All sections to be completed in full

APPLICATION FORM
Care Assistant
St. Raphael’s Centre, Youghal
Ref No. CAIDS0620
Please return completed application form to:

Section A Please carefully note the following instructions:

 Please ensure you completion all areas of the application form in fill. Failure to complete all areas
of the application form may result in you not being brought forward to the interview stage of the selection
process.

 Please ensure that your completed Application Form reaches this office no later than 12 noon on
Friday 19th June 2020. Applications received after this date and time will not be accepted.

 In relation to details of employment, if the space provided is insufficient, please attach additional pages
ensuring to use the same format.

 Please read the Job Specification which provides useful information about the requirements of these
posts. Please note that the Job Specification is not intended to be an exhaustive list of duties and
responsibilities and may be reviewed to reflect the needs of the service.

 All previous employers may be contacted for reference purposes.

 Should you be invited for interview, you may take a copy of your application form with you.

 The Health Service Executive will run this campaign in compliance with the Code of Practice prepared
by the Commission for Public Service Appointments (CPSA). Codes of practice are published by the
CPSA and are available on http://www.hse.ie/eng/staff/Jobs/ and were sent as an attachment with this
application form.
 The Health Service Executive is an Equal Opportunities Employer.

 The Health Service Executive recognises its responsibilities under the Data Protection Acts 2003 & 1988
and the Freedom of Information Acts 2003 & 1997.

E-mail: [email protected]
Post: Ms. Susan Wall, Interim Director of Centre, St. Rapheal’s Centre, Youghal, Co. Cork

Closing date for applications: Friday 19th June 2020 @ 12 noon

It is anticipated that interviews will be held: Shortly after the closing date

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Applicant Details:
Position Applied for: Care Assistant
Position Reference No.: CAIDS0620

Candidate Reference No (office use only)

Personal Details:
First name :

Last Name:

Address for correspondence:

MOBILE TELEPHONE (mandatory):

Contact Tel No. 2:

E-mail Address (mandatory):

(You may provide more than one)

PPS Number (mandatory):

Where did you see this position advertised?

European Economic Area

Are you an EEA (European Economic Area) National? Yes / No

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 QUALIFICATIONS & ELIGIBILITY CRITERIA
In this area of the application form we ask you to please outline your qualifications and professional
experience.
We will then examine how your particular experience and qualifications meet any specific criteria for the
post of Care Assistant. Educational eligibility will be decided based on the information provided here.
Please note if you omit information in this section pertinent to the eligibility criteria you may be deemed
ineligible and subsequently not called to interview

Please details all information which applies to your individual educational qualification(s) in the space
provided below.

Educational Achievement Date of Award

Name of Course 00/00/0000

A FETAC Level 5/QQI Major Award in Healthcare Support

A Component Certificate will not suffice. A full QQI FET/FETAC major award requires a minimum of 120
credits

Please outline your component (s) and credit values below

Title Level Credit Value

Total =

ADDITIONAL EDUCATIONAL ACHIEVEMENTS

Please include second level and third level educational achievements:

Dates Educational Conferring Body Course of Study Qualification Grades

Institution Achieved Achieved
From
MM/YY
To
MM/YY

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4
 CURRENT CONTRACTUAL STATUS

I am currently a HSE employee* Yes No

Please tick the HSE Area in which you work

Dublin Mid Leinster South

Dublin North East West

If you answered yes to the above question, please choose the option below which best matches your current
contractual status:

 I have a permanent contract

or
 I have a temporary contract

*HSE Employee = you are a direct employee of the HSE and not in a post funded or partially funded by the HSE

What is your current employment title?

Current Grade/ Level as per Consolidated Pay Scales e.g. Senior

Physiotherapist, Clinical Nurse Manager 2, Clerical Officer
Grade III etc.

Date of your appointment to this post

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 DETAILED CAREER HISTORY – listing the most recent first

Please ensure all career history is clearly outlined below (e.g. if you took a career break, spent time out
of work, please include this information so there are no gaps in your career history from when you left
full-time education to present date).

If you work in a part-time capacity please list your monthly hours and total months of work.

From Date To Date Average Total Name of Title of Post List of Duties
00/00/00 00/00/00 Monthly Hours Months Employer

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 Knowledge / Experience Relevant To The Role
Please indicate below how your experience meets the requirements of the post. This section will be assessed by a
board of Senior Managers to consider your experience as it is relevant to the post.
Short listing may occur based on the information provided here and in the other areas of this application form.
Please complete each section below.
Please include dates i.e. from x date to x date, the name of the employer /department you worked in.
Date(s) from – Date(s) to Employer(s) & Department Name

 Demonstrate knowledge of the role of Care Assistant and the provision of a service to clients with an intellectual
disability.

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Declaration:

It is important that you read this Declaration carefully and then sign it in the space below.

Part 1: Obligations Placed on Candidates who participate in The Recruitment Process.

