Kumeu Village Aged Care

APPLICATION FOR EMPLOYMENT

Attached is an application for employment form which you are requested too personally
complete.

The application form is a source of information that will be used by us to consider your suitability
for the position for which you are applying. If successful, such information will form part of our
personnel records. Failure to supply the information requested would prejudice our ability to
assess your suitability for the position.

In accordance with the Privacy Act 2020, We collect personal information from staff, including
information about your:
• Name
• Contact information and details of contact person in case of emergency
• CV with work history, referees and references, qualifications, APC
• Tax and bank details
• Driver’s license and/or passport details (if required)

We collect your personal information in order to:

• Employ the right person for the position

Providing some information is optional. If you choose not to enter a work history or references, or
consent to a police vetting, we'll be unable to offer employment.

We keep your information safe by storing it in a secure place and it is only accessible to
authorised personnel.

You have the right to ask for a copy of any personal information we hold about you, and to ask
for it to be corrected if you think it is wrong. If you’d like to ask for a copy of your information, or
to have it corrected.

You are entitled to access this information upon request to the manager where the information
is held.

This location is currently in Elmo and/or Leecare which are both secure applications used by
Kumeu Village. A hard copy in our locked filing cabinet located in the management office.

We would like to keep your application form and CV as part of our records.
If you agree, please sign where indicated. If you choose not to sign and your application is
unsuccessful your application form and CV shall be either returned to you or destroyed by us.
The above information is provided in accordance with the Privacy Act 2020.

Full Name:

Signature

Date

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 1
 Kumeu Village Aged Care
APPLICATION FOR EMPLOYMENT

This form is to be completed personally by the applicant. The Information you provide
in this form is used as part of the recruitment decision to appoint. If you were to be
appointed to the role, this form, and the information you have provided will be held
by Kumeu Village as part of your personnel file. If you are not successful, this form will
be destroyed.

Position applied for: Date:

Personal Details

Mr / Mrs / Ms / Miss / Dr

First name: Surname:

Date of birth (optional):

Address:

Home phone: Work phone:

Mobile phone: Email address:

Country of Birth:

NHI Number:

Ethnicity:

Are you a New Zealand resident? ❑Yes ❑ No ❑ Not Applicable

If no, do you have residential status? ❑Yes ❑ No ❑ Not Applicable

If no, do you have a current work permit? ❑Yes ❑ No ❑ Not Applicable

Are you an assisted immigrant under bond to

the government or any other employee? ❑Yes ❑ No ❑ Not Applicable

If you are offered a position, you will be asked to supply evidence of your
identification and if required entitlement to work in New Zealand. E.g. a birth
certificate, passport, or work permits.

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 2
Work History

Present or most recent employer:

Your position start date: Finish date:

Organisation:

Address:

Outline your main responsibilities for this role:

What is/was your reason for leaving?

For the purposes of compliance with the Privacy Act 2020. Do you consent to the
company contacting your present employer for the purposes of reference checking?

❑Yes ❑ No ❑ Not Applicable

Next most recent employer:

Your position start date: Finish date:

Organisation:

Address:

Outline your main responsibilities for this role:

What is/was your reason for leaving?

Have you worked for Kumeu Village / Ladybug before? ❑Yes ❑ No

Do you have secondary employment? ❑Yes ❑ No ❑ Not Applicable

If yes, please give details:

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 3
Give details of any other job which may be relevant:

Briefly explain the reasons why you are seeking this position:

Education

This includes tertiary or further education if applicable:

Secondary school attended:

Number of years attended:

Qualification gained:

Other Educational Institutes attended:

Number of years attended:

Qualification gained:

Other qualifications:

General

Is English your first language? ❑Yes ❑ No

If English is not your first language what is?

What other languages do you speak?

Do you have any disabilities or medical conditions that would prevent you from
carrying out the responsibilities of this position? Applicants are advised that failure to
disclose any condition that could affect their ability to fulfil their duties to the required
and expected standard that they were employed, may result in their employment
being terminated.

❑Yes ❑ No

If yes, please provide details:

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 4
Have you had any injuries or medical condition caused by a gradual process, disease,
or infection which the responsibilities of this position may aggravate or contribute to?
e.g. hearing loss, sensitivity to chemicals, repetitive strain injuries

❑ Yes ❑ No

If yes, please provide details of these injuries or medical conditions;

Have you been convicted of a criminal offence

(including serous traffic offences)? ❑Yes ❑ No

Are you awaiting the hearing of charges

in a civil or criminal court of law? ❑Yes ❑ No

If you have answered yes to either of the above questions, please give brief details of
conviction and charges at the end of this form (except those cases where our asking
you to declare them would breach the Criminal Records (Clean Slate) Act 2004). Please
note you will be required to fill out a “Consent to Disclosure of Information Form” which
is forwarded to the NZ Police for vetting.

Do you have a current driver’s licence? ❑Yes ❑ No

Are you prepared to work overtime if required to do so? ❑Yes ❑ No

Are you prepared to work at another facility if required? ❑Yes ❑ No

Are you prepared to work shifts? ❑Yes ❑ No

Are you prepared to be flexible & cover shifts to help the team out? ❑Yes ❑ No

Have you reached the minimum school leaving age? ❑Yes ❑ No

Are you prepared to have random Covid Swab Tests? ❑Yes ❑ No

What transport arrangements do you have to attend work?

If your application is accepted, when could you commence employment?

What are your interests/hobbies or community activities?

Are there any other commitments or reasons you have that may prevent you from
fulfilling the responsibilities of this position?
❑Yes ❑ No

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 5
If you have answered yes, please give a reason:

Referees

Please provide the name, address, and telephone number of three referees. Two of the
referees must be work related, the third can be a personal referee of suitable standing
or position in the community, it cannot be a friend, or relative. If you have provided a
written reference, please be aware that we may contact that referee.
Referee One:

Name:

Position:

Company and address:

Telephone number:

Referee Two:

Name:

Position:

Company and address:

Telephone number:

Referee Three:

Name:

Position:

Company and address:

Telephone number:

I consent to the company seeking verbal or written information about me from

representatives of my previous employers and/or referees and authorize the information
sought, to be released.

❑Yes ❑ No
Review Date: 02.11.21 Section: Qas 12A
Review: B Employment Application Page 6
Declaration and Authorisation

The information provided in this application form is complete and correct to the best of
my knowledge. If any of the information I have given is false, or misleading, or any
material fact is suppressed, I understand that I will not be offered employment, or my
employment may be terminated. I also understand that any false information given in
relation to any aspect of my medical history can result in my loss of entitlement for any
compensation from ACC.

I authorise Kumeu Village to contact the nominated referees and authorise the release
of the information as requested.

I also understand that if I have omitted any information regarding criminal and traffic
offences that my employment may be terminated immediately.

Name of Applicant:

Signature of applicant: Date:

Details of Convictions and Charges

Applicants are advised that failure to disclose a criminal conviction may result in not
being employed or employment being terminated.

Date of Offence:

Give a full account of the offence:

Outcome:

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 7
 Kumeu Village Aged Care
HEALTH QUESTIONNAIRE FOR JOB APPLICANTS

Date:

Full Name of Applicant:

Completion of this form is optional. If you choose not to complete it, you will be
required to obtain a medical clearance from your doctor before we will be able to
offer you employment.

This information is collected for the purpose of ensuring the safety of all employees and
residents within the home. This information will be confidential to the Manager, Clinical
Coordinator and Company Doctor.

1. DO YOU CURRENTLY SUFFER FROM OR HAVE A HISTORY OF THE FOLLOWING?

YES NO
MRSA Infection ............................................................ ❑ ❑
Hypertension (high blood pressure) .......................... ❑ ❑
Diabetes ....................................................................... ❑ ❑
Asthma or chronic cough .......................................... ❑ ❑
Epilepsy ........................................................................ ❑ ❑
Heart Disorders ............................................................ ❑ ❑
Back or Neck pain or injury ........................................ ❑ ❑
Hepatitis or known carrier .......................................... ❑ ❑
AIDS or HIV positive ..................................................... ❑ ❑
Psychiatric Illness ......................................................... ❑ ❑
A Notifiable Communicable Disease (see over) ..... ❑ ❑
Tuberculosis.................................................................. ❑ ❑
Boils, paronychia or skin wounds, skin rash ............... ❑ ❑
Persistent diarrhoea / vomiting .................................. ❑ ❑
Osteoarthritis ................................................................ ❑ ❑
Rheumatoid arthritis .................................................... ❑ ❑
Gout ............................................................................. ❑ ❑
Dermatitis/eczema ..................................................... ❑ ❑
Known latex allergy .................................................... ❑ ❑

2. HAVE YOU EVER HAD TREATMENT FOR:

MRSA Infection ............................................................ ❑ ❑
Psychiatric Illness ......................................................... ❑ ❑
Hepatitis A, B or C ....................................................... ❑ ❑
Back or Neck pain or injury ........................................ ❑ ❑
A serious injury ............................................................. ❑ ❑

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 8
3. HAVE YOU HAD THE FOLLOWING VACCINATIONS? YES NO DATE

Tuberculosis ................................................................. ❑ ❑ ………..……..

Tetanus......................................................................... ❑ ❑ ………..……..
Hepatitis A ................................................................... ❑ ❑ ……………….
Hepatitis B .................................................................... ❑ ❑ ………..……..
Measles ........................................................................ ❑ ❑ ………..……..
Meningitis ..................................................................... ❑ ❑ ………..……..
Influenza ...................................................................... ❑ ❑ ………..……..
Covid ........................................................................... ❑ ❑ ………..……..
Others (specify) ........................................................... ❑ ❑ ………..……..

4. Have you ever worked in a hospital unit where MRSA was present? ...... ❑Yes ❑ No
5. Are you pregnant? ................................................................................... ..... ❑Yes ❑ No
6. Do you smoke? ………………………………………………......................... ..... ❑Yes ❑ No
7. Do you agree to undergo a medical exam if required? ......................... ❑Yes ❑ No
8. Are you allergic to, have any sensitivity to any substance or chemical? ❑Yes ❑No
9. Do you require corrective lenses or contact lenses? ............................ ❑Yes ❑ No
10. Have you claimed accident compensation in the last 12 months? ........ ❑Yes ❑ No

NOTE:
A. This facility is Smoke Free.
B. If you have answered YES to any of number 1, 2, 4 or 5 you may be required to
obtain a medical clearance from your doctor.
C. If you have answered YES to being vaccinated for Hepatitis B, you may be required
to show proof of vaccination.
D. It is our facility policy to offer flu vaccinations to employees annually free of cost.
E. You are reminded that you must declare any notifiable disease to your employer.
F. Due to the nature of the working environment, we strongly recommend that you
vaccinate yourself for the conditions listed above in number 3 prior to beginning
employment with us and keep your vaccinations up to date.

I declare that the above information is correct, and I have read and agreed to the
notes above:

Signed: …………………………………………………… Date …………………………………

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 9
Infectious Diseases Notifiable to a Medical Officer of Health and Local Authority
Acute gastroenteritis Campylobateriosis
Cholera Crytosporidiosis
Giardiasis Listeriosis
Legionellosis Salmonellosis
Meningoencephalitis Typhoid
Shigellosis Paratyphoid Fever
Yersiniosis

Infectious Disease Notifiable to Medical Officer of Health

Acquired Immunodeficiency Syndrome Anthrax
Arboviral diseases Brucellosis
Cretzfeldt Jakob disease; and
other spongiform encephalopathies
Diphtheria
Hepatitis (viral) – not otherwise specified
Haemophilus Influenzae B Hydatid Disease
Leprosy Leptospirosis
Malaria Mumps
Pertussis Plague
Poliomyelitis Rabies
Rheumatic Fever Rickettsial Diseases
Rubella Viral haemorrhagic fevers
Yellow fever

As per COVID-19 Public Health Response (Vaccinations) Order 2021 it is required that
people working in the health and disability sector are fully vaccinated by 1st of
January 2022 and must receive their first dose of the vaccine by 15th of November
2021.
For that reason, we need to ask you:
Did you have the Covid vaccination: First dose Yes No Date:

Second Dose Yes No Date:

Evidence sited and copied for file. Yes No Date:

If you have a medical reason not to be vaccinated, Yes No Date:

do you have evidence from a medical practitioner.

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 10
 Kumeu Village Aged Care
CONSENT TO DISCLOSURE OF INFORMATION
Licensing & Vetting Service Centre
Police National Headquarters
PO Box 3017
WELLINGTON 6140

I,......................................................................................................................................
(Surname) (Fore Names)

........................................................................................................................................
(Maiden or any other names used)

Sex...........(M/F) Date and place of birth.............................................................

Nationality.............................. Residential Address...............................................

Suburb........................................ City.........................................................................

NZ Driver Licence number .........................................................................................

I hereby consent to the disclosure by the New Zealand Police information they
may have pursuant to application to Kumeu Village Aged Care. I understand
that any record of criminal convictions I might have will automatically be
concealed if I meet the eligibility criteria stipulated in Section 7 of the Criminal
Records (Clean Slate) Act 2004.

Signed................................................. Date....................................................

13 COMMENTS FROM THE NEW ZEALAND POLICE

Agency code: T21541

Review Date: 02.11.21 Section: Qas 12A

Review: B Employment Application Page 11