Caregiver Candidate Form
Agency Contact
Which location are you interested in working for?
Please Select
Arizona
Nevada
Utah
Southern Utah
Date of Application
-
Month
-
Day
Year
Date
Applicant Info
Applicant Name
First Name
Last Name
Applicant Email
example@example.com
Applicant Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
DOB
-
Month
-
Day
Year
Date
How did you hear about Cardinal Caregivers?
Indeed
Facebook
Nextdoor
Other
Please Describe
Applicant Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is a good emergency contact for you?
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
CPR/First Aid Certified?
Yes
No
Certified Caregiver?
Yes
No
Any other licenses/certifications?
Yes
No
If yes, please list here
Current negative TB test result?
Yes
No
Fingerprint Clearance Card
Yes
No
Do you have a DACS background check?
Yes
No
Have you done caregiver work before?
Yes
No
If yes for how long?
Do you have any restrictions on working around pets? (Cats or dogs)
Yes
No
Please describe
Are you willing to work with both male and female clients?
Yes
No
Please list the gender you are NOT willing to work with
Will you work with smokers?
Yes
No
Do you have a valid Driver's License
Yes
No
Do you have a reliable vehicle?
Yes
No
What type of vehicle do you drive?
How far are you willing to commute?
Will you drive a client's vehicle for them if they request it?
Yes
No
Please check all options that you have experience working with:
Transfers
Bathing
Toileting
Mobility Assistance
Feeding
Stroke
Oxygen Equipment
Dementia / Alzheimer's
Parkinson's
Diabetes
Incontinence care
Bed Bound Patients
Hospice
Hoyer lift
Colostomy bag
Catheter
Nephrostomy bag
Looking for part time or full time?
Part time
Full time
Full time but willing to start part time
Hours of availability
Rows
Start
Finish
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Are you able to work overnight shifts?
Yes
No
Are you willing to work short shifts? (less that 4 hours)
Yes
No
How far are you willing to drive for short shifts?
Able to work weekends?
Yes
No
What else would you like us to know about you?
Please provide 3 professional references
Rows
Name
Phone Number
Email
Reference #1
Reference #2
Reference #3
Please click SUBMIT if you have filled in all of the above information
Back
Submit
Next
For OFFICE use only
What type of worker?
W-2
1099
Applicant Status
No Contact
Spoke on phone
Interview Scheduled
Hired
Not a good candidate
Candidate declined position
W-2 New Hire Checklist
Added to SwyftOps
SS Card and ID received and uploaded to SO
I-9 received
W-4 signed and received
Direct deposit form received
Caregiver Agreement signed
Sent Employee Handbook
Background Check after first 60 hours worked
W-2 New Hire Checklist - UT
Added to SwyftOps
SS Card and ID received and uploaded to SO
I-9 received
W-4 signed and received
Direct deposit form received
Caregiver Agreement signed
Sent Employee Handbook
Background Check (DACS) done
Current Negative TB test result received
First Aid / CPR training certificate received
1099 New Hire Checklist
Added to SwyftOps
Independent Contractor Agreement signed (fill out our portion first)
W-9 signed and received
Direct deposit form received
Background Check (if possible) after first 60 hours worked
Notes
Submit
Should be Empty: