Careworthy Home Care Employment Application

Relevant Information
Date You Can Start*

MonthDayYear
Salary Desired*
Position Interested In (check all that apply):*

Full TimePart TimeTemporaryFloater
Please confirm that you are aware that effective July 1, 2025, Indiana state law requires personal services agencies like Careworthy Home Care to report any individual who applies for employment with our agency that is found to have a prohibited crime on their record?*

Yes, I am aware of this new law
Have you EVER had any abuse findings, neglect findings or misappropriation findings on any state nurse aide registry, Indiana or otherwise, regardless of how long ago it happened?
Have you EVER been barred from participating in any Medicaid program? Are you currently or have you ever been listed on the Office of the Inspector General's Exclusion list due to past offenses?
Do you have a felony conviction for controlled substance charges?
Do you have a conviction for DUI that resulted in bodily injury, catastrophic injury or death?
THEFT QUESTION: Do you have a conviction (misdemeanor or felony) for any theft related crimes, including, but not limited to, shoplifting, criminal conversion, burglary, robbery, attempted robbery, identity theft, identity deception, embezzlement, check forgery, petty theft, grand theft, larceny, fraud, receiving stolen property, carjacking, etc. This does not include any crime that has been successfully expunged. We are only asking about crimes still on your record. *
If you answered "YES" to the theft crime question, please explain below:
CRIME OF VIOLENCE QUESTION: State law prohibits any home care agency from employing or contracting with any person who has been convicted of a crime involving Murder, Attempted Murder, Involuntary Manslaughter, Voluntary Manslaughter, Reckless Homicide, Battery, Domestic Battery, Aggravated Battery, Kidnapping, Rape, Criminal Deviate Conduct, Child Molesting, Sexual Misconduct with a Minor (Level 1 or Level 2 felony), Robbery (Level 2 or Level 3 felony), Burglary (Level 1, 2, 3 or 4 felony), DUI causing death or catastrophic injury, DUI causing serious bodily injury to another person, Child exploitation (Level 4 or Level 5 felony), Resisting law enforcement (felony), Unlawful possession of a firearm by a serious violent felon, and/or Strangulation (Level 5 felony). DO YOU CURRENTLY HAVE ANY CONVICTION (MISDEMEANOR OR FELONY) FOR ANY OF THE AFOREMENTIONED CRIMES THAT WOULD BAR YOU FROM WORKING AS A CAREGIVER? This does not include any crime that has been successfully expunged. We are only asking about crimes still on your record. *
ADDITIONAL CRIMINAL HISTORY QUESTION: State law prohibits any home care agency from employing or contracting with any person who has been convicted of a crime involving theft, battery, murder, manslaughter, sex crime, exploitation of an endangered adult, abuse or neglect of a child and failure to report battery, neglect, or exploitation of an endangered adult or dependent. We perform a Nationwide background check. Do you currently have any conviction (misdemeanor or felony) for any of the aforementioned crimes that would bar you from working or contracting as a caregiver? This does not include any crime that has been successfully expunged. We are only asking about crimes still on your record. *
If you answered "YES" to the criminal background question, please explain below:
Do you have an active, valid Indiana Driver's license with no violations and accidents?

Yes, I have a valid Indiana driver's license with no violations or accidentsI have a valid driver's license but have violations / accidents in the last 3 yearsI have a valid driver's license but have violations / accidents more than 3 years agoI do not have a valid Indiana driver's license and seeking a non-driving position

Skills/Qualifications:
Why do you want to be a caregiver for our agency?*
List three words that describe your personality:*
What skills and experience do you have that are useful in the role of a caregiver? Feel free to be as in depth as possible.*
Have you ever worked in a home or facility and used a Hoyer lift on a client?
Have you ever worked with a client on oxygen?
Have you ever worked with a client with intellectual disorder or mental health disorder?
Have you ever had to give a full shower bath or a full tub bath to a client in a residential facility or in a home setting? (Do not use classroom experience)
Have you ever had to give a partial bath to a client in a residential facility or in a home setting? (Do not use classroom experience)
Have you ever worked with an incontinent client before that required assistance with toileting and/or changing soiled diapers/depends? (Do not use classroom experience)
Have you ever had to perform light housekeeping for a home care client including, but not limited to, washing dishes, cleaning toilet, cleaning tub, sweeping, mopping and laundry?
GROOMING REQUIREMENTS: Our personal Care Assistants help clients with their personal hygiene as part of their role. The amount of assistance will vary from client to client but may include, bathing, assisting with bathing, assisting with oral hygiene, assisting with combing hair, assisting with applying lotion and deodorant and dressing. Do you understand this is part of the job and are you willing to perform these duties if hired? *
TOILETING REQUIREMENTS: Our personal Care Assistants may have to help a client with their toileting and elimination. This includes assisting to and from the bathroom, assisting with clean up, assisting with Depends or diapers, assisting with bedside commodes, etc. Do you understand this is part of the job and are you willing to perform these duties if hired? *
LIGHT HOUSEKEEPING REQUIREMENTS: Our personal Care Assistants perform light housekeeping to support our clients in maintaining a clean, hygienic, and safe home. Light housekeeping will include washing dishes, sweeping, mopping, vacuuming, dusting, cleaning and sanitizing bathrooms, changing bed linen, doing laundry, taking out trash, etc. Do you understand this is part of the job and are you willing to perform these duties if hired? *
MEAL PREP REQUIREMENTS: Our personal Care Assistants help clients with their nutrition as part of job responsibilities. This includes, but not limited to, meal planning, meal prepping, cooking, plating the food, grocery shopping, visiting pantries, etc. PCAs are expected to prepare hot meals for clients as part of their duties. Do you understand this is part of the job and are you willing to perform these duties if hired? *
CPR Certification Status*

I have attended in person CPR training in the past and my certification is still validI have attended in person CPR training in the past but my CPR cert has expiredI have a valid CPR certification but I have never attended in person trainingI have never held a valid CPR certification
List any additional relevant training you have received, including caregiving training, health & safety training, dementia training, culinary training, etc.*
Anything else you would like to share:*

Education:
High School*
Name of High School Attended
Graduated High School?*
College*
Name of College/University Attended
College Status?*
List of other professional training, licenses or certifications:*
i.e. Home Health Aide, CNA, LPN, Medical Assistant, etc.
Have you EVER held a professional license in another state besides Indiana? This includes any MA, HHA, CNA, QMA, LPN, RN license and /or certifications, even if that license is currently expired.*

Yes, I had a license in another state or country beforeNo, I never had a license in any other state besides IndianaI have never held any professional certification or license in any state or country, including Indiana
If you answered yes to the previous question, please share which state(s) you hold or held professional licenses or certifications in.*

Mandatory Job History
Employer #1 *
i.e. Name of Family
Position*
Your job title
Employer Start Date*

MonthDayYear
Employer End Date*

MonthDayYear
Duties and Responsibilities*
Please include an in-depth job description
Reason for Leaving*
Employer #2
i.e. Name of Family
Position
Your job title
Start Date

MonthDayYear
End Date

MonthDayYear
Duties and Responsibilities
Please include an in-depth job description
Reason for Leaving
Employer #3
i.e. Name of Family
Position
Your job title
Start Date

MonthDayYear
End Date

MonthDayYear
Duties and Responsibilities
Please include an in-depth job description
Reason for Leaving

References:

Please include at least three; at least 1 must be a former employer. A signed reference form is required for each reference. Please click the link and sign a reference form for each reference.
Reference # 1*
Full name of reference
Reference # 1 - Authorization Form

Please complete a reference form for the aforementiond applicant.

For a professional reference, click here
Did you complete the authorization form for Reference #1 ?

YesNo

References:

Please include at least three; at least 1 must be a former employer. A signed reference form is required for each reference. Please click the link and sign a reference form for each reference.
Reference # 2*
Full name of reference
Reference # 2 - Authorization Form

Please complete a reference form for the aforementiond applicant.

For a professional reference, click here
Did you complete the authorization form for Reference #2 ?

YesNo

References:

Please include at least three; at least 1 must be a former employer. A signed reference form is required for each reference. Please click the link and sign a reference form for each reference.
Reference # 3*
Full name of reference
Reference #3 - Authorization Form

Please complete a reference form for the aforementiond applicant.

For a professional reference, click here
Did you complete the authorization form for Reference #3 ?

YesNo

Attachments
Optional: Please Upload Your Resume

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Optional: Upload Copies of any Professional Certifications or Licenses you hold

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Optional: Please Upload Copy of your CPR Certification

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Optional: Please Upload Copy of your TB Skin Test Results

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Optional: Please Upload Proof of Auto Insurance

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I certify to Careworthy Home Care Services that the information provided on this employment application are true and complete to the best of my knowledge, and I consent Careworthy Home Care Services in processing personal data about me for purposes related to my employment. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my termination of employment.
Applicant Signature

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Caregiver Application

Relevant Information

Skills/Qualifications:

Education:

Mandatory Job History

References:

References:

References:

Attachments