Job Application Employee Application Form Please complete all steps within the application process. Applicant Details Training Availability Competency Nursing Experience Declaration Company Position Please specify the position you are applying for in the list below. Select the job you wish to apply for * Support Workers - Liverpool and Surrounds Registered Nurse - Liverpool and surrounding suburbs Support Worker's - Young Personal Details Title * Mr Miss Mrs Ms First Name * Surname * Address * address line 2 City State State NSW VIC QLD TAS WA SA NT ACT Postcode Phone * Mobile Date of Birth * Email * Languages spoken other than English Person to contact in case of an emergency Name * Relationship * Contact Number (Home) * Work * Training & Experience Nursing Level * Registered Nurse Enrolled Nurse AIN PCA (no nursing qualification but 2+ years experience) Other Years of service * Transportation Do you have a current drivers licence? * Yes No Can you arrange your own transport? * Yes No How far are you willing to travel? * Less than 30kms 30kms - 60kms 60kms or more Please tick the days and times you are available to work for us Monday Morning 5am - 12pm Afternoon 12pm - 5pm Evening 5pm - 11pm Night 11pm - 7am Tuesday Morning 5am - 12pm Afternoon 12pm - 5pm Evening 5pm - 11pm Night 11pm - 7am Wednesday Morning 5am - 12pm Afternoon 12pm - 5pm Evening 5pm - 11pm Night 11pm - 7am Thursday Morning 5am - 12pm Afternoon 12pm - 5pm Evening 5pm - 11pm Night 11pm - 7am Friday Morning 5am - 12pm Afternoon 12pm - 5pm Evening 5pm - 11pm Night 11pm - 7am Saturday Morning 5am - 12pm Afternoon 12pm - 5pm Evening 5pm - 11pm Night 11pm - 7am Sunday Morning 5am - 12pm Afternoon 12pm - 5pm Evening 5pm - 11pm Night 11pm - 7am Competency In the list below please tick the boxes for the tasks/items that you are competent to perform. Housework Personal Care Transport for clients Palliative Care Meal Preparation Dementia Care Catheter Care Brain Injury Shopping Toileting Slide Sheets Tube/Peg Feeds Transferring (with / without a hoist) Bowel Care (enema, manual evacuation/PR, Stoma care) Caring for people with physical disabilities (Motor Neurone Disease, Quadrilegia, Vision/hearing impaired, Stroke/CVA) Caring for adults with mental health issues Respite / Social Support Overnight care Caring for people with intellectual disabilities Challenging Behavious Care of clients of various ages (Babies) Airway Management (Tracheostomy care) Nursing Experience We require contact details for 2 references - these must be work related. How many years nursing experience do you have in Australia? Are you currently employed? * Yes No Previous Employer Length of time employed with employer Duties Performed Skills and/or certificates obtained Reference from previous employer Reference Name * Position * Company * Phone number * Pre Existing Injury or Disease Do you have a pre-existing or current injury, disease or disability (physical or mental), which may affect your ability to carry out your duties? * Yes No Do you currently or have you previously had a Worker’s Compensation claim or injury? * Yes No Criminal History Criminal History * I declare that I DO NOT have a history of any criminal convictions or a record of any disclosable court outcomes. I understand that if I supply Nursing Group incorrect or misleading information it will result in dismissal and may lead to legal action taken by Nursing Group. I declare that I DO have a history of any criminal convictions or a record of any disclosable court outcomes. I understand that if I supply Nursing Group incorrect or misleading information it will result in dismissal and may lead to legal action taken by Nursing Group. Choice Application Declaration Application Declaration * I declare that the information I have provided in this application is true and correct.
