Personal Assistant Register – Disability North

Disability North Personal Assistant register

People in need of support and looking for PAs can download and complete the online referral form here and email it to directpayments@disabilitynorth.org.uk

To see our FAQs for employers, personal assistants, or Local Authorities please click on the relevant link.

For more information contact our team on directpayments@disabilitynorth.org.uk
or by telephone 0191 2840480.

Individual employers can submit a referral for support, as well as Social workers, Care managers and other support organisations.

Please complete all fields below

1. First Name/Given Name: *

2. Surname/Family Name: *

3. Email address: *

4. Phone Number: *

5. Home Address: *

6. Postcode: *

7. Gender (we are asking this as some people may prefer a PA of the same gender)?

Woman

Man

Nonbinary

Prefer not to say

8. Are you looking to support Adults and/or Children?

Children

Adults

Both

9. Can you provide support with live-in care?

Yes

10. Can you provide overnight care?

Yes

11. Please indicate which hours you would be available for work and tick all that apply:

Mon:

Evening

Overnight

Tues:

Evening

Overnight

Wed:

Evening

Overnight

Thur:

Evening

Overnight

Fri:

Evening

Overnight

Sat:

Evening

Overnight

Sun:

Evening

Overnight

12. Could you work extra hours at short notice?

Yes

13. What areas of the region are you available to work in?
[checkbox regions-county-durham use_label_element "County Durham]

Gateshead

Newcastle Upon Tyne

North Tyneside

Northumberland

South Tyneside

Sunderland

Teesside

York

14. Do you have a Valid UK Driving Licence?

Yes

15. Do you have access to a car to use for work purposes?

Yes

16. Would you be willing to drive a wheelchair accessible vehicle which may be larger than a standard car?

Yes

17. Are you comfortable working around pets?

Yes

18. Please add further information if necessary

19. Would you be prepared to work in a house where smoking is not permitted?

Yes

20. Do you have a current DBS certificate (less than 3 years old)?

Basic

Enhanced

21. Are you proficient in any other language? *

22. Do you have permission to work in the UK?

Yes

23. Please list any visa restrictions: *

24. Can you provide personal care including washing, dressing and help with using the toilet? Please tick all that apply:

Women

Men

Young people

Children

25. Can you provide support with any of the following? Please tick all that apply:

Communication support

Household/domestic duties

Lifting

Physiotherapy

Reading/writing/form filling

Sighted guiding

Support paying bills/simple arithmetic

Using a hoist

26. Do you have any training/experience in the following (you may be asked for proof)? Please tick all that apply:

BSL

Catheter care

Deafblind manual

First aid certificate

Food hygiene

Infection control

Makaton

Medication handling and management

Moving and handling

PECS

Peg feeds

Stoma care

Suction care

Tracheostomy care

Working with people who have Dementia

27. Have you worked as a Personal Assistant before?

Yes

28. If yes, please enter the employer’s name and address: *

29. Please provide a summary of your relevant skills and experience: *

30. Please provide a summary of your most recent employment: *

31. What makes you a good candidate for the role of a Personal Assistant? *

32. What do you like to do in your spare time and what are your interests and hobbies? *

33. Are there are any Personal Assistance tasks that you cannot perform, either for religious, cultural, medical reasons or just because you would not want to? *

34. Please give the details of two people who have agreed to act as referees for you. One must be a current or most recent employer if you have one and neither should be a close member of your family.

Current/recent employer:

Name: *

Job Title: *

Address: *

Tel no: *

Email: *

Contact following interview but prior to job offer?

Yes

Second reference:

Name: *

Relationship to you: *

Address: *

Tel no: *

Email: *

Disability North will hold your data securely. However, to accept your support we may need to share your details with trusted partners (e.g. Local Authority Social care/Local CCGs and the Individual employers). Your details will not be shared anywhere else. Are you happy for us to do this? *

I Agree

I confirm that, to the best of my knowledge the information I have provided on this form is accurate and that I have not altered or omitted any facts which may have a bearing on the PA support I am able to provide *

I Agree

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