Silver Home Care Employment Application

Employment Application

DEMOGRAPHICS
Full Name *

First Name Middle Name Last Name
Home Phone
Cell Phone
Can we text?

Yes No
Address *

Street Address

Street Address Line 2

City State

Zip Code
E-mail *

Caregiver Employment Application

DEMOGRAPHICS
Are You Legally Eligible to Work in the US? *

Yes No
Years of Caregiving Experience
Do You Have A Valid Drivers License and Vehicle Insurance? *

Yes No
Do You Have a Reliable Vehicle? *

Yes No
What hours and days are you available?
When Can You Start *

Month Day Year
Date

Caregiver Employment Application

EDUCATION
Highest Level of Education Completed *

GED High School Diploma Associates Degree Bachelors Degree or higher
Please select all that Apply:

I am a CNA I am a Nursing Student None of the Above
CNA Registration Number (If Applicable)

Caregiver Employment Application:

CURRENT EMPLOYMENT
Are you currently employed?

YES NO
Current Employer *
Current Position *
Current Duties *
Start Date *

Month Day Year
End Date (leave blank if still employed)

Month Day Year
Current Pay Rate *
Current Supervisor *
Supervisor's Phone Number *

Area Code Phone Number
Supervisor's Email
May We Contact? *

Yes No

Caregiver Employment Application

PREVIOUS EMPLOYERS
Previous Employer 1 *
Name of Previous Employer
Position *
Duties *
Reason for Leaving? *
Ending Pay Rate
Start Date *

Month Day Year
End Date *

Month Day Year
Supervisor *

First Name Last Name
Supervisor's Phone Number *
Supervisor's Email
May we contact? *

Yes No
Would you like to add another employer?

YES NO

Caregiver Employment Application

PREVIOUS EMPLOYER
Previous Employer 2
Name of Previous Employer
Position
Duties
Start Date

Month Day Year
End Date

Month Day Year
Ending Pay Rate
Reason for Leaving?
Supervisor

First Name Last Name
Supervisor's Phone Number
Supervisor's Email
May we contact?

Yes No
Would you like to add another employer?

YES NO

Caregiver Employment Application

PREVIOUS EMPLOYER
Previous Employer 3
Name of Previous Employer
Position
Duties
Start Date

Month Day Year
End Date

Month Day Year
Ending Pay Rate
Reason for Leaving?
Supervisor

First Name Last Name
Supervisor's Phone Number
Supervisor's Email
May we contact?

Yes No
Do you have any additional professional references you would like to provide?

Yes No

Professional Reference
Name

First Name Last Name
Company
Phone Number

Area Code Phone Number
Email
example@example.com
May we contact?

Yes No
Add Another?

Yes No

Professional Reference
Name

First Name Last Name
Company
Phone Number

Area Code Phone Number
Email
example@example.com
May we contact?

Yes No

Authorization to Conduct Reference Checks

This authorization will be emailed (or faxed) to the references that you have authorized us to contact above.
I have applied for employment with Silver Home Care and have provided information about my previous employment. I authorize Silver Home Care to conduct a reference check with my present and/or previous employer(s). I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary and employment history. My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to Silver Home Care, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Silver Home Care from any and all liability arising from their giving or receiving information about my employment history or qualifications, and my suitability for employment with Silver Home Care.
Name

First Name Last Name
Date

Month Day Year
Date
Signature

Clear

Personal References:

Two verifiable Personal References, not related to you are Required
Reference 1 *
Name of Reference
Relationship *
Years Acquainted *
Phone *
Email *
Reference 2 *
Name of Reference
Relationship *
Years Acquainted *
Phone *
Email *
Reference 3
Name of Reference
Relationship
Years Acquainted
Phone
Email
I authorize Silver Home Care to contact the References listed above. *

Yes No
Signature

Clear

Consent for Drug Testing
Successful completion of pre-employment drug testing is a requirement of employment with Silver Home Care. You have the right to refuse this testing but in doing so your application will will be denied. Drug testing will be administered following the completion of your interview if you have been offered a position. We will use an oral swab to collect your saliva to test for the presence of Cocaine, Marijuana, Opiates, Amphetamines, Methamphetamine, and Benzodiazepines. If you are prescribed any medications that may produce a positive result, please notify us in advance of the test. If you believe the results of the test are not accurate, you have the right to request a retest of the original sample at a licensed laboratory of your choice within 3 days.
Full Name *

First Name Middle Name Last Name
I have read and understand the scope, method and policy stated above.

YES NO
I agree to submit to an Oral Swab test to screen for the use of Cocaine, Marijuana, Opiates, Amphetamines, Methamphetamine, and Benzodiazepines.

YES NO
I agree to submit to a drug and alcohol test in the event that I am involved in an accident or other incident where my actions/decisions or lack thereof are potentiallya contributing factor or if drug or alcohol use during work hours is suspected.