The Public Services Management (Recruitment and Selection) Act 2004 makes very specific provisions in
relation to the responsibilities placed on candidates who participate in recruitment campaigns and these are
detailed in Section 4 of the Code of Practice issued under the Act.

These obligations are as follows:

Any canvassing by or on behalf of candidates shall result in disqualification and exclusion from the recruitment
process. Candidates shall not:
 knowingly or recklessly make a false or a misleading application
 knowingly or recklessly provide false information or documentation
 canvass any person with or without inducements
 impersonate a candidate at any stage of the process
 knowingly or maliciously obstruct or interfere with the recruitment process
 knowingly and without lawful authority take any action that could result in the compromising of any test
material or of any evaluation of it
 interfere with or compromise the process in any way

Any person who contravenes the above provisions, or who assists another person in contravening the above
provisions, shall be guilty of an offence.

It is the policy of the HSE to report any such above contraventions to An Garda Siochana.

In addition, where a person found guilty of an offence was or is a candidate at a recruitment / selection process,
then, in accordance with the Public Services Management (Recruitment and Selection) Act 2004:
 where he / she has not been appointed to a post, he / shall be disqualified as a candidate; and
 where he / she has been appointed as a result of that process, he / she shall forfeit that appointment

Part 2
Declaration: “I declare that to the best of my knowledge and belief there is nothing in relation to my conduct,
character or personal background of any nature that would adversely affect the position of trust in which I would
be placed by virtue of my appointment to this position. I hereby confirm my irrevocable consent to the Health
Service Executive to the making of such enquiries, as the Health Service Executive deems necessary in respect
of my suitability for the post in respect of which this application is made.

I hereby accept and confirm the entitlement of the Health Service Executive to reject my application or terminate
my employment (in the event of a contract of employment having been entered into) if I have omitted to furnish
the Health Service Executive with any information relevant to my application or to my continued employment with
the Health Service Executive or where I have made any false statement or misrepresentation relevant to this
application or my continuing employment with the Health Service
Executive.

Furthermore, I hereby declare that all the particulars furnished in connection with this application are true, and
that I am aware of the qualifications and particulars for this position. I understand that I may be required to
submit documentary evidence in support of any particulars given by me on my Application Form. I understand
that any false or misleading information submitted by me will render me liable to automatic disqualification or
render me liable to dismissal, if employed.”

Failure to sign application will render it invalid1.

Signed: __________________________(Name of Applicant) Date: _____________________

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If you are submitting your application form via email we will accept the application form unsigned but you will be
required to sign the Declaration at interview should you be invited to one.

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References:

Please give three referees (including your current employer). We retain the right to contact all previous
employers. Do you wish us to contact you prior to contacting your referees?

Yes: No:
____________________________________________________________________________________

1. Name and Job Title of Referee:

Professional Relationship to candidate:

Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:
____________________________________________________________________________________

2. Name and Job Title of Referee:

Professional Relationship to candidate:

Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:

____________________________________________________________________________________

3. Name and Job Title of Referee:

Professional Relationship to candidate:

Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:

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Proficiency in Irish
Candidates will be afforded the added opportunity to demonstrate their ability to perform the duties of the office
through Irish. This assessment will be on a pass/fail basis and will not disturb the marks awarded in the
selection process. Where vacancies arise for which proficiency in Irish is a management requirement, the HSE
will offer such posts in order of merit to candidates who have successfully passed the Irish assessment. Please
indicate if you wish to undertake an Irish assessment exam Yes / No

Please tick Yes/No as appropriate

Are you currently in receipt of a pension from any of the following YES NO
superannuation schemes?
Local Government Superannuation Scheme (LGSS)
Health Service Executive Employee Superannuation Scheme
Voluntary Hospital’s Superannuation Scheme (VHSS)
Nominated Health Agencies Superannuation Scheme (NHASS)

If you have answered ‘yes’ in relation to any of the above Superannuation Schemes you are not eligible to apply
for this recruitment campaign. Former Health Service and public sector employees must ensure that they adhere
to their contractual obligations where they have previously availed of the Incentivised Scheme of Early
Retirement (ISER), 2010 Voluntary Early Retirement Scheme (VER) or 2010 Voluntary Redundancy Scheme
(VRS).

EEA Nationals
EEA nationals who do not require work permits / visas / authorizations are nationals of the following countries:
Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, The Netherlands,
Portugal, Spain, Sweden, United Kingdom, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta,
Poland, Slovakia, Slovenia, Norway, Iceland, Liechtenstein, Switzerland, Bulgaria and Romania.

NON-EUROPEAN ECONOMIC AREA APPLICANTS WHO RESIDE WITHIN THE STATE.

In order that we can process your application it will be necessary for you to provide the HSE with the relevant
documentation showing you have permission to be in this state and have the relevant work
permit/visa/authorization required to be employed within this state.

For more details on EEA countries please visit the Department of Jobs, Enterprise and Innovation website
www.djei.ie

Please provide details of Work Permit/Visa/Authorization below

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