EN application
How to apply
Forward this application with the following:
•
•
•
•
Covering letter
Clinical placement evaluations
Interim Academic record
Current police check (copy)
To 1+ Learning & Development Coordinator
Calvary Wakefield Hospital, 300 Wakefield Street, Adelaide SA 5000
Please number from 1 to 4, your preference for CHCA hospital site:
Calvary Wakefield Hospital, 300 Wakefield Street, Adelaide 5000
Calvary North Adelaide Hospital, 89 Stangways Terrace, North Adelaide 5006
Calvary Rehabilitation Hospital, 18 North East Road, Walkerville 5081
Calvary Central Districts Hospital, 25 Jarvis Road, Elizabeth Vale 5112
APPLICATIONS CLOSE 12th AUGUST 2016
oneplus Application Form
Personal
Details
Personal Details
Surname:
First Names:
Address:
Phone: (home)
(mobile)
Are you legally entitled to work in Australia?
Please indicate:
Citizen
(work)
Yes
Permanent Resident
No
(give details as below)
Sponsorship Visa Required
Work Permit/Expiry Date
oneplus Graduate Enrolled Nurse Program
If successful with this application what date could you commence employment?
As a participant in the graduate program you will be required to work shift work i.e. morning, evening, nights and weekends
throughout the 12 month contract. Is there any reason that you would not be able to undertake this requirement?
Yes (give details as below)
Details:
Calvary Health Care Adelaide Ltd
ABN 85 106 314 229
No
How Did You Hear About Us?
We are interested to know how you first became aware of our graduate program:
Promotional talk
Clinical Placement
Website
Relative of a patient
Feedback from other graduates / students
Other:
Education
Tertiary Qualifications (Academic transcripts will need to be provided at interview)
Course Title
Eg: Bachelor of Science (Nursing)
Commencement
Date
Completion
Date
Grade
Average
Institution
Dec 04
P1
Uni SA
Jan 02
Employment History
Please provide your employment history (include any full-time, part-time or casual work, nursing related or otherwise).
Employment
Position
Duration
Hours per week
E.g. St Peter’s Nursing Home
Nursing Assistant
Jan 2002 – Present
Approx 16 hours/wk
Referees
Please give the names, telephone number and email address (if possible) of two recent work referees who have
supervised you e.g a clinical facilitator from a recent practicum placement and a manager from part time employment.
Name:
Title:
Employer:
Telephone Number:
Has the referee given permission for contact?
Email Address:
Yes
Name:
No
Title:
Employer:
Telephone Number:
Has the referee given permission for contact?
Calvary Health Care Adelaide Ltd
ABN 85 106 314 229
Email Address:
Yes
No
Employee Referee Consent
Do you consent to Calvary Health Care Adelaide discussing the information contained in your application
with the referees listed?
Yes
No
N.B. Referees will only be contacted after interview unless otherwise advised.
Personal and Professional Interests
Some of my personal and professional interests/activities include:
Please complete the following statements My Short Term Career Goals are:
My Long Term Career Goals are:
I have shown commitment personally and professionally by:
I would like to be considered for a position on the oneplus because:
Employee Health Record
Disclosure of an illness will not preclude you from consideration for employment for the position sought.
Calvary Health Care Adelaide is committed to providing a safe work environment for all staff. The Work Health and
Safety Act 2012 obligates Employers to ensure the workplace health and safety of each employee at work.
In an effort to assist us to meet these obligations you are requested to complete the following questionnaire. The
information provided on this form will assist us in placing strategies to reduce risk of infection or injuries to our staff.
Please note: The information that you disclose on this form is for the internal use of the hospital only and will be
kept strictly confidential.
Do you suffer or have ever suffered from the following medical conditions:
Disease/Conditions
Allergies e.g. latex,
chemicals, medications
Dermatitis
Asthma
Calvary Health Care Adelaide Ltd
ABN 85 106 314 229
Yes
No
Unsure
Details/Treatments/Comments
Do you suffer or have you ever suffered from the following musculoskeletal problems
(i.e. sprains/strains)
Body Location
Yes
No
Unsure
Details/Treatments/Comments
Back
Neck
Shoulders/Arms
Hips/Legs
Ankles
Have you ever been immunised for Hepatitis B?
Yes
No
If yes, did you achieve an immune response
Yes
No
Tuberculosis: Have you had a mantoux test?
Yes
No
Have you ever had Chicken Pox?
Yes
No
Have you ever had an MMR
(Measles, Mumps, Rubella) immunisation?
Yes
No
Have you had Tetanus immunisation?
Yes
No
Have you had Pertussis immunisation?
Yes
No
Have you had Poliomyelitis immunisation?
Yes
No
Is there any reason or medical condition that may impair
your ability to perform the job you are applying for?
(working 24 hour / 7 day week roster)
Yes
No
Yes
No
If yes, what year?
If yes, what year?
If yes, please provide details:
You may be asked to attend a function capacity test
as part of the recruitment process.
Do you agree to this request?
Declaration
I declare that the information I have given is true and correct and I have not withheld any relevant information you should
be aware of when considering whether to employ me. I understand that you could terminate my employment if you find that I
have given you untruthful, inaccurate or misleading information.
If required, I agree to a medical examination at any time during my employment. A medical officer will be nominated by
Calvary Health Care Adelaide. I understand that this will be done in the best interests of my health and the safety of my work
colleagues and patients.
I authorise Calvary Health Care Adelaide to obtain any information and documents relevant to any injury, illness or
medical condition I may sustain during the period of my employment with Calvary Health Care Adelaide which may be in
the possession of the following:
1. This or another hospital; or
2. Any ambulance service; or
3. A doctor, provider of treatment or rehabilitation service or person qualified to assess cognitive, functional or
vocational capacity; or
4. A previous employer; or
5. Insurers that carry on the business of providing Workers Compensation Insurance, Compulsory Third Party Insurance,
personal accident or illness insurance, or insurance against the loss of income through disability, superannuation
funds or any other type of insurance; or
6. A department, agency or instrumentality of the Commonwealth or the State.
I understand that if I am employed this application and my resume will become a permanent document of my personnel file.
If I am not successful in obtaining employment this document will be stored and destroyed after six months.
I sign this declaration to confirm I have read and agree with the above conditions.
Signature:
Calvary Health Care Adelaide Ltd
ABN 85 106 314 229
Date: