Site Title

Position applied for: _____________________________________________________ Facility: ___________________________________________________________________

Personal Details

First Name: ________________________ Surname: _________________________ Initials______________________ Known as: _______________________________ ID number: ______________________________________________________________ Gender:       M⚪ | F⚪           Race:   African ⚪ Coloured⚪ Asian⚪

Gender: M⚪ | F⚪ Race: African ⚪ Coloured⚪ Asian⚪

Date of birth: ⬜⬜⬜⬜⬜⬜⬜⬜ [Year/Month/Day]

Do you have disability as defined by the department of labour with a health text. ⚪ Yes No⚪

Are you a Ghanaian? ⚪Yes No⚪

If yes please specify: _______________________________________________________

If no, do you have a permit to work in Ghana? ⚪Yes No⚪

If yes, please attach a certified copy to this form

Contact details

Cell phone number: ________________________ Landline___________________

Alternative number: ________________________

Residential Address: ____________________________________________________

Postal Address: ____________________________ Postal code: ______________

Job Information

Part time? ⚪Yes ⚪No Full time? ⚪ Yes ⚪No

How did you hear about this position? ________________________________

General

Have you previously applied to work at trust hospital? ⚪Yes⚪No

Have you worried about been unemployed?     ⚪Yes       ⚪No

If yes, when ____________________________________________

Do you a relative employed by trust hospital? ⚪Yes ⚪No

If yes, please give details

Name of Introducer: ____________________________________________________

Position title at the hospital: ______________________________________________

Do you have any physical health initiations that will prevent you from performing the job you are applying for? ⚪Yes ⚪No

If yes please give details: ____________________________________________________________________________________________________________________________________________________________

When applicable and in the execution of your normal duties, you may be exposed to certain health risks. The following are examples of such health risks:

•Manual handing of objects or patients (i.e) mascular skeletal problems..back ,neck or shoulder pain. •Latex (i.e) dermatitis, asthma. •Radiation (i.e) pre-maligant or malgant condition. •chemicals (i.e) dematistis, asthma, chronic bronchitis

Revised Feb 2022