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HEALTHCARE ASSISTANT APPLICATION FORM

Please complete this form in black ink and complete ALL sections

Position Applied for Care worker

Forename and Surname Kawsar Ahmed

On completion of this form please call the office to book an Interview

on 01902 425500.

Smithridge Healthcare Ltd

Head Office
22 Darlington Street
Wolverhampton
WV1 4HW

Data Protection Statement

The personal information (data) collected on this form, and on the attachments, (which includes the collection of sensitive
personal data) are collected for the purposes of recruitment, personnel administration (for new employees) and monitoring.
Unless you direct otherwise (for example in a situation where you would like this Application kept on file for future vacancies)
the Application Forms (and attachments) of unsuccessful applicants will be destroyed after 6 months. It is the policy of the
Agency to protect, and keep secure, all personal data collected. All personal data is processed for the purposes of
recruitment, and, in the case of successful Applicants, for the satisfactory administration of their employment, and for no other
purpose. Smithridge Healthcare’s records are kept securely in a safe location in line with the Data Protection Act 1998. You
understand that any personal detail held by Smithridge Healthcare, may be accessed from time to time by authorized
inspectors from the Care Quality Commission (CQC) and NHS Framework (Buying Solutions)

Equal Opportunity Statement

The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that
all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital
status, sexual orientation, religion or belief, disability, or offending background .
This employment is not exempt from the provisions of the rehabilitation of young offenders Act 1974 you are not therefore
entailed to withhold information requested by the company about any previous convictions in this country or abroad you may
have, even if in other circumstances these would appear spent. I confirm that the information I have given is true. I understand
that if information given on the application form is found to be false it may result in disciplinary action which could include
dismissal.

Confidentiality
All information you see or hear in the course of your duty is confidential. You must not disclose to any other personal details or
information relating to clients, their medical conditions or company matters.
 Section 1 – Personal Details

Surname: Ahmed Forename(s): Kawsar Title: Mr

Address: 14 St Matthews Close , walsall

Postcode: WS1 3DG

Telephone No: 07732217699 Email:

[email protected]
Which languages do you speak?
(please indicate your first spoken language)

How did you hear about Smithridge Healthcare?

Indeed  Online Search  Social Media  Local Advertisements  Shopping Centre Screen 
Job Centre Referral: Black Country Impact  Workbox Wolves  Wolves At Work  Wolves At Work 18-24 
Other Job Centre Referral (please state) ___________________________________
Referred By A Friend  what is their name ____________________________________
Other (please state) ___________________________________

Section 2 - Experience
Please list your areas of experience or list the condition, disabilities and illnesses you have experience caring for.

Sylhet MAG Osmani Medical Hospital

Sylhet,Bangladesh

- January 2021 to June 2021 (Part time )

- Provided care by administering medications, managing intravenous lines, monitoring patients'
conditions, maintaining records and communicating with doctors
 Section 3 - Preference Regarding Work
Please specify which types of work you would prefer. You should tick all appropriate boxes. The service we give
depends on accurate, up to date information. Please keep us informed of all developments, in your career and
work preferences.

Positions part time full time

Type of work preferred: Nursing Homes Care Homes Supported Living
Other, please specify _______________________

Preferred Shifts: days nights

Do you have any other work commitments? Yes/No

If yes please provide details

No

When will you be available to start work? ASAP

I agree that I may work for more than an average of 48 hours a Signed:
week. If I change my mind, I will give my employer 3 months notice
in writing to end this agreement.
Date: 07/07/2023

Section 4 – Education, Qualifications & Training

*please list all education you have achieved from age 11
(continue on a separate sheet of paper if necessary)

Name of School, University, Date From Date To Name of Qualification

College (month & (month & (GCSE, A Level, Masters etc.)
year) year)
Secondary School Certi cate SCC
Shahjalal Jameya Islamia Kamil January 2019 December 2019
Result : 4.72 (out of 5.00 )
Madrasah. Sylhet ,Bangladesh
Group: Science
Higher Secondary School Certi cate HSC
Shahjalal Jameya Islamia Kamil January 2019 February 2022
Result : 4.88 ( iut of 5.00 )
Madrasah, Sylhet , Bangladesh
Group : Science

Sheffield Hallam university January 2023

fi
fi
 Section 5 – Employment History
*please list all of your employment for the last 10 years
(continue on a separate sheet of paper if necessary)

Company Name & Address Date Started Date Finished Job Title Reason for Leaving
(month & year) (month & year)

Section 6 – Gaps in Education/Employment History

*please list all of the gaps in your education or employment history and the reasons why
(if you have no gaps in your history please leave this section blank

Date From (month & year) Date To (month & year) Reason for Gap
 Section 7 – References
Please list the person’s name, company name, number & email address for 2 care companies you have worked with.
If you only have 1 care company please list that and a character reference.
(continue on another piece of paper if necessary)

Person’s Name Company Name Phone Number Email Address

Section 8 – Passport and Driving License Details

If you have a non EU passport please provide details of your eligibility to work in the UK.

