Caregiver Data Sheet
Name
*
First Name
Last Name
Location
City
State
Phone Number
*
Please enter a valid phone number.
Email
*
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Training
Certifications/Licenses/Training (Select all that apply )
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CNA or STNA Licensed by State
Awaiting Exam/Test Date - CNA/STNA Course completed
CNA or STNA course completed NOT Currently Licensed by State
PCA-Personal Care Aide Course Completed
HCA- Home Care Aide Course Completed
GNA course completed- Licensed by State
GNA course completed - not currently licensed
Med Tech Certification
OTHER - Please list any additional training in text box below
CNA/STNA License Information
License #
State Issued
Additional Training/License Notes:
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Experience
How many years experience do you have as Caregiver?
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Experience: Check All that Apply
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Home Care - Agency
Skilled Care Facility-Nursing Home Care
Assisted Living Community
Independent/Senior Living Community
Home Care Private Client/Private Duty
Memory/Dementia Care Unit
Hospital Care
Clinic Care- Dr. Office
Physical Therapy -Rehabilitation Department or Facility
Other: Please list other experience in text box below
Please list any additional work experience below:
Type of Care- Experience
*
Companion Care- Meal Prep/Errands/Conversation
Personal Care - Assist: Bathing/Dressing/Toileting/Hygiene/Mobility
Bed Bound Care - Assist: Clients who are unable to get out of bed.
Dementia/Alzheimer's
Parkinson's Client Care
Lewy Body Dementia Client Care
Assist w/ Glucose Monitoring - Diabetes medications
Working w/ combative clients - physically abusive clients
Working with "resistant" clients"
Working w/ clients w/ memory issues
Working with clients who are verbally abusive
Working w/ clients who try to wander off
Incontinence Care: Bladder and Bowel Incontinence
Handicapped Care - persons in wheelchairs
Persons with Mental Disabilities
Persons with Physical Disabilities
Assisting w/ exercise
Transportation- Transporting clients to Appointments/Shopping/Errands
Medication Supervision/Reminders
Cooking - special diets/nutritional meals
Hydration - encouraging adequate fluid intake
Stand By Care: Stand by when client ambulating for safety
Use of MECHANICAL (non electric) Hoyer Lift
Use of Electric Hoyer Lift
Use of Gait Belt
Use of Sliding Board
Monitoring: Blood Pressure/Temperature/Pulse
As Needed: Using Protective Equipment/Universal Precautions: gloves/masks/gown
Care for clients w/ COVID-19
Hospice Care
Care for clients w/ Tube Feedings
Care for clients with catheter (emptying bag etc..)
Care for clients w/ colostomy/ileostomy - change bags, cleaning stoma
Housekeeping: Laundry/Dishes/Vacuum
Assisting w/ Pets - food/water
Caring for deaf or severely hearing impaired clients
OTHER - Please list additional care experience in text bow below
Additional Care Experience:
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WORK RELATED REFERENCES:
Please list TWO WORK RELATED REFERENCES Below:
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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Miscellaneous
Why did you decide to become a professional caregiver?
What do you feel are the TOP 3 Qualities of a Great Caregiver?
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