Casual Support Worker Application Form V1 Nov 14
User Manual: Application-Form-Support-Worker-v1-Nov-14
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Office Locations CONFIDENTIAL Casual Support Worker Application Form All information is collected in accordance with National Privacy Principles 1.3 and 1.5 PARAQUAD SA (PQSA) / HomeCare+ is committed to ensuring an effective and efficient recruitment process which is transparent, professional and timely. The recruitment process will be fair and equitable based on merit and complying with legislation to promote a diverse workforce. Equality of employment opportunity and selection on merit is a guiding principle of PQSA / HomeCare+. Please write clearly and endeavour to answer all questions, even if answers have been given in an accompanying CV. Should this application be successful, this form will be the basis of a personnel record. Write N/A (not applicable) if the question is not appropriate to your application. Referral source: □ Radio □ Advertisement □ Friend 1. Other: ________________________ PERSONAL DETAILS Title: Mr / Mrs / Miss / Ms (Please circle) Head Office 28 Lower Portrush Rd PO Box 396 MARDEN SA 5070 Ph 8355 3500 Fax 8355 3511 South East Shop 6, Ripley Arcade, MOUNT GAMBIER SA 5290 Ph 8723 3788 Fax 8723 1660 Riverland 7 Riverview Drive PO Box 210 BERRI SA 5343 Ph 8582 4654 Fax 8582 4491 Mid North 4 Swan Street PO Box 1639 PORT PIRIE SA 5540 Ph 8632 2122 Fax 8632 2122 Eyre Peninsula 6 Bligh Street PO Box 623 PORT LINCOLN SA 5606 Ph 8683 3188 Fax 8682 1267 Yorke Peninsula 31 Hallett St PO Box 249 KADINA SA 5554 Ph 0420 924 883 Family name: _________________________________ Given name: __________________________________ Preferred name: _______________________________ Current residential address (a post office box is not acceptable as a residential address) ____________________________________________ Phone Home ( ) _______________________ __________________________Postcode __________ Mobile ___________________________ Address for correspondence Fax ( ) _______________________ (if the same as your residential address, write “AS ABOVE” ) ____________________________________________ Email ____________________________ __________________________Postcode __________ Place of Birth: Town / City, Country: _____________________________________________ Do you wish to identify yourself as: □ Aboriginal □ Torres Strait Islander Are you an Australian Citizen? Yes / No If No: Visa Status ________________________ Work Restrictions: __________________________ Passport Number: ________________________ Expiry Date: _____/_____/_____ (A copy of Passport will be required) Do you hold a current drivers licence? Yes / No (A copy of current Drivers Licence will be required) Drivers licence number: _________________ State: ______ Class: _______ Expiry Date: ____/____/_______ Are you a member of a Job Network? Yes / No Casual Support Worker Application If Yes: Name of Job Network: ________________________ v1 Nov 14 1 2. EDUCATION AND TRADE QUALIFICATIONS (If resume submitted refer point 3) Secondary Schooling School Attended: _____________________________________ From______________ to _____________ Give details of all post secondary qualifications (Copies of all support documentation will be required e.g. certificates) (List your most recent qualification first) Institution and City: ___________________________________ From______________ to _____________ Qualification: _________________________________________ Year Completed: _______________ Subjects/Modules completed Institution and City: ___________________________________ From______________ to _____________ Qualification: _________________________________________ Year Completed: _______________ Subjects/Modules completed Are you currently undertaking studies? Yes / No Institution and City: ___________________________________ From______________ to _____________ Qualification: _________________________________________ Anticipated Completion: ________________ Subjects/Modules completed ________________________________________________________________________________________ Would you be willing to undertake a traineeship in Certificate III Home and Community Care? Yes / No Copies of all support documentation will be required eg. Certificates Casual Support Worker Application v1 Nov 14 2 3. EMPLOYMENT DETAILS (If resume submitted refer point 4) Give details of your employment for your last four (4) positions (Please list your most recent experience first) From ___________ to ____________ Employer: __________________________________________________ Position held: __________________________________ Type of business:_______________________________________ Employer Address:___________________________________________________________________________ Duties:____________________________________________________________________________________________ __________________________________________________________________________________________________ Reason for leaving: __________________________________________________________________________________ From ___________ to ____________ Employer: __________________________________________________ Position held: __________________________________ Type of business:_______________________________________ Employer Address:___________________________________________________________________________ Duties:____________________________________________________________________________________________ __________________________________________________________________________________________________ Reason for leaving: __________________________________________________________________________________ From ___________ to ____________ Employer: __________________________________________________ Position held: __________________________________ Type of business:_______________________________________ Employer Address:___________________________________________________________________________ Duties:____________________________________________________________________________________________ __________________________________________________________________________________________________ Reason for leaving: __________________________________________________________________________________ From ___________ to ____________ Employer: __________________________________________________ Position held: __________________________________ Type of business:_______________________________________ Employer Address:___________________________________________________________________________ Duties:____________________________________________________________________________________________ __________________________________________________________________________________________________ Reason for leaving: __________________________________________________________________________________ 4. REFERREES Nominate three (3) people other than relatives or personal friends. 