form

Title Title

Title

Surname *

Surname

Forename *

Forename

Address *

Address

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Country

Email *

Email

Phone *

Phone

Emergency contact name *

Emergency Contact Name

Emergency contact Telephone *

Emergency Contact Telephone

Do you hold a current DBS check? *

Yes

No

Do you have an un-spent conviction under the Rehabilitation of Offenders Act 1974? *

Yes

No

If yes please give details of the Un-spent conviction

Do you have any spent convictions under the Rehabilitation of Offenders Act 1974? *

Yes

No

If yes please give details of the conviction

Do you have any pending prosecutions *

Yes

No

Work History

Company *

Address *

Address

City

State/Province

Zip/Postal

Country

Job Title *

Duties *

Add Remove

References

Please give details of two or more people/companies to whom we may refer. one of these should be your most recent employer and preferably both should be professional.

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone (if known)

Email (if Known)

Your job title *

Add Remove

Medical Questionnaire

Acadia Care must ensure that all temporary workers have an understanding and are aware of their responsibilities towards health and safety. Therefor we require all applicants to fill out the following questions for their own safety and the safety of the people they are working with.

Do you suffer from or have ever suffered from any of the following conditioned?

Epilepsy, Blackouts, Fits, Migraines, Severe Headaches, Fainting, Ect? *

Yes

No

Sinusitis? *

Yes

No

Mental or Nervous Breakdowns? *

Yes

No

Lung disease including, Asthma, Bronchitis or Tuberculosis? *

Yes

No

Abdominal condition including hernia? *

Yes

No

Have you ever been refused work on medical grounds? *

Yes

No

Ear conditions including deafness? *

Yes

No

Impaired vision not corrected by lenses? *

Yes

No

Colour blindness? *

Yes

No

Skin alergies including dermatitis and eczema? *

Yes

No

Heart disease, high blood pressure, low blood pressure, or any other problems that effects your work efficiency? *

Yes

No

Rheumatic fever, Rheumatism or Arthritis? *

Yes

No

Typhoid or Paratyphoid? *

Yes

No

Dysentery? *

Yes

No

Jaundice, Hepatitis? or any other ailments of the stomach, bowels or digestion? *

Yes

No

Disease of the Nervous system? *

Yes

No

Back Strain, Disc trouble, Hemia or difficulty with bending or lifting? *

Yes

No

The nature of some of the work undertaken by Acadia Care Temporary Staff may carry a small risk of repetitive strain injury ( inflammation of tendons in the arms, neck and hands, caused by repeated movements over a length of time). therefore it is important that you answer the following questions.

Do you, or have you ever suffered from neck or shoulder pain, radiating towards your elbows? *

Yes

No

Have you ever suffered from pain in your wrists? *

Yes

No

Have you had a history of vibration white finger? *

Yes

No

Have you ever had time off work due to back pain, back injury or Sciatica? *

Yes

No

Are you able to attend a medical examination if required? *

Yes

No

If you are to work a night shift, do you require a health check? *

Yes

No

Do you agree to inform Acadia Care if you develop any medical conditions during your assignment with us? *

Yes

No

Have you had any long-term absences in the last 3 years? *

Yes

No

Please note the number of sick absences in the past 12 months? *

Are you sick, claiming statutory sick pay at the moment? *

Yes

No

If so what is the period of your sick note? *

You may be requested to re-complete these questions in the future, E.G in the case of a re-registration.

If there is any change to these answers in the future we must be informed immediately.

Are you looking for?

A temporary job?

A permanent time job?

Both?

Preffered working days?

Preferred working times?

Days

Nights

Morning

Evening

Transport to work

GDPR Consent *

Some information provided in this form may be classed as sensitive data under the Data Protection Act 1998, for this we require your explicit consent to hold this information. by signing the deceleration you are consenting to us holding and processing data under the rules of the Data Protection Act 1998 and that we have your authorisation to disclose relevant details to a third party where necessary. I confirm that the information provided is true and you may have authorisation to seek references and to approach any government bodies to undertake any relevant checks on me as required under the EEA regulations 2003.

Work History

References

Medical Questionnaire

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Acadia Support + Services Stafford

Acadia Support Kent