Please Use Black Ink and Write Clearly. Please Refer to Guidance Notes

APPLICATION FORM

Please use black ink and write clearly. Please refer to guidance notes.

1JOB DETAILS

Application for Post of: Healthy Families Fit for Life (HFFL) Support Worker

Grade JNC point 21-27-(21hrs) Post Ref: HFFL-09-12

Where did you see the post advertised?

2 PERSONAL DETAILS

Title (Mr, Miss, Mrs, Ms, other):

Forename(s):Surname:

Previous Surname: Known as:

Address: Postcode:

N.I Number:

Do you hold a current driving licence?YesNo

If yes, do you have access to a car?YesNo

Contact Details:

Daytime:Evening:Mobile:

3PRESENT / LAST EMPLOYER

Name of Organisation:

Contact Name:Telephone Number: Address: Postcode:

Dates From:To: Position Held:

Main duties / responsibilities: Level / Grade:

Salary:Benefits package:

Period of notice required: If last employer – reason for leaving:

If present employer – reason for this application:

4 PREVIOUS EMPLOYMENT

Please provide details of your previous employment, accounting for any gaps. You should use a separate box for each position held, starting with the most recent and work back.

5QUALIFICATIONS

a)Please give details of qualifications attained starting with your secondary education and working up to present day. Continue on a separate sheet as required.

Qualification / Level –
e.g. GCSE, NVQ, BSc
+ grade / Date achieved /
expected to achieve

6TRAINING

Please give details of any training and development you have completed, including vocational training that you feel is relevant to your application and not covered by any other section.

Date / Training / Development / Provider / Duration

7MEDICAL HISTORY

Please give details of any occasions of absence from work in the last two years. Your employment will be subject to the satisfactory completion of a pre-employment medical questionnaire.

a)How many episodes of illness have you had during the pasttwo years?
EPISODES ______
b)How many days in total have you been ill and unfit for work over the same two year period?
DAYS IN TOTAL ______
Please provide any comment you wish to make regarding your health or attendance record:

8LEISURE INTERESTS

Please tell us what you enjoy doing in your spare time

9ADDITIONAL INFORMATION

The following section will ensure we successfully recruit people who believe in and can demonstrate the behaviours and values sought by Walton Youth Project.

a)Please use this space to explain how you meet the specific requirements in the enclosed Person Specification and Job Description, including any personal / life experiences which you feel may be relevant to this position. Please continue on a separate sheet if necessary.

b)Are you willing to work weekends, nights and overtime when required?

YesNo

10THE REHABILITATION OF OFFENDERS ACT 1974 (EXEMPTION ORDER1975)

If you have any previous convictions (for this position, you must not withhold information about convictions or cautions which for other purposes are “spent” under the provision of the Act) – please enter any details below. Failure on your part to do so could result in subsequent dismissal. Any information given will be completely confidential.

Have you ever had a Criminal Records Bureau/Enhanced Disclosure Scotland check made by an employer?

YesNo If yes, when was it requested and was it approved?

As the Walton Youth Project meets the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974 (Exemption Order 1975), all applicants who are offered employment will be subject to an enhanced criminal record check from the Criminal Records Bureau before the appointment is confirmed. This will include details of cautions, reprimands or final warnings, as well as convictions.

11PROFESSIONAL REFERENCES

These must be your manager, not colleagues (we reserve the right to contact all previous employers).

1. Name: / 2. Name:
Company: / Company:
Position: / Position:
Address: / Address:
Telephone: / Telephone:
Fax: / Fax:
Email: / Email:
3. Name: / References will be sought before a job
Company: / offer is made. Please indicate below if this
Position: / is acceptable.
Address: / Reference 1. Yes No
Reference 2. Yes No
Telephone:
Fax: / Reference 3. Yes No
Email:

12DECLARATION

I certify that the information given by me in this application is accurate and complete to the best of my knowledge. I understand that if any of these statements are found to be false, this will be grounds for dismissal. I also understand that at least the first three months of employment will be a probationary period.

Signed: Date:

DIVERSITY MONITORING FORM

This form must be forwarded to the Human Resources Department for monitoring

We are currently striving to be an equal opportunities employer. The aim of our policy is to ensure that no job applicant or employee receives less favourable treatment on the grounds of race, ethnic or national origin, political opinion, sex, marital status, sexual orientation, disability, or age or is disadvantaged by conditions or requirements which cannot be shown to be justifiable.

We are committed to an ongoing programme of action to make this policy fully effective. To ensure that this policy is fully and fairly implemented and monitored, and for no other reason, would you please provide the following details.

Are you:

MALE / FEMALE

What is your date of birth?:

What would you describe as your ethnic origin?:

WHITE:
British / Irish
Any other white background
MIXED:
White and black Caribbean / White and black African
White and Asian / Other mixed background
ASIAN OR ASIAN BRITISH:
Indian / Bangladeshi
Pakistani / Other Asian background
BLACK OR BLACK BRITISH:
Caribbean / African
Any other black background
OTHER ETHNIC GROUPS:
Chinese / Any other
PREFER NOT TO SAY

Disability

Disability is a physical or mental difficulty which has a major and long-term negative effect on a person’s ability to carry out normal day-to-day activities.

In these terms do you consider yourself to have a disability? Yes  No 

Signed: Date:

Full Name:

PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE

Name …………………………………………

Position applied for …………………………………………

The information below is requested with your interests in mind and you are asked to complete all the questions. Should this information give rise to concern for your health, you may be required to attend a medical examination conducted by a doctor appointed by Walton Youth Project.

A.Have you at any time: / Yes / No / Please give details
Been refused or dismissed from employment due to health reasons?
Received a disability pension?
Been registered disabled?
Been made ill by your work
Been refused a driver's licence because of ill health?
B.Do you suffer from, or have you ever had:
Diabetes / Yes / No / Skin rashes/eczema / Yes / No / Back problems / Yes / No
High blood pressure / Yes / No / Headaches (frequent) / Yes / No / Hearing problems / Yes / No
Asthma / Yes / No / Heart trouble / Yes / No / Eye problems / Yes / No
Cough (frequent) / Yes / No / Chest trouble / Yes / No / Nerve problems / Yes / No
Rheumatic fever / Yes / No / Fainting or dizziness / Yes / No / Any mental illness / Yes / No
Arthritis / Yes / No / Hay fever / Yes / No / Dermatitis / Yes / No
Epilepsy/fits / Yes / No / Jaundice / Yes / No
Do you have any current medical condition that the Company first aiders should be made aware of?
Do you require treatment by hypodermic needle? / Do you take medicine regularly? / Have you worked in a dusty trade? / Have you ever had a head injury?
Yes / No / Yes / No / Yes / No / Yes / No
C.Have you ever suffered from, or are you a known carrier of:
Diphtheria / Yes / No / Poliomyelitis / Yes / No / Typhoid / Yes / No
Dysentery / Yes / No / Meningitis / Yes / No / Paratyphoid / Yes / No
Diarrhoea / Yes / No / Scarlet Fever / Yes / No / Type 'A'
Infectious Hepatitis / Yes / No
Enteritis / Yes / No / Small Pox / Yes / No / Type 'B' Hepatitis / Yes / No
Erysipelas / Yes / No / Tuberculosis / Yes / No / Any notifiable disease / Yes / No
Gastro Enteritis / Yes / No / Persistent Vomiting / Yes / No
Any Salmonella
Infection / Yes / No / Cholera / Yes / No
D.Do you have any disability of any type which may require the Company to make any adjustments to your working conditions? If yes, please give details:-
E.To the best of my knowledge and belief the information given above is correct. I understand that if I am appointed and this information is found to be inaccurate or misleading, the Company may terminate my employment.
Signature...... ……...... Date:...... ……………………......

Procedure/Guidance

Recruitment of Ex-Offenders

As an organisation using the Criminal Records Bureau (CRB) Disclosure service to assess applicants’ suitability for positions of trust, Walton Youth Project complies fully with the CRB Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a Disclosure on all basis of a conviction or other information revealed.

Walton Youth Project is committed to the fair treatment of its staff, potential staff or users of its services, regardless of race, gender, religion, sexual orientation, responsibilities for dependants, age, physical/mental/disability or offending background.

We have a written policy on the recruitment of ex-offenders, which is made available to all Disclosure applicants at the outset of the recruitment process.

We actively promote equality of opportunity for all with the right mix of talent, skills and potential and welcome applications from a wide range of candidates, including those with criminal records. We select all candidates for interview based on their skills, qualifications and experience.

A Disclosure is only requested after a thorough risk assessment has indicated that one is both proportionate and relevant to the position concerned. For those positions where a Disclosure is required, all applications forms, job adverts and recruitment briefs will contain a statement that a Disclosure will be requested in the event of the individual being offered the position.

Where a Disclosure is to form part of the recruitment process, we encourage all applicants called for interview to provide details of their criminal record at an early stage in the application process. We request that this information is sent under separate, confidential cover, to a designated person with Walton Youth Project and we guarantee that this information will only be seen by those who need to see it as part of the recruitment process.

Unless the nature of the position allows Walton Youth Project to ask questions about your entire criminal record, we only ask about ‘unspent’ convictions as defined in the Rehabilitation of Offenders Act 1974.

We ensure that all those in WYP who are involved in the recruitment process have been suitably trained to identify and assess the relevance and circumstances of offences. We also ensure that they have received appropriate guidance and training in the relevant legislation relating to the employment of ex-offenders e.g. the Rehabilitation of Offenders Act 1974.

At interview, or in a separate discussion, we ensure that an open and measured discussion takes place on the subject of any offences or other matter that might b e relevant to the position. Failure to reveal information that is directly relevant to the position sought could lead to withdrawal of an offer of employment.

We make every subject of a CRB Disclosure aware of the existence of the CRB Code of Practice and make a copy available on request.

We undertake to discuss any matter revealed in a Disclosure with the person seeking the position before withdrawing a conditional offer of employment.

Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the position and the circumstances and background of your offences.