1. Name __________________________________ Organisation:__________________________________ Relationship: Manager / Supervisor / Co-worker Other: _______________________________________ Phone: _________________________ Mobile: ______________________________________ 2. Name __________________________________ Organisation:__________________________________ Relationship: Manager / Supervisor / Co-worker Other: _______________________________________ Phone: _________________________ Mobile: ______________________________________ 3. Name __________________________________ Organisation:__________________________________ Relationship: Manager / Supervisor / Co-worker Other: _______________________________________ Phone: _________________________ Mobile: ______________________________________ Casual Support Worker Application v1 Nov 14 3 5. GENERAL EMPLOYMENT INFORMATION You will be given the opportunity to discuss information provided before any final decision is made about your selection. QUERY YES / NO DETAIL Have you filed an application with HomeCare+ or The Paraplegic and Quadriplegic Association of SA Inc (PQSA) before? Date: Have you ever been employed by HomeCare+ or PQSA? Date: Do you have any relatives currently employed with HomeCare+ or PQSA? BB Are you physically and psychologically able to fulfil the duties of a Support Worker as described in the Position Description? *If you answered yes, please provide details: Do you have any pre-existing illness or injury which may impact on your ability to safely perform the inherent requirements of the position of a Support Worker? The inherent requirements include (but are not limited to) repetitive actions such as bending, stooping, reaching, twisting and physical work such as Manual Handling of clients. Have you ever been discharged from employment? Do you speak any other language or have any other skills, which you believe may be useful as a Support Worker? E.g. Sign language. Do you have or have you applied for a Child Related Employment Screening through DCSI with at least six (6) months validity? Proof of Child Related Employment Screening is a condition of employment. Do you have any objection to a HomeCare+ representative seeking verification and additional information on any matter within this application? Is there anything you know or believe may affect your application? * Medical Clearance will be required under these circumstances. Casual Support Worker Application v1 Nov 14 4 6. AVAILABILITY- Please tick the times when you are available to work. Please be specific in indicating below the times when you are available to work 6am-9am 9am-11am 11am-14pm 14pm-17pm 17pm-21pm 21pm-0000 Overnight 2230-0700 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Please advise of the number of hours per week that you wish to work? ___________________________________________________________________________________________________ The interview and the selection process A selection panel will be made up of two (2) HomeCare+ representatives. The selection panel assesses applications against the selection criteria. Applicants who best meet the selection criteria will be called for further assessment. The selection panel may use a number of methods to assess your ability to do the job including interview questions, work samples, tests and referee checks. Referee check A HR representative will phone your referees if you are one of the best applicants interviewed for the job. Your nominated referees should be able to comment on your recent work performance. The HR representative will ask your referees to comment on your work behaviour and performance and can be asked to verify or comment on claims made by you. Child Related Employment Screening HomeCare+ requires that a Child Related Employment Screening be supplied by all applicants with at least six (6) months validity. A Child Related Employment Screening can be obtained by applying through the Department of Communities and Social Inclusion. All employees of HomeCare+ must renew their Employment Screening every three (3) years. ______________________________________________________________________________ APPLICANTS DECLARATION Please read the following statements carefully; they constitute the conditions under which you may be employed: I _____________________________________________________________ certify that: 1. The information I have provided on this application is accurate to the best of my knowledge and is subject to validation. 2. I have no physical, psychological or other impediment that may affect my ability to carry out the role of Support Worker. 3. I authorise any person who can verify and/or supply additional information to support my application to do so. This may include reference checks and referee reports. 4. I understand and agree that: a) Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of, or if employed, termination of employment. b) b) A DCSI Child Related Employment Screening Check (at my own expense) is a required part of the employment process. 5. I understand that all information concerning PQSA, its members, clients and employees is strictly confidential and any unauthorised disclosure of such information will be regarded as a breach of confidentiality and may result in termination of employment. Applicants Signature: _________________________________ Date: _____/_____/_____ Witness Name: ____________________________________ Signature: _______________________________ Date: _____/_____/_____ Casual Support Worker Application v1 Nov 14 5
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