Application Test Form Personal DetailsTitle *Please selectMrMrsMissMsFirst Name *Last Name *Street Address *Apartment, suite, etcCity *State/Province *Post Code *Phone *MobileDate of Birth *Email *Languages spoken other than EnglishPerson to contact in case of an emergencyName *Relationship *Contact Number (Home) *Contact Number (Work) *Training & ExperienceNursing Level *Please selectRegistered NurseEnrolled NurseAINPCA (no nursing qualification but 2+ years experience)OtherOther - please specifyYears of service *For AINs, do you have any of the following?(A copy of each certificate will need to be provided)CertificatesCertificate 3 in Aged Care or DisabilitiesCertificate 4 or higherCurrent First Aid CertificateNational Crime CheckTransportationDo you have a current drivers licence? *YesNoLicence No *Licence Classification *Can you arrange your own transport? *YesNoHow far are you willing to travel? *Less than 30kms30kms - 60kms60kms or moreAvailabilityPlease tick the days and times you are available to work for usMondayMorning 5am - 12pmAfternoon 12pm - 5pmEvening 5pm - 11pmNight 11pm - 7amTuesdayMorning 5am - 12pmAfternoon 12pm - 5pmEvening 5pm - 11pmNight 11pm - 7amWednesdayMorning 5am - 12pmAfternoon 12pm - 5pmEvening 5pm - 11pmNight 11pm - 7amThursdayMorning 5am - 12pmAfternoon 12pm - 5pmEvening 5pm - 11pmNight 11pm - 7amFridayMorning 5am - 12pmAfternoon 12pm - 5pmEvening 5pm - 11pmNight 11pm - 7amSaturdayMorning 5am - 12pmAfternoon 12pm - 5pmEvening 5pm - 11pmNight 11pm - 7amSundayMorning 5am - 12pmAfternoon 12pm - 5pmEvening 5pm - 11pmNight 11pm - 7amCompetencyIn the list below please tick the boxes for the tasks/items that you are competent to perform.HouseworkPersonal CareTransport for clientsPalliative CareMeal PreparationDementia CareCatheter CareBrain InjuryShoppingToiletingSlide SheetsTube/Peg FeedsTransferring (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 issuesRespite / Social SupportOvernight careCaring for people with intellectual disabilitiesChallenging BehaviousCare of clients of various ages (Babies)Airway Management (Tracheostomy care)Nursing ExperienceWe 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? *YesNoCurrent EmployerLength of time employed with employer *Duties Performed *Skills and / or certificates obtained *ReferenceName *Position *Company *Phone number *Previous EmployerLength of time employed with employerDuties PerformedSkills and / or certificates obtainedReferenceName *Position *Company *Phone number *Pre Existing Injury or DiseaseDo you have a pre-existing or current injury, disease or disability (physical or mental), which may affect your ability to carry out your duties? *YesNoPlease specify *Do you currently or have you previously had a Worker’s Compensation claim or injury? *YesNoPlease specify, and if applicable a clearance certificate will need to be provided before work can commence. *Criminal HistoryCriminal 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.Application DeclarationApplication Declaration *I declare that the information I have provided in this application is true and correct.Submit
