Application for Employment

Transcription

1 1 Application for Employment Applicant s Full Name: Any previous names Preferred Name: Position Applied For: Contact Phone Numbers: Work: Mobile: Home: Address: Information for applicants Forté Health s objective is to recruit (fairly) the best applicant for the position using all the available information. We ask that you cooperate by providing full details in this application form and during the selection process. This information will be used for the purpose of evaluating your suitability for employment with Forté Health. If you are employed, the information collected will be retained as part of Forté Health 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 If you are not employed by Forté Health, 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. Forté Health 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.

2 2 SECTION A. ALL APPLICANTS TO COMPLETE 1. General Information 1.1 Are you a permanent resident of New Zealand? If not, do you have a work permit? Please note, you will be required to provide evidence of eligibility to work in New Zealand should you be successful. We will require an original primary identity document to verify your identity eg passport, NZ Birth certificate, NZ citizenship certificate We will require an original secondary identity document eg New Zealand driver licence, New Zealand 18+ card, New Zealand student photo ID number, Inland Revenue number 1.2 Are you fluent in any languages other than English? If yes, please list languages you are fluent in: N/A 1.3 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? If you have had any convictions you must disclose these to us. Do you give consent for FHL to undertake a Criminal Conviction History Check or Police Vet, using the required forms 1.4 Do you have a current Drivers Licence? If Yes, please specify class(es) covered: 1.5 If the position for which you are applying requires a credit and/or security check (e.g. financial role), any offer of employment will be subject to the completion of these checks. Do you give your consent for Forté Health to undertake these checks if necessary? 1.6 Are you prepared to work rostered shifts if applicable? 1.7 Are you prepared to work overtime if required? 1.8 Do you have a spouse/partner/relative working at Forté Health? If yes, give details and dates:

3 3 2. Qualifications 2.1 Do you have any tertiary qualifications, licenses or other relevant certificates? If Yes, please give details of date qualification received and the awarding body or institution: NOTE. You may be required to provide evidence if requested. Yes No 2.2 Please list any work-related trade, business or professional memberships: 2.3 Please complete if applicable to the role for which you are applying: HEALTH PROFESSIONALS REGISTRATION: Name of Register: (Nurses, Medical, Physiotherapists, Dieticians, etc) Registration No: Name of Specialist Register: Registration No: Annual Practising Certificate No: Valid to: Do you have any other information to disclose regarding your registration status or previous employment or professional disciplinary history.

4 4 3. Employment History (both voluntary and paid) please give details of the last 5 positions you have held 3.1 Present or Most Recent Employer: Name of Company: from: to: Position(s) Held: Main Responsibilities: Number of Hours Worked/Week: Reason for Leaving: 3.2 Next Most Recent Employer: Name of Company: from: to: Position(s) Held: Main Responsibilities: Number of Hours Worked/Week: Reason for Leaving: 3.3 Next Most Recent Employer: Name of Company: from: to: Position(s) Held: Main Responsibilities: Number of Hours Worked/Week: Reason for Leaving:

5 5 3.4 Next Most Recent Employer: Name of Company: from: to: Position(s) Held: Main Responsibilities: Number of Hours Worked/Week: Reason for Leaving: 3.5 Next Most Recent Employer: Name of Company: from: to: Position(s) Held: Main Responsibilities: Number of Hours Worked/Week: Reason for Leaving: 3.6 Please indicate your expected salary/wage range: 3.7 Are you engaged in any other form of employment (apart from your primary position) e.g. secondary part-time employment? If yes, please provide details of employment, including employer, role and hours

6 6 4. Employment Referees If you are an internal Forté Health applicant, please provide your current manager s details as one of your referees. Do you given consent for FHL to contact the referees provided or any other person or organisation necessary to gather information to assess your suitability for the position. Name Their Relationship to You Company Contact Phone Number DECLARATION I, (full name) declare that Forté Health can request verbal or written references from my above named referees and authorise the information sought to be released by them to the organisation. I understand and accept that any references that are obtained by Forté Health will be confidential and will be used by Forté Health solely to evaluate my suitability for employment with Forté Health and due to this being evaluative material (in accordance with the Privacy Act 1993), I will not be entitled to have access to any references obtained. I also declare, to the best of my knowledge, the information given in Section A of the Application for Employment is correct and I understand that if any false or 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: OFFICE USE ONLY Pre- Employment Interviews Please attach completed Interview Questionnaires to Application Form Reference Checks A minimum of 2 reference checks are completed for each candidate. Please attach completed forms. Please continue overleaf

7 7 SECTION B: PRE-EMPLOYMENT HEALTH QUESTIONNAIRE To be completed by all applicants Purpose This information is collected for the purpose of assessing your suitability for employment at Forté Health and could include subsequent changes in employment with Forté Health. The Health & Safety in Employment Act 1992 and its Amendments 2002 require employers to ensure the safety of employees while at work. To assist in achieving this Forté Health require information from applicants to assess their ability to carry out the duties of the position. The following questions reflect the principles of the Health and Safety in Employment Act 1992 and Injury Prevention, Rehabilitation and Compensation Act 2001 and Amendment Act. 1 Do you have any medical conditions which you may require emergency treatment for e.g. epilepsy, diabetes, asthma? 2 Are you at present receiving medical treatment and/or taking any medication which may be relevant to your application? e.g. mental health treatment, cardiac conditions, TB 3 Do you have you any allergies or sensitivities to any substances or chemicals, (e.g. food types, latex, chemicals)? 4 Do you agree to undergo a medical examination if required?

8 8 5 Have you ever claimed Accident Compensation Claim /Sickness Benefit? If yes, please give details of the type of injury, whether it was work related or not or required time off work. Please include all work related ACC claims you have lodged within the past five years: 6 Have you ever had any back, neck, shoulder, leg problems, OOS (Occupational Overuse Syndrome), Repetitive Strain Injury problems or any other physical conditions that may affect your ability to carry out the functions and responsibilities of the position applied for? 7 Do you have any condition/s, injury or special needs which may be aggravated by the proposed position or may affect your ability to effectively carry out the functions and responsibilities of the position applied for? 8 Is there anything else we need to know that you would prefer not to state here? Please discuss with your recruiting manager. 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. The recruiting manager should refer to the Pre-Employment Health Questionnaire (Section 7 in the Health & Safety Manual) for further advice. 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 Section B 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:

9 9 SECTION C. 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? 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. (a) Have you worked or been a patient in a healthcare facility in New Zealand in the last 6 months? (b) Have you worked or been a patient in a healthcare facility overseas in the last 6 months? 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. (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. (b) Have you had a BCG (TB Immunisation) If yes, please advise date: Have you, close family or anyone in your household ever been treated for tuberculosis? If yes, where? Have you worked in a healthcare facility in NZ or overseas or visited overseas in the past 12 months? If yes, please state: Have you lived overseas in the past 12 months? If yes, please state:

10 10 Chemical Hazards Have you ever worked with chemicals, such as glutaraldehyde and/or formaldehyde etc? Have you worked with any chemical substances that have caused respiratory difficulties, skin irritations, etc? If you have answered Yes to either of these questions, you will be required to complete the Exposure to Chemicals Health Questionnaire Section D. This form is located within the Pre- Employment Guidelines (Section 7) in the Health & Safety Manual. Transmissible Disease Are you suffering from or been in close contact with any diseases that may pose a risk of infection to others? Eg. MRSA, TB, Hepatitis A, B or C, HIV/AIDS, CJD. If yes, give details including type and dates Confidentiality and sensitivity is maintained at all times. NOTE: 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 and the recruiting manager should refer to Pre-Employment Health Questionnaire & Screening Guidelines for further advice. 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 I, (please print full name) declare that, to the best of my knowledge, the information given in Section C of the 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: