New Starter Form

Step 1 of 11

Section Break

Payroll Details – new employee

Full Name Including Any Middle Names(Required)

Email Address(Required)

Mobile Number(Required)

Landline Number

Postal Address

Street Address Address Line 2 City County Post Code

Date of Birth(Required)

DD slash MM slash YYYY

Sex(Required)

Copy of Certificates For Qualifications Relevant to the Role

Max. file size: 24 MB.

Date commenced

DD slash MM slash YYYY

Position(Required)

Department(Required)

NI No

Name of bank and address(Required)

Sort Code No(Required)

Account No(Required)

Name in which account is held(Required)

Building Society No (if applicable)

P45 received from previous employment

Accepted file types: pdf, doc, docx, Max. file size: 24 MB.

HMRC Employee Statement

Do you have another job?

Select Statement C for the question below

Do you receive payments from a state, workplace or private pension?

Select Statement C for the question below

Since 6 April have you received payments from another job which has ended, or any of the following taxable benefits: Jobseekers Allowance (JSA), Employment & Support Allowance (ESA) or Incapacity benefit

If yes, select statement B for the question below

If no, select statement A for the question below

Employee Job Statement

Do you have a student or postgraduate loan?(Required)

Do any of the following statement apply?

You’re still studying on a court that your student loan relates to.

You completed or left your course after the start of the current tax year, which started 6 April

You have already repaid your loan in full

You’re paying the Student Loan Company by Direct Debit from your bank to manage your end of loan repayments

Do any of the above apply to you?

To avoid repaying more than you need to, tick the correct student or loans you have

Loan Types

Plan 1

Plan 2

Plan 4

Postgraduate loan (England & Wales only)

Next of Kin / Emergency Contact (If No Next of Kin)

Next of Kin – Relationship

Name

Address

Street Address Address Line 2 City Post Code

Mobile

Telephone Number

Health Questionnaire

For the purposes of the companies health and safety obligations, candidates who have been offered employment with the company must complete this form. If the answer is yes to any of the questions on this form, please give full details in the space provided of the dates, duration and outcome of the illness or condition. If we have any concerns about your fitness to work, employment will be subject to satisfactory medical reports.

Self described sex

Have you had any of the following?

Tuberculosis, asthma, bronchitis or chest problems

Chest pains, heart condition or raised blood pressure, a stroke

Epilepsy, blackouts or fits of giddiness

Depression, mental illness or nervous breakdown

Rheumatism or arthritis

Back trouble

Typhoid, paratyphoid or other glandular trouble

Digestive or bowel disease

Diabetes, thyroid or other gland trouble

Bladder or kidney trouble

Dermatitis or skin trouble

Allergies

Do you have any problems with your sight that are not corrected by glasses

Do you have any problems with your hearing

Any other accident, operation or illness in the previous five years

Have you any reason to believe you may be infected with any communicable disease

Any other current or recent medical condition or treatment which might affect your attendance or performance at work

Do you intend to work night duties on a regular basis

For how many days has sickness or illness prevented you from attending work in the last year

Any illness or medical condition that prevented you from attending work on your normal duties or activities for more than one week during the past year

Any physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities? If yes, please specify any adjustments required in relation to work

If yes to any of the above, please add information below

Medical history

We regularly update our website, newsletters, activities information leaflets, and all other information material we may produce, including events we have here at Horsfall House. Some of this material may include your image, some named, most unnamed, and we would therefore request your permission to use your image in all of this material. The same applies to any image of any relative of yours, who is a client of/resident at Horsfall House.

Data protection options(Required)

Permission Given

No Permission Given

We look forward to you joining the team at Horsfall House and hope you will enjoy working with us.

However, before you commence employment a DBS check has been made and these checks are expensive for a small charity such as ourselves. Therefore, we would like to point out that should you decide not to take your appointment further with us after the DBS has been applied for, or you do not wish to continue with the employment within a year of your commencement date, the amount will be deducted from your final salary payment.

Equally, if you leave Horsfall House within one year of completing any course/training. You will be required to refund any monies spent by Horsfall House towards that training.

Consent to Payback DBS and Training Costs(Required)

Please tick to confirm your acceptance of this condition

We, Horsfall House are an equal opportunity employer. The aim of our policy is to ensure that no job applicant or employee receives less favourable treatment because of age, disability, gender reassignment, marriage and civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation. Our recruitment selection criteria and procedures (including the areas or media sources which are used in the recruitment process) are frequently reviewed to ensure that individuals are selected, promoted and treated on the basis of their relevant merits and abilities and that no applicant or employee is disadvantaged by provisions, criteria or practices which cannot be shown to be justified.

We would like to use your data to ensure that this policy is fully and fairly implemented. We will use your data to compile statistics on the representation amongst our workforce of the categories listed. To use this information, we need your consent. Signing in the space below will indicate that you consent to your data being used for the purpose stated. You may withdraw your consent at any time by contact Horsfall House. Completion of this form is optional. Any responses you give will assist us in our commitment to equality, diversity and inclusion in the workplace. Your responses will be kept strictly confidential and will not be used in any decisions affecting you.

Which of the following best describes your gender?

