Application

Getting to Know You

Recruiter Email

example@example.com

First Name*

Last Name*

Full Name

Maiden Name

Aliases or Other Names

Cell Phone*

Home Phone

Birthday

Date

Email*

example@example.com

How were you referred to us?*

Current Address

Current Address 1*

Current Address 2

Current City*

Current State*

Current Zip Code*

Previous Address

Previous Address 1*

Previous Address 2

Previous City*

Previous State*

Previous Zip Code*

Have you lived in SC for the last 12 months?*

YesNo

Since you have NOT lived in SC for the last 12 months (Non-Resident), did you live in a previous state for more than 12 months?

YesNo

Great! SC requires us to gather information to prove that someone is a resident of SC or another state. Before your first interview, you will be asked to provide that information. If you'd like you can upload it here or provide that to your intake coordinator / recruiter. We only need ONE of these to be provided for SC or the previous state that you lived in for 12 months.

Drivers License / State ID

Bank Statements

Rent, Utilities, Mortgage

Pay Stubs in your name

Social Security Card

Ever lived in NY state?*

YesNo

NY state requires the individual to acquire their own background check. While this is unlike other states, we wanted to make you aware of this in advance of hiring.

OWN your own vehicle?*

YesNo

If you do not have your on car, you cannot discuss any PHI (protected Health Information) during your ride to or from work. This would be a violation of HIPAA.

Emergency Contact

Emergency Contact

First NameLast Name

Phone Number

Relationship to you

Education, Certifications and Training

Upload Resume (optional):

Years of Experience*

Not Family Caregiving

Last Year of School*

Certification / License

Active

YesNo

State

Certification / License

Active

YesNo

State

Certification / License

Active

YesNo

State

Certification / License

Active

YesNo

State

Any special training that you have received:

0/100

Ambulation*

Bed Bath*

Shower*

Tub Bath*

Dressing*

Incontinence Cleaning*

Change Adult Briefs*

Feeding a Patient*

Catheter Care*

Medication Reminders*

Oral Hygiene*

Dentures / Partials*

Oxygen*

Repositioning in Bed*

Bed Bound*

Toileting*

Transferring*

Using Gate Belt*

Using Hoyer Lift*

Using Transfer Board*

Client with Diabetes*

Client with Stroke*

Client with CHF*

Client with Parkinson's*

End of Life Care*

Taking Vital Signs*

Fall Precautions*

We have 2 categories of caregivers, Companion and Home Health Aid. Here is the difference between the 2 categories.

Companion	Home Health Aid
Transportation	Incontinence Care
Companionship	Bathing
Light Housekeeping	Bed Bound
Running Errands	Transferring, Lifts
Pet Care	Hands On Care
Play Games	Advanced Disease Management

Which category are you?*

Stating that you are a Home Health Aid category means that you both have the skillset AND the willingness to perform those tasks. Merely having the skills does not qualify you as a Home Health Aid, you need to be willing to accept clients at that level of care. This is a factor in considering pay scale.

Are there situations that you do NOT want to work with?

Light housekeeping ok:*

YesNo

Negative TB Test*

YesNo

Accommodation Needed*

YesNo

List any accommodations needed for work:

Work History

Last company*

Position you held:*

Approximate Start Date:

Date

Approximate End Date:

Date

Starting Pay:

Ending Pay:

Supervisor's Name:

Phone Number:

Email Address:

Job Duties:

What caused you to leave this company?

0/100

2nd to Last Company:*

Position held:*

Approx. Start Date:

Date

Approx. End Date:

Date

Starting Pay:

Ending Pay:

Supervisor's Name:

Phone #:

Email Address:

2nd to Last Job - Job Duties:

2nd to Last Job - What caused you to leave this company?

0/100

Required for background checking:

Legal US citizen*

YesNo

Any criminal record:*

YesNo

Please explain any misdemeanor or felony convictions or pending cases:

0/100

Social Security Number

Gender

Ethnicity

What you're looking for in a new team:

Desired Hourly Pay:*

Ideal # of hours/week*

Desired start date

Date

Days or Nights Desired*

DayNight

Available weekends*

YesNo

Full time or Part time*

FTPT

That's great new! Working weekends will definitely help to increase your pay! You MUST work weekends howeever to get higher rate of pay.

What is your true availability to work?*

What are the most important considerations for you in joining the team? *

SC Dept of Public Health Required Training:

Employment Application