YES NO
Date

Month Day Year
Date
Signature

Clear

Tell us how you heard about us and why you are interested in working for Silver Home Care
What do you feel is the most important thing we should know about you?
Upload Cover Letter/Resume/References

If you have a cover letter, resume or written references you may upload them here, it is not required.
Cover Letter/Resume/References

Upload a File

Cancel of
For Office Use Only

PA Background Check Guidelines
Candidates awaiting the results of a PA Background check may be hired provisionally for 30 days. To reduce the need for provisional hiring, it is the policy of Silver Home Care to submit the PA Background check prior to the employee's start date. Additionally, all candidates must sign the criminal background attestation form and disclose any prior criminal offences. If the IF the background check comes back "under review" AND the employee did not disclose a previous record, Silver Home Care will contact the employee to () and the employee will be required to fill out the () form prior to being scheduled.

Procedures

Conduct PA Background Status Check at 21 days from DATE OF HIRE

Remove from schedule at 31 days from DATE OF HIRE
PA Background Check 21 day Status Check:

Month Day Year
Date
PA Background Check Provisional Hire Expiration Date:

Month Day Year
Date

FBI Check Guidelines
Exempt Employees: Employees who are able to show proof of PA residency are exempt from an FBI background check.

Acceptable Documents:

Valid PA Drivers License or State ID (issued no less than 2 years ago)
Rent receipts for the past 2 years
Copy of lease dated at least 2 years previous
Combination of utility statements or other bills for the past two years
Employees who have not been a resident of PA for the past 2 years consecutively may be provisionally hired up to 90 days pending the results of an FBI (fingerprint) background check.

Procedures:

The employee will be provided with the payment code and how to schedule an appointment to have thier fingerprints taken when the job is offered.
Employees must make this appointment within 1 week of hire
The appointment must occur within 3 weeks of hire
The employee will be informed that they will receive the results of the background check in the mail and that they MUST provide Silver Home Care a copy.
A follow uo call will be made at 30 days to confirm status
Employees who have not completed their fingerprints at day 45 will be taken off the schedule until they are complete
Employees will not be allowed to work beyond 90 days if the results of the background check have not been received.
1 week

Month Day Year
Date
3 weeks

Month Day Year
Date
30 days

Month Day Year
Date
45 days

Month Day Year
Date
90 Days

Month Day Year
Date

PPD Guidelines
PPD Guidelines: Silver Home Care follows the direction of the CDC in regards to TB testing. Currently, all employees must complete a two step PPD with the first step having been completed before and within 6 months prior to the start date. If the second step is not presented at hire, it must be initiated within 10 days. A negative chest xray or blood test within the last 6 months may replace the two step PPD.

Employees presenting with a negative chest exray older than six months should be referred to the Agency manager for further instructions.

Employees with Step two PPD results not received at 15 days of the start date will be removed from the schedule until the PPD is completed.
Step 2 must be completed by:

Month Day Year
Date

Provisional Hire Supervision Schedule
Name

First Name Last Name
Direct Random Supervision Week 1

Month Day Year
Date
Client Feedback Week 1

Month Day Year
Date
Client Feedback Week 2

Month Day Year
Date
Direct Supervision Week 3

Month Day Year
Date
Client Feedback Week 4

Month Day Year
Date
Direct Supervision Week 5

Month Day Year
Date
Client Feedback Week 6

Month Day Year
Date
Direct Supervision Week 7

Month Day Year
Date
Client Feedback Week 8

Month Day Year
Date
Direct Supervision Week 9

Month Day Year
Date
Client Feedback Week 10

Month Day Year
Date
Direct Supervision Week 11

Month Day Year
Date
Client Feedback Week 12

Month Day Year
Date

Drug Testing Results

Silver Home Care
Candidate:

First Name Last Name
Test Date:

Month Day Year
Date
Test Method

Oral Urine
Result

Positive Invalid Negative
Test Conducted By

Clear

Supervision (non provisional)
Name

First Name Last Name
Week 1 Client Feedback

Month Day Year
Date
Week 2 Direct Observation

Month Day Year
Date
1 Month Client Feedback (at 6 weeks)

Month Day Year
Date
Quarterly Supervision1 (by phone or in person at 12 weeks and quarterly thereafter) Musst have in person visit every 6 months)

Month Day Year
Date
Quarterly Supervision 2 (by phone or in person at 12 weeks and quarterly thereafter) Must have in person visit every 6 months)

Month Day Year
Date
Quarterly Supervision 3 (by phone or in person at 12 weeks and quarterly thereafter) Musst have in person visit every 6 months)

Month Day Year
Date
Quarterly Supervision 4 (by phone or in person at 12 weeks and quarterly thereafter) Musst have in person visit every 6 months)

Month Day Year
Date
Add new supervision schedule to calendar on:

Month Day Year
Date

Employment Application

Caregiver Employment Application

Caregiver Employment Application

Caregiver Employment Application:

Caregiver Employment Application

Caregiver Employment Application

Caregiver Employment Application

Professional Reference

Professional Reference

Authorization to Conduct Reference Checks

Personal References:

Consent for Drug Testing

Upload Cover Letter/Resume/References

Pre Interview Screening

Interview Notes

PA Background Check Guidelines

FBI Check Guidelines

PPD Guidelines

Provisional Hire Supervision Schedule

Drug Testing Results

Supervision (non provisional)