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PA Questionnaire - Merton Council - Home

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PA Questionnaire - Merton Council - Home Powered By Docstoc
					                                            Personal Assistance Database Questionaire

Name



Address




Telephone
                      Home


                      Mobile
                      Please circle
                      appropriate
Age                   answer:             16 to 18   19 -21 22-30   31-40   41-50   51-60   61-65   66+



Gender                                    Male                        Female

Which Service
Areas of people
have you worked       Please delete all Older People/ Adults with Physical Impairments/Adults with Learning Impairments/Adults with
with?                 that do not apply. Mental Health Impairments/ Children with Impairments/Children/Carers.

What types of
support can you       Please delete all Personal Care (bathing & dressing)/Housework/Escorting/
provide?              that do not apply. Administration/Gardening/Cooking/Ironing/Laundry

Can you provide any other support
that is not listed above?


What hours or days                       MONDAY:       Morning/Lunchtime/Afternoon/Evening/Night TUESDAY:
can you work?                            Morning/Lunchtime/Afternoon/Evening/Night WEDNESDAY:
                                         Morning/Lunchtime/Afternoon/Evening/Night THURSDAY:
                                         Morning/Lunchtime/Afternoon/Evening/Night    FRIDAY:
                                         Morning/Lunchtime/Afternoon/Evening/Night    SATURDAY:
                      Please delete all Morning/Lunchtime/Afternoon/Evening/Night    SUNDAY:
                      that do not apply. Morning/Lunchtime/Afternoon/Evening/Night



Would you like to
be employed F/T or
P/T basis or as and
when required?

Language Skills                 Please
list any language/ communication skills
which you have: e.g. Urdu.or Makaton or
BSL
Do you hold a full  Please delete all
UK driving license? that do not apply. YES/NO

Do you have any specific
requirements with regard to your
work? (e.g., physical or cultural
factors)




Are you able to carry out manual
handling or other heavy tasks?

                      Please delete all
Can you provide       that do not apply.
proof that you can
work legally in the                          British Passport / EU Passport / Residence permit issued by the Home Office / Registration
UK?                                          card / NI number / Birth Certificate / Work Permit.

Additional            e.g. CRB check
Information:          or special skills or
                      interests.




References; (One      Please include
personal & One        Name, Address &
professional)         your relationship
                      to the referree (If
                      you have a copy
                      of your reference,
                      please attach)




                      Consent for
                      Merton's Direct
                      Payments users
                      to use your
Signature             details
naire




1-60    61-65    66+




nts/Adults with Learning Impairments/Adults with
pairments/Children/Carers.


ork/Escorting/
 undry




/Evening/Night TUESDAY:
WEDNESDAY:
THURSDAY:
    FRIDAY:
    SATURDAY:
   SUNDAY:
ermit issued by the Home Office / Registration
rmit.

				
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