Ability to Work Form

Name

By completing the form below, you agree that you are able to perform the tasks required of a Home Health Aide or Direct Support Professional (DSP).

Please answer the following questions:

1. Are you pregnant?

If you are pregnant, how many months pregnant are you?

2. Have you had complications with this or any previous pregnancies that would keep you from performing the types of tasks required for a Home Health Aide or Direct Support Professional?

If you answered yes to the above question, please explain

3. Are you currently under a doctor's care for any physical or mental challenges, or conditions that would keep you from performing tasks required for a Home Health Aid or Direct Support Professional

If you answered yes to the previous question, please explain

4. Are you able to work in a private residence?

If you answered no to the previous questions, please explain

5. Are you physically able to stand?

6. Are you physically able to sit?

7. Are you physically able to stoop and squat?

8. Are you physically able to kneel or get down on your knees?

9. Are you physically able to bend at your hips?

10. Are you physically able to crouch?

11. Are you physically able and willing to assist with pivots, transfers, bed baths, showering, or assisting a client on and off of a toilet or bedside commode?

If you answered "No" to any of questions 5 through 11, please explain below:

Signature of applicant

Date

Statement Of Ability To Work