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  • Employee Intake Form Instructions

    Complete the information below to apply with Kalkaal Home Care. You must also upload a copy of your Drivers License or State ID, Social Security Card for background study verification, and PCA Certificate. When your background study/enrollment is completed you will receive an invitation to complete your pre-employment paperwork (W4, I9, Direct Deposit, etc.). Please have your IDs available to re-submit at that time for I9 verification. When you are approved to work you will receive a Start Work Letter. You are not approved to work and not an employee until you receive a signed Start Work Letter from our office.

  • Application Date*
     - -
  • Job Title*
  • Application type?*
  • Which gender do you identify with?
  • Expiration Date*
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Are you 18 years old or older?*
  • If you are under 18 years old, have you worked for another agency?
  • Are you a previous employee?*
  • Have you Lived outside Minnesota in the last five years? Inaccurate information may delay the background study*
  • Do you receive services, or have you received services in the past 12 months?*
  • Do you currently have a PCA/CFSS certification? *

  • If you are not already certified, please use the following link to complete the PCA/CFSS training and test.

    PCA and CFSS Training and Test

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  • Review the Data Privacy Notice (DHS-6276)
  • Review the Background Study Notice:
  • Review the Kalkaal Home Care Employee Manual:

  • Use the following links to complete the require forms: 

    • DHS-4611: Individual Direct Support Worker Provider Agreement
    • Direct Deposit Authorization Form
    • W4
    • I9

    Please note that all the required fields must be filled out for each of the linked forms. The forms are compatible with a laptop, tablet, or phone. Please reach out to us if you have issues and require additional assistance. 

  • Are you enrolled with Medicare?*
  • Have you ever been convicted of a criminal offense related to your involvement in any program under Medicare, Medicaid, Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the inception of these programs?*
  • Have you ever had civil money penalties or assessments imposed under section 1128A of the Social Security Act?*
  • Have you ever been excluded from participation in Medicare or any of the State health care programs?*
  • Medical Reimbursement Plan*
  • Preferred Method(s) of Contact*
  • Do you consent to having sensitive information discussed via voicemail or text messages?

  • Form Submission:

    Please make sure to click Review Answers -> Continue -> Sign Document  after completing the application to ensure that its correctly submitted.

    You are free to save your submission and continue it at a later time if you choose to do so, but this is not mandatory. Additionally, we do not recieve saved submissions that have not been signed and submitted. 

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