Revised April 2013 EXPLANATORY NOTES The application form is designed to ensure that applicants provide the necessary information to determine how they meet the essential criteria, as well as providing additional information required at the various stages of the recruitment process. Please see below for some useful tips on completing your application form. Remember it is important that you allow sufficient time to submit your application form, ensuring that it is accurate and complete. JOB APPLICATION FORM You must complete all relevant sections of your application form in sufficient time to ensure that it is received on or before the closing date and time as recorded on the top right hand corner of your form. If you have insufficient space to record all your qualifications and experience on your application form, you may continue on a separate sheet. Your application will not be considered if you only state „see separate sheet‟ or „see CV attached‟. JOB DESCRIPTION The job description describes the purpose, scope, main duties and responsibility of the job. Study the job description before completing your application form, then indicate on your form how, in your opinion, your experience and/or qualifications are relevant to the post you have applied for. PERSONNEL SPECIFICATION Study the criteria within the Personnel Specification carefully and ensure that you accurately record all of your experience and qualifications that demonstrates that you meet the criteria. The minimum criteria describe the essential requirements for the post but depending on the number of applicants, the panel may decide to increase the criteria to include additional factors which are desirable. You should therefore include a full record of your qualifications and experience and clearly demonstrate how you feel you meet the criteria as detailed in the personnel specification. Failure to do so will result in your application not being shortlisted or being rejected at a later stage in the process. Remember that the panel cannot make assumptions about your qualifications or experience, therefore it is your responsibility to ensure that you have detailed all of the relevant information required in order to demonstrate that you meet the criteria. Please Note: The selection process may take the form of an aptitude test or tests, you may be required to attend an assessment centre or submit a written paper on a specific topic or undertake other methods of assessment prior to interview. DISABILITY REQUIREMENTS We ask on the application form if you require any reasonable adjustments, due to disability, to enable you to attend the interview or undertake the duties of the post. Details of any disability are only used for this purpose and do not form any part of the selection process. If you require any reasonable adjustments to be made throughout the recruitment process, please contact the Recruitment & Selection Department to make arrangements for your requirements in advance of your test, assessment centre or interview. Completing the Criminal Convictions / Offences Section Legislation requires you to tell us about any criminal convictions or offences that you may have. Within the HSC, criminal convictions are never regarded as spent and therefore you must tell us about all previous or pending convictions or offences, even if they happened a long time ago, this even includes motoring offences. The Trust is committed to the equality of opportunity for all applicants, including those with criminal convictions. Whilst the disclosure of information does not automatically prevent an individual from obtaining employment, it is essential that all convictions are disclosed to allow us to adequately consider their relevance to the post in question. We consider failure by an applicant to declare complete and accurate information about convictions to be a serious breach of trust which will normally result in any withdrawal of offer. Access NI Disclosure – The Trust operates in line with the Access NI Code of Practice. Further details can be obtained from www.accessni.gov.uk Revised April 2013 Data Protection The information you provide will be processed in accordance with the Data Protection Act 1998. EDUCATION Below is an example of how you should record your qualifications: Awarding Body C.S.E Grade Year Awarding Body I 1986 R.S.A B 1987 C A O Level G.C.S.E Subject Passed Computer Studies English Language Mathematics G.C.E Mathematics G.C.E Leaving Cert. Std N.V.Q Leaving Cert Hons N.V.Q Business Admin. O A Business Admin. Stage/ Level Part Typewriting II 1 Dist. 1990 R.S.A Typewriting II 2 Pass 1990 1989 R.S.A II 1 Pass 1993 B 1989 R.S.A II 2 Pass 1993 C 1990 R.S.A III 1 Pass 1994 1992 R.S.A III 2 Pass 1994 1992 O.C.R 2 2004 O.C.R Text Production Word Processing Pass 1994 Word Processing Word Processing Audio Transcription Audio Transcription Text Production Text Production Pass 2004 II III B Secretarial Subjects 2 Grade Year It is important that you accurately record all qualifications e.g. if English Language is an essential subject required in the criteria you will NOT be short listed if you only record English (except GCSE English), identifying double awards. It is also essential that you accurately record all your typing qualifications including the relevant parts, for example Part I & II for all stages. Completing Your Current / Previous Employment Details Ensure that full details are provided. Be specific about all the dates that you provide, these should be stated in the following format DD/MM/YYYY. Explain any gaps between periods of employment and include reasons for leaving each post. Provide a list of key duties that you have been responsible for in current post / previous posts. If you are employed on a “Bank” or “ As and When Required” capacity – please specify the days/hours per week/month that you work. For care posts please ensure that when entering details of the post and description of duties that you specify the client group (e.g. Elderly, Mentally Ill, etc). Completing the Medical History Section This section requires you to tell us about any periods of sickness you have had in the last 2 years, whether you have been in employment or not. Please ensure that you include all dates that fall within this time period giving relevant details of the nature of the illness / absence. Your sickness absence record will be verified through the reference checking process; therefore it is important that you give full and accurate information. Failure to disclose all periods of sickness may affect your application. Completing the Reference Section Your references should normally cover previous employment, training and or education. Ensure that you have provided the names of two referees (who must not be relatives). One of your references should have knowledge of your present work / or most recent employment and be in a supervisory/managerial capacity. If you are a student you should provide the name of your college tutor/lecturer or teacher/principal. Please note that where applicable, we will always seek a reference from your last HSC/NHS manager / employer. Revised April 2013 Please see below for guidance: Candidate Employment Position Currently employed Not currently employed Never been employed Previously employed in the HSC/NHS Self Employed Reference 1 Reference 2 From current employer From employer prior to current From most recent employer From previous employer Character* reference / relevant Academic** reference / Other From current employer From previous HSC/ NHS employer Character reference* From previous employer / relevant Academic** reference / Other *Character Reference – e.g. Accountant, Banker, HM Revenue & Customs, Solicitor, Client references or voluntary organisation **Academic Reference – e.g. school, college, university This section must be completed in full, therefore be sure to include complete names, job titles, and addresses, including email addresses for both of your referees. Completing the Equal Opportunity Monitoring Form Please note that this information is regarded as part of your application and you are strongly encouraged to complete this section. This information is treated in the strictest confidence and is for monitoring /statistical purposes only. Selection panels do not have any access to this information at any stage of the recruitment process. Submitting your completed form to the Recruitment & Selection Team Your application must be received by the Recruitment & Selection Team by the stated closing date and time. Late applications will not be accepted. Forms will also not be accepted if they are incomplete or have been reformatted i.e. printouts of online applications only give a summary of your information and some information can be omitted, this may lead to your application not going forward in the recruitment process. If you are applying online you are required to submit your application online. Please remember that the standard Application Form is the only acceptable method of application. Application forms can be submitted through one of the following channels: http://www.westernhealthjobs.com – full details on completing an on line application form are provided at this web address. REMEMBER to not leave it until the last minute as something could happen to the internet at either end Posted to the Recruitment & Selection Department, Lime Villa, 12c Gransha Park, Londonderry, BT47 6WJ. st *Applicants using Royal Mail should note that 1 class mail does not guarantee next day delivery. It is the responsibility of the applicant to ensure that sufficient postage has been paid to return the form to the address above by the stated closing date and time. Finally, please check to ensure that you have answered yes or no to the question on car driver. Revised April 2013 WESTERN HEALTH & SOCIAL CARE TRUST Recruitment Department 12C Gransha Park Clooney Road Londonderry BT47 6WJ Tel: (028) 7186 0616 An Equal Opportunity Employer OFFICE USE Applicant No _________________________________ Ack___________________ Appoint______________ S/L___________________ Reserve______________ Int Time_______________ Waiting List___________ Int Date_______________ Regret_______________ References Received and Checked 1 2 Please state clearly the details of the post you wish to apply for. Failure to do so will result in your application not being considered. Post title:____________________________________ Ref. Number:_________________________________ Closing Date:_________________________________ FAILURE TO COMPLETE ANY PART OF THIS FORM MAY RESULT IN YOUR APPLICATION NOT BEING CONSIDERED. CV’s ARE NOT ACCEPTABLE 1. PERSONAL DETAILS Mr/Mrs/Miss/Ms/Dr Surname National Insurance No Any Former Surname Citizen of EC Country Forenames Non EC (Please State) YES/NO Address Do you have access to a Motor Car YES/NO Do you possess a Current Full Driving Licence YES/NO Do you have a disability as defined in the Disability Discrimination Act 1995? Postcode Do you require special arrangements to be made when Tel No Home attending interview / test / assessment centre? Work or Other Contact No Email Address YES/NO