Eye Surgery, this information will be destroyed unless you request otherwise. The completion of this form does not indicate there is any obligation on the company to engage the applicant.

All information you provide is strictly confidential and will not be shown to anyone who is not authorised to access it. You will be entitled to access this information on request.

Failure to provide information could affect our ability to assess your suitability for the position.

Christchurch Eye Surgery is an Equal Opportunity Employer. We employ, train and promote without regard to race, colour, national or ethnic origin, sex, sexual orientation, marital status, religious/ethical belief, age, employment status, political opinion, family status, employee representation or disability in accordance with the Human Rights Act 1993, The Privacy Act 1993, The Employment Relations Act 2000, The Vulnerable Children Act 2014.

Offers of appointment will be subject to originals of certificates, work permits and other documentation relating to your application being sighted.

Title: / Mr / Mrs / Ms/ Miss / Dr
Applicants Name:
If known by other name:
Contact Phone Number: / Work:
Mobile: Home:
Email:
Position Applied for:
Date of Application:
Address:
IRD Number:
PERSONAL DETAILS / GENERAL INFORMATION
Name of next of kin: Telephone No:
Relationship to you
Drivers Licence No: / Classes Covered by Licence:
I am a New Zealand or Australian Citizen; or Yes No
* I am legally entitled to accept employment in New Zealand Yes No
* Please attach a copy of work permit or proof of residency
Are you fluent in any language other than English?  Yes (please state below) No
Have you been convicted of any criminal offence which is not eligible to be concealed under the Criminal Records (Clean Slate) Act 2004 or are you awaiting the hearing of any charges?
 YesIf yes, please give details.  No If you have had any convictions you must disclose these to us.
Do you give consent to CESL to undertake a Criminal Conviction History Check or Police Vet, using the required forms?
 Yes  No
If the position for which you are applying requires a credit and/or security check (eg financial roles), any offers of employment will be subject to these checks being completed. Do you consent for CESL to undertake these checks if necessary?
 Yes  No
Are you prepared to work rostered shifts?  Yes  No
Are you prepared to work additional hours if required?  Yes  No

QUALIFICATIONS

Do you have any tertiary qualifications, licenses or other relevant certificates?
If yes please list below with the date of the qualification and awarding institute / body.
Please list any work-related trade, business or professional memberships below:
HEALTH PROFESSIONALS’ REGISTRATION
Do you have:
A Current New Zealand practising certificate: Yes No
Which Register?______
Practising Certificate No:______
Expiry date: ______

Please indicate your expected salary / wage range:

PREVIOUS EMPLOYERS. Please give details of your last three positions.

  1. CURRENT EMPLOYER

Position Held
Employer
Date From:
Area of work
Reason for Leaving

2.

Position Held:
Employer:
Dates From & To:
Area of Work:
Reason for Leaving:

3.

Position Held:
Employer:
Date From & To:
Area of Work:
Reason for Leaving:
HEALTH QUESTIONNAIRE

This information is required to assist us in meeting our obligations under the Health & Safety in Employment Act 1992, and its Amendments 2002 and the Accident Rehabilitation and Compensation Act 1992.

Have you had or do you currently have any injury or medical condition or disability that may affect your ability to effectively carry out the functions and responsibilities of the position you are applying for?
 Yes No
If YES, please detail:
Do you have any medical conditions which may require emergency treatment; ie. Epilepsy, diabetes, asthma?
 Yes No
If YES, please detail:
Are you allergic or sensitivities to any substances; including food, latex, chemical, medications?
 Yes No
If YES, please detail:
Have you ever suffered from any of the following? If Yes, please specify
• Hepatitis B or C Yes / No
• MRSA Yes / No
• Any mental illness Yes / No
• Spinal disability / Back injury Yes / No
• TB Yes / No
• Gradual process injury (e.g. 00S, RSI) Yes / No
• Dermatitis or Eczema Yes / No
Have you had a claim accepted by ACC in the last five years? YES / NO

The Pre-employment Health Questionnaire must be fully completed with results of tests and relevant reports received before a job offer can be made, as appropriate. Any indications of health problems or previous work related injuries or disease should be discussed in more detail.

Once employed, if your health status significantly changes and affects your ability to perform your duties, it is your responsibility to inform your manager as soon as possible.
DECLARATION / DISCLAIMER
I, ______(please print full name) declare that, to the best of my knowledge, the information given in this Section of this Application for Employment is correct and I understand that if any false or deliberately misleading information is given, or any material suppressed, I will not be accepted, or if I am employed, my employment may be terminated.
Signature of Applicant: ______Date: ______

PRE-EMPLOYMENT HEALTH SCREENING QUESTIONNAIRE

CLINICAL ROLES ONLY

To be completed by all applicants who have direct patient contact or work with hazardous waste e.g. linen, infectious materials etc.

HEPATITIS B
Do you have Hepatitis B immunity?  Yes No
If yes, please enclose laboratory result.
If no, you will be required on employment to undertake the Hepatitis B immunisation programme to ensure your safety from contracting Hepatitis B
MRSA (Methicillin- Resistant Staphylococcus Aureus)
Have you been found to be previously infected or colonised with MRSA?
If yes, please enclose recent laboratory result of MRSA clearance. / Yes  / No 
(a) Have you worked or been a patient in a healthcare facility in New Zealand in the last 6 months? / Yes  / No 
(b) Have you worked or been a patient in a healthcare facility overseas in the last 6 months? / Yes  / No 
If you have answered yes, you will be required to undertake MRSA testing prior to an offer of employment.
TUBERCULOSIS
Do you have evidence of a recent mantoux test for TB within the last 12 months?
If yes, please enclose laboratory result. / Yes  / No 
(a) Have you had Mantoux (injection under skin on forearm)?
If yes, please advise date: ______
If no, prior to commencing employment, you will be required to undertake the mantoux test. / Yes  / No 
(b) Have you had a BCG (TB Immunisation) If yes, please advise date: ______ / Yes  / No 
Have you, close family or anyone in your household ever been treated for tuberculosis?
If yes, where? ______ / Yes  / No 
Have you worked in a healthcare facility in NZ or overseas or visited overseas in the past 12 months?
If yes, please state: ______/ Yes  / No 
Have you lived overseas in the past 12 months?
If yes, please state: ______/ Yes  / No 
VARICELLA
Have you ever had chicken pox?  Yes No
Have you ever been tested for Varicella?  Yes No
If yes, please advise date: ______

REFEREES

Please give details of two referees, recent employers are preferred from whom we can obtain verbal or written on your work, background and experience.

Name of Referee
Job Title
Work Relationship to you
How long you have known them for
Contact details – Phone number
Email
Name of Referee
Job Title
Work Relationship to you
How long you have known them for
Contact details – Phone number
Email

DECLARATION

I consent to the company obtaining confidential verbal or written information about me from my nominated referees or the author of any written reference or statement of service that I have provided for the purpose of assessing my suitability for this position.
I declare that the information I have supplied in this application (and other supporting information including the attached CV) is true to the best of my knowledge. I accept that false declaration or failure to disclose relevant information could result in my immediate dismissal.
Name of Applicant:______
Signature of Applicant:______
Date:______

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