Male

Female

Prefer to self describe

Prefer not to say

Self describe option

Gender identity: Do you identify as trans?

Yes

Prefer your own term

Prefer not to say

Self describe option

Is the gender you identify with the same as your gender at birth?(Required)

Yes

Prefer not to say

Age

16-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65+

Prefer not to say

What is your ethnicity?

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box.

Asian or Asian British

Indian

Pakistani

Bangladeshi

Chinese

Other

Prefer not to say

Any other Asian background, please write in

Black, African, Caribbean or Black British

African

Caribbean

Other

Prefer not to say

Any other Black, African or Caribbean background, please write in

Mixed or Multiple Ethnic Groups

White & Black Caribbean

White & Black African

White & Asian

Other

Prefer not to say

Other

Any other mixed or multiple ethnic background, please write in

White

English

Welsh

Scotish

Northern Irish

Irish

British

Gypsy or Irish traveller

Other

Prefer not to say

Any other white background, please write in

Other ethnic group

Arab

Other

Prefer not to say

Any other ethnic group, please write in

Do you consider yourself to have a disability or health condition?(Required)

Yes

Prefer not to say

What is the effect or impact of your disability or health condition on your work? Please write in here

The information in this form is for monitoring purposes only, if you believe you need a ‘reasonable adjustment’ then please discuss this with your manager, or the manager running the recruitment process if you are a job applicant.

Which of the following best describes your sexual orientation?(Required)

Heterosexual

Gay

Lesbian

Bisexual

Prefer to self describe

Prefer not to say

Option to self describe

What is your religion or belief?(Required)

No religion or belief

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

Other

Prefer not to say

It is the policy of Horsfall House that we are smoke-free, and is smoke-free in all areas including any areas of the grounds and in any work vehicles, and complies totally with the Law. The Law states:

Smoking isn’t allowed in any enclosed workplace, public building or on public transport in the UK. (This has been in place since 1st July 2007).

Overall responsibility for policy implementation and review rests with the General Manager (registered manager). However all staff are obliged to adhere to, and support the implementation of the policy. The General Manager will inform all employees, individuals in our care, contractors and visitors of our policy and their role in implementation and monitoring of the policy. All new personnel will receive a copy of this policy on recruitment/induction. If staff wishes to smoke in their own vehicles they must drive off the premises. All employees wishing to smoke( in their break periods) must leave the premises; uniforms must be covered whilst off the premises. Please note that the local Authority Law applies with regard to littering the streets (please see below).

Appropriate non-smokers signs are clearly displayed at the entrances to and within the premises, and in all company vehicles.

Local disciplinary procedures will be followed if a member of staff does not comply with this policy. Workers can be fined up to £200 if caught smoking in the workplace.

NB Stroud District Council clearly state that cigarette butts count as litter, and as such, if smokers drop cigarette butts in the street they will face a penalty.

The following items are prohibited:
• Cigarettes

•Cigars

• E-cigarettes

• Vapes

Staff breaks at Horsfall House are paid breaks and should be taken as allocated by the unit manager/nurse in charge of the shift.

The Working Time Regulations state that “Staff are entitled to an uninterrupted break of 20 minutes when daily working time is more than 6 hours “If your shift is less then 6 hours these are concessionary breaks and must be authorised by the unit manager/nurse in charge.

4 hour shift:10 minutes mid shift as allocated. 6 hour shift:15 minutes as allocated. 8 hour shift:30 minutes as allocated 11–13 hour shift : 75 minutes, made up of 2 x 15 minutes and 1 x 45 minute break.

Non smoking breaks are to be taken in the staff room. Staff who wish to smoke may do so during their standard break as authorised by the unit manager/nurse in charge, in the areas designated in the Horsfall House Smoke-free Policy. Drinks must not be taken off the premises and consumed in the street as this may cause offence to neighbours of Horsfall House.

The Care Quality Commission (CQC) requires you to complete and sign a declaration concerning previous convictions for criminal offences, bindovers, and/or cautions before taking up your position with Minchinhampton Centre for the Elderly. We are then required to lodge the declaration with the Care Quality Commission (CQC) pending a report from the Disclosure & Barring Service (DBS).

Please would you, therefore, read carefully and complete the declaration at the foot of this letter, deleting whichever of the bracketed words are not appropriate, and return to the Administrator at the above address as soon as possible.

Please Tick to Confirm(Required)

I, the undersigned, hereby declare that I have not been subject to any previous convictions, conditional discharges, bindovers and/or cautions at any time before the date of this declaration.

The Care Quality Commission (CQC) requires you make a declaration that you are mentally and physically fit for the purposes of work to be performed by you whilst you are employed by Horsfall House. This is required by the Care Standards Act 2000, The Care Home regulations and Essential Standards for Quality 7 Safety (ESQS).

Please would you read carefully and complete the declaration below.

Please Tick to Confirm(Required)

I, the undersigned, hereby declare that I AM physically and mentally fit for the purposes of my work according to my job role.

Consent(Required)

I, the undersigned, certify that the information I have provided in this application form is true, accurate, and complete to the best of my knowledge and belief.

Name(Required)

Signed

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Name

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