YES/NO IMPORTANT: ALL CONVICTIONS MUST BE DECLARED INCLUDING MOTORING OFFENCES Have you been at any time convicted of a Criminal Offence or Cautioned or do you have any Prosecutions Pending? Please see Explanatory Notes for guidance. YES NO If Yes please detail:………………………………………………………………………………………………………………. PROTECTION OF CHILDREN & VULNERABLE ADULTS NB Child Care / Learning Disability / Regulated Posts / Care Positions Only: Have you ever had any involvement in or been the subject of any adult or child abuse investigations? YES If YES please give dates, details and outcomes of all incidents on a separate sheet. Please state all previous addresses. Continue on separate page if necessary: NO Revised April 2013 2. EDUCATION Your results - General Certificate of Education/Leaving Certificate/Senior Certificate/General Certificate of Secondary Education, etc. please specify A Awarding Body Subject Level Grade Year Awarding Body Secretarial Subjects Stage Part Grade Year University Degree(s), Diploma(s), Technical Qualifications (or equivalent) Obtained with Dates B Qualification University/College Dates C Apprenticeship Details Date Completed 3. PROFESSIONAL QUALIFICATIONS A By Examination Name of Professional Body or Bodies B By Election (Give Details) C Registration Details Examination Taken Intermediate with date Final with date and result and result Examination Yet to be taken with dates (i) PROFESSIONS SUPPLEMENTARY TO MEDICINE / ALLIED HEALTH PROFESSIONALS Type of Registration: Date of Expiry: Registration/Enrolment No: (ii) NURSING NMC PIN No: Expiry Date: Part(s) of live NMC Register: (iii) MIDWIFERY POST: Are you eligible to practise? YES NO IF APPOINTED, YOU WILL BE REQUIRED TO PROVIDE ORIGINAL CERTIFICATES FOR ALL EDUCATIONAL/PROFESSIONAL QUALIFICATIONS LISTED AND PROOF OF REGISTRATION Revised April 2013 4. PRESENT EMPLOYMENT DETAILS (It is not necessary to record this again in Section 6.) Present or most recent Employer Name and Address Title of Post Held & Grade/Band Location/Base Date appointed to this post Present Salary Period of notice required by present Employer Brief description of current duties 5. TRAINING / CONTINUING PROFESSIONAL EDUCATION Please give details of any courses you have attended (with dates) and details of training and development received. Revised April 2013 6. EMPLOYMENT RECORD Please list across column 1-5 your previous posts beginning with the most recent and indicate how in your opinion this experience has a bearing on your present application. 1. DAY DATES FROM MTH YEAR 2. DAY TO MTH YEAR 3. NAME AND ADDRESS OF EMPLOYER TITLE OF POST HELD/GRADE/BAND AND BRIEF DESCRIPTION OF DUTIES 4. REASON FOR LEAVING 5. SALARY Revised April 2013 EMPLOYMENT RECORD (Continued) Please list across column 1-5 your previous posts beginning with the most recent and indicate how in your opinion this experience has a bearing on your present application. 1. DAY DATES FROM MTH YEAR 2. DAY TO MTH YEAR 3. NAME AND ADDRESS OF EMPLOYER TITLE OF POST HELD/GRADE/BAND AND BRIEF DESCRIPTION OF DUTIES 4. REASON FOR LEAVING 5. SALARY Revised April 2013 7. ATTENDANCE RECORD Number of days absent on sick leave in the past 2 years: Number of sick leave episodes in the past 2 years: This information may be subject to verification with your employer 8. OTHER INFORMATION Please give details of any information which you think may have a direct bearing on your application, e.g., voluntary work or spare time activities 9. REFEREES Please name two referees, at least one of whom should have knowledge of your present work/or most recent employment and be in a supervisory/managerial capacity. If you are a student you should provide the name of your college tutor, lecturer, teacher or Principal. (Relatives should not be named as referees). If you have worked in the HSC/NHS, your last HSC/NHS Line Manager or Employer must be one of these referees. Your references should normally cover your last 3 years of employment, education or training. 1. Name 2. Name Designation Designation Address Address Tel No. Tel No. E-mail E-Mail If you do not wish your Referees to be contacted prior to an offer of employment please tick here: 10. MEDIA DETAILS Please indicate how you became aware of this vacancy Belfast Telegraph (M001) Derry Journal (M402) Londonderry Sentinel (M408) Tyrone Constitution (M411) Ulster Herald (M412) Fermanagh Herald (M406) The Impartial Reporter (M407) Internet (M417) Training & Employment Agency (M413) Health & Social Services Trawl (M006) Internal Trawl (M017) Other Publications - Please Specify Revised April 2013 11. DECLARATION I declare that the foregoing information is true and correct to the best of my knowledge and belief. I understand that appointment may be subject to satisfactory vetting and medical examination, and that canvassing will disqualify. I am aware that I will be held responsible for the accuracy of this Declaration and that if any information is found to be false within my knowledge or if any relevant fact has been wilfully suppressed, that the Trust may terminate my existing contract of employment, or if appointed to this post my contract may be terminated or any offer of employment withdrawn. I agree, if the post involves working with children, young people, persons with a learning disability, or is classed as a care position or regulated post, that the Trust can request relevant information from the DHSSPS and the PSNI. I understand that in submitting this application form and in any subsequent employment with this Trust, I consent to my information being processed in accordance with the Data Protection Act 1998. Signature ………………………………………………….. Date ………………………………………………………. The Trust will treat the information given in this application as confidential. Applicants are advised that legal processes may require the Trust to disclose the form to certain statutory bodies. Application form will not be acknowledged unless a stamped addressed envelope is received. HAVE YOU COMPLETED YOUR MONITORING FORM? Revised April 2013 EQUAL OPPORTUNITIES MONITORING Reference No________________ The Health & Social Care (HSC) organisation is committed to equality of opportunity for all staff and job applicants. The HSC organisation selects those suitable for employment and advancement solely on the basis of merit and is also monitoring its activities to ensure that its equal opportunity policy is effectively implemented. Section 75 of the Northern Ireland Act 1998 requires us to promote equality of opportunity on the basis of all nine categories. To assist in this monitoring process it is necessary to ask you a number of questions. / / (1) Date of Birth: (2) Sex: Male  Female (3) Marital Status: Single  Married/Civil Partnership    Other (4) Community Background: To demonstrate our commitment to equality of opportunity in employment we need to monitor the community background of applicants and employees, as required by the Fair Employment and Treatment (NI) Order 1998. We therefore ask you to indicate your community background by ticking the appropriate box below . Please note that it is an offence under the Fair Employment and Treatment (NI) Order 1998 to give false information to the Trust. a) I am a member of the Protestant community  b) I am a member of the Roman Catholic community  c) I am a member of neither the Protestant nor the Roman Catholic community  d) We recognize that there may be occasions where religious belief differs from perceived community background. In order that our records are correct, we therefore would ask you to indicate your religious belief by ticking one box. (5) Muslim  Hindu  None  Other (please specify) ________________________ Sikh  Jewish  Buddhist  Christian  To which of these ethnic groups do you consider you belong: White Chinese Indian Filipino     Black African Irish Traveller Black Caribbean Black Other     Bangladeshi Pakistani Mixed Ethnic Group    Any Other Ethnic Group (please specify) _________________________ Please also specify your nationality: (e.g. Latvian, Lithuanian, Polish, British, Scottish, Welsh, Irish, Portuguese etc.) _________________________________ (6) Do you have caring responsibilities for: (tick each box that applies to your circumstances) a child (or children) a dependent older person a person(s) with a disability none of the above (7)     Disability: The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and long-term effect on a person's ability to carry out normal day-to-day activities. "Normal day-to- Revised April 2013 day activities" listed in the Act are mobility; manual dexterity; physical co-ordination; continence; ability to lift, carry or otherwise move everyday objects; speech, hearing or eyesight; memory or ability to concentrate, learn or understand; or perception of the risk of physical danger. Anyone diagnosed as having cancer, HIV or multiple sclerosis is automatically and immediately protected by the DDA. (If you take medication, treatment or have a prosthesis to manage your condition, would you consider that you had a disability if you were without these? If so, you should answer ‘yes’ below.) Having read this definition, do you consider yourself as having a disability? Yes   No  I do not wish to answer If yes, please indicate which type of impairment(s) apply to you: (please tick all that apply to you) Physical Impairment, such as difficulty using arms or, mobility requiring a wheelchair or crutches  Sensory Impairment, such as blind/visual impairment or deaf/hearing impairment   Mental health condition, such as depression or schizophrenia Learning disability, such as Down’s Syndrome, Dyslexia or Cognitive Impairment such as Autism   Illness, such as cancer, HIV or multiple sclerosis  Long standing illness, such as diabetes, chronic heart disease or epilepsy Other ________________________________________________________________ (8) Sexual Orientation: My sexual orientation is towards someone: Of the opposite sex  I do not wish to answer Of the same sex  Of the same sex and of the opposite sex   (9) Political Opinion: Please tick the appropriate box to indicate your political opinion. Broadly Unionist Broadly Nationalist Other I do not wish to answer     (10) Are you currently an employee of the organisation to which you are applying (excludes agency workers)? Yes  No  Access to this information will be strictly controlled. Monitoring will involve the use of statistical summaries of information in which the identities of individuals will not appear. Whilst the HSC organisation will treat the information given on this monitoring form as confidential, staff are advised that legal processes may require the HSC organisation to disclose the information given to certain statutory bodies, and, in some circumstances, open Tribunal. Employees should complete the form in the knowledge that it will be processed in line with requirements of the Data Protection Act 1998. The information will subsequently be transferred to the monitoring system operated by the HSC organisation. There it will be strictly controlled in accordance with an agreed Code of Practice. 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