Caregiver Job Application

ALLIANCE HOME CARE

Job Application
Personal Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip
Social Security Number*
Date of Birth*

MonthDayYear
Cell Phone Number*
E-mail*
example@example.com
Emergency Contact Name*
Emergency Contact Phone Number*
Languages Spoken
Cities/Counties Preferred to Work
Can you perform all the job-related functions of the position(s) with or without any special accommodation?*

YesNo
Please explain

Caregiver Job Description
I understand that my job/responsibilities as caregiver will include but not be limited to the following:
Provide personal care service to the client for which the client needs physical assistance.

Some examples of Personal care are listed below:

• Ambulation – physically assisting a patient who otherwise would be unable to move about independently

• Personal hygiene – which includes bathing the patient

• Dressing – physically applying a patient’s clothing to the patient’s body

• Toileting – assisting a patient to go to and from toileting facilities and in the activities of toileting.

• Eating – includes hand feeding a patient who is incapable of self-feeding

• Provide competent, state of the art care to its patients.

• Follow the Caregiver Service Plan (CSP) or the plan of care to perform the tasks agreed upon.

• For security reasons, the caregiver should not disclose or knowingly permit the disclosure of any information in a client record except to appropriate provider staff, the client, responsible party (if applicable), the client's physician or other health care provider, the regulatory department, other individuals authorized by the client in writing or by subpoena.

• In case of an emergency at a client's home, the caregiver must immediately contact the Client's emergency contact name (as stated in the client's file) and notify the Alliance Home Care office.

- The caregiver must notify the Alliance Home Care office and the Client's responsible party of any changes in the Client's condition.

- The caregiver is encouraged to report to the office any changes that may improve the quality of care a patient is receiving.

- Reports to Administrator.

I understand that the clients I will be working with are the clients of Alliance Home Care, LLC. I also understand that in the event the contract between Alliance Home Care LLC and the client(s) is terminated due to any reason, I cannot work with that client or their family for at least one year either independently or with another agency. Should this happen, Alliance Home Care, LLC will take full legal action.
Signature*
Orientation

Please read and enter initials*

	Initials
Objectives and philosophy of the organization
Confidentiality
Client rights
Mandated reporting of abuse, neglect, exploitation
Applicable personnel policies
Emergency preparedness procedures
Infection control practices and measures
Cultural awareness
Applicable laws, regulations and other policies and procedures that apply to specific positions

Signature*
Attach File (CLEAR photo of two forms of ID)*

Cancelof
Attach File (CLEAR photo of your home care certificate)

Cancelof
Attach File (CLEAR photo of your CPR card)

Cancelof
Attach File (CLEAR photo of your TB test)

Cancelof

	Yes	No
Have you ever been exposed to anyone who has been sick with TB in the last two years?
Have you lived or traveled to Africa, Western Europe, Russia, Mexico, Central or South America, India or the Philippines?
Have you lived or worked in a correctional facility, long term care facility or homeless shelter?
Are you infected with HIV?

	Yes	No
New productive cough lasting for more than 2 weeks
Coughing up blood
Night sweats lasting more than 1 week
Fever and/or chills lasting more than 1 week
Unintentional weight loss over the past 2 months
Unusually/excessively tired over the past 3 weeks

	Yes/No	1	2	3	4
Bathing
Grooming (i.e. hair, oral, nail and skin care)
Toileting (i.e. assisting to bathroom, bed pan, changing, diapers, etc.)
Dressing & changing clothes
Mobility, ambulation & transfers
Assist eating & drinking/feeding

	Yes/No	1	2	3	4
Grocery shopping
Transportation/traveling in the community
Laundry
Handling money
Using the telephone
Reading of specific items
Washing equipment

ALLIANCE HOME CARE

Personal Information

Education Information

References

Verification of Previous Employment

Sworn Disclosure Statement

Consent For Criminal Background Check

Hepatitis B

Caregiver Job Description

Orientation

Initial Competency Evaluation Form