Work Permit Type: Expiry date: / /

(e.g. student, indefinite leave)

Do you hold a valid UK driving license? YES / NO Expiry date: / /

Section 9 – Criminal Records

This position is exempt from the provisions of the Rehabilitation of Offenders Act 1974. You are therefore not entitled to
withhold information requested by the Company about any previous convictions in this country or abroad which you may
have, even if in other circumstances these would be regarded as “spent”.

Do you have any criminal convictions in the UK or abroad? YES / NO

Have you ever been barred from working with vulnerable adults or children? YES / NO

If your answer is yes to either of the above questions, please provide details below:
Have you had a criminal records check? YES / NO
DATE:

Section 10– Next of Kin

Please provide the name & number of 2 people we can contact in case of emergency

Name Phone Number Relationship To You

Saima khatun 00 44 7574 429774 Sister

Shamim Ahmed +44 7543 523122 Brother

Section 11 – Equality & Diversity

Smithridge Healthcare Ltd is committed to equal opportunities. The information you enter on this Equality and
Diversity monitoring form will be used for monitoring purposes only. No applicants will be discriminated against on the
grounds of age, colour, disabilities, ethnicity, gender, race, religious beliefs or sexual orientation. Healthcare organisations
are required to collect details about an applicant’s age, disabilities, ethnicity, gender, religious beliefs and sexual
orientation. This is to ensure they meet their statutory requirements and to encourage the recruitment of a diverse
workforce that represents the communities they serve and this information is collected to fulfil that obligation.
Gender: Male Female Prefer not to say

Sexuality: Heterosexual Homosexual Bisexual Prefer not to say

Other (please state) _______________________

Age: 18-24 25-35 36-45 46-55 56-65 66+

Religion: Atheist Buddhist Christian Sikh Hindu Islam Jewish Prefer not to say

Other (please state) _______________________

White asian
Please state your ethnic origin: ____________________________

Do you consider yourself to have a disability: Yes No Prefer not to say

If yes please state __________________________

 Section 12 – Signature and Candidate Consent

I confirm that the information I have given is true. I understand that if information given on the application form is
found to be false it may result in disciplinary action which could include dismissal. Additionally I
understand that any personal information stored by Smithridge Healthcare, may be accessed from time to time by
authorized inspectors from the Care Quality Commission (CQC). I give permission for these individuals to have
access to my records.

Signed:

Printed: Date:

SKILLS EVALUATION
NAME:

Please tick the box to indicate your level of competence:

1. I am experienced and competent at this
2. I am familiar with this procedure but do not have experience
3. No knowledge

Personal Care 1 2 3 Comments

Bath / Shower
Use of bath aids
Shaving
Assisting clients to dress / undress
Moving / Handling client
Mouth care
Eye care
Pressure area care

Toileting 1 2 3 Comments
Use of commode
Use of bedpans
Catheter / Uro sheath care
Colostomy care
Stoma care

Client observations 1 2 3 Comments

Skin / Nails / Hair
Food and Fluid
Bowels and Bladder
Weight Loss
 Diabetic awareness 1 2 3 Comments
High / Low blood sugar
Food and Fluids
Finger prick
Urine test
Insulin administration

Nutrition and Cooking Skills 1 2 3 Comments

Cooking for clients
Peg feeding
Do you have experience of catering for Yes / No Please state which?
Special diets

General 1 2 3 Comments
Housekeeping
Bed making with sheets / slide sheets
Medication administration
Shopping for clients
Managing house expenses
Report writing
Recording instructions e.g. from GP or District
Nurse
Supporting clients with appointments
Observing changes in clients condition
Experience in emergency situations
Working as part of a multi disciplinary team

Equipment 1 2 3 Comments
Wheel chair
Monkey Pole
Hoist
Walking Frames
Electronic beds / chairs
Air bed
Crutches
Slide sheets
Transfer Boards

I declare that the information I have given is true. I understand that if information given on the application form is
found to be false, it may result in termination of the recruitment process or disciplinary action which could result in
dismissal.

Signed: Date: 07/07/2023