Screening Form | Thestaffroom

First name

Last name

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Birthday

Day

Month

Year

Todays Date

Emergency Contact

How did you hear about Apex Care job advertisement?

Are you a New Zealand Citizen/Resident

New Zealand Resident

Residency Visa

Please upload your residency visa

What Drivers License do you hold?

NZ Full

NZ Restricted

None

Please upload your license front

Please upload your license back

Please upload a secondary form of ID e.g. Passport

Do you have your own vehicle?

Yes

No

If required, would you agree to a drug/alcohol test?

Yes

No

Do you have previous experience working in the health/mental health or social service sector?

Yes

No

Regions your willing to work in

Waikato

Bay of Plenty

Northland

Are you willing to travel for work?

Yes

No

Do you have previous experience working with youth?

Yes

No

Have your ever worked with high needs or complex mental health clients before?

Youth

Elderly

Adults

No

Do you feel confident in handling/supervising and charting medication

Yes

No

Are you confident in cooking, cleaning and personal cares as required by some of our clients.

Cooking

Cleaning

Personal Cares

Do you have training /experience in using hoists?

Standing

Ceiling

Lazy Sue

Are you prepared to handle all products, materials, or equipment used in the industry?

Yes

No

Do you have access to the internet and a device for filling in daily notes and accessing your roster.

Yes

No

Have you had any criminal convictions or faced charges? Please be aware that as part of our checks we do a full Police check, not just a Clean Slate check.

Are you aware of any medical conditions or infectious diseases that you have that could be passed onto Apex Care clients?

Yes

No

Are there any aspects of your health you feel should be revealed to ensure your safety at work?

Yes

No

If Yes please give details

Please list your qualifications

Please upload all your qualifications certificates, if you have qualifications you MUST upload the certificates now, It may delay your application if not supplied.

Do you have a current first aid certificate

Yes

No

Will expire this year

Please upload your first aid cert.

References: Employers or Supervisors we can contact. These must be within the last year. If you have worked in the health sector, the references should come from there.

Reference Name

Position Held

Reference Email

Reference Phone

References: Employers or Supervisors we can contact. These must be within the last year. If you have worked in the health sector, the references

Reference Name

Position Held

Reference Email

Reference Phone

Days of the week you are not available, Ie Study, Religious Commitments, Child care etc

Do you have any planned vacation or need for leave coming up?

If employed by Apex Care, when can you start, do you need to give notice?

Other Employment - Please list below any other employment you will be continuing with whilst working for Apex Care

Please Upload your Cover Letter here if you choose to supply one. Recommended as it's a great way to introduce yourself.

If you do not have a cover letter, then please explain here why you are right for this position.

How would you handle a client you were working with if they were known to escalate and become violent?

How would you help somebody to stay motivated to reach their goals?

What are your strengths?

How do you describe/define professional boundaries and how would you make sure they are maintained at all times?

You walk into a client’s room, and they are self-harming, how do you react, what do you do?

Do you have Te Reo Māori or any other language? If so please list.

Please upload your resume/CV if you have not already supplied.

In accordance with the privacy laws, I allow Apex Care permission to contact the verbal references I have provided

- I hereby confirm I am entitled to work in NZ

- I hereby confirm I have disclosed all my criminal

convictions, charges or impending charges.

Declaration - I declare that the above information I have given is true and correct - I understand this application does not guarantee me work

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