• BROWN COUNTY DEVELOPMENTAL SERVICES, Inc.

    "Expanding Horizons for People with Developmental Disabilities"

  • PERSONAL INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you a US Citizen?
  • Date Available to Begin Working
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you been convicted of a criminal offense?
  • If selected for employment, are you willing to submit to a DRUG TEST, CRIMINAL RECORD check, ABUSE REGISTRY check, and MOTOR VEHICLE RECORD check?
  • Do you have a current, valid driver's license?
  • If yes, are you comfortable driving BCDS clients in BCDS vans in the community and occasionally out of town? (must be 21 or older to drive BCDS vehicles)?

  • FITNESS FOR POSITION:

  • Staff duties may include assisting a person to stand, sit, get off the floor, sit in a wheel-chair, on to the toilet, into a shower, in and out of bed, onto a ramp van including strapping wheelchairs down which requires bending, pushing a wheelchair outdoors and inside, assisting people using a gait belt, and similar duties. The majority of BCDS clients do not require this much assistance. BCDS also requires 2 staff for any lifting of people including when using hydraulic lifts, or repositioning. Job duties could also require use of vacuums, lifting grocery sacks, wet mop-ping, lifting laundry baskets or similar household duties and equipment. 

  • EDUCATION

  • High School - Did you receive a Diploma?
  • If you did not, do you have your GED?
  • Did you attend college?
  • How many years? 1 2 3 4 yrs.
  • Degree Attained
  • Are you currently certified in CPR and/or First Aid?
  • Have you received Hepatitis-B vaccinations?
  • If not, do you want to receive them?
  • Are you interested in health or dental insurance?
  • retirement plan?
  • Section 125 plan?
  • You will earn paid time off for every hour worked. Do you want full-time?
  • Part time?
  • Can you work part time until full time is available?
  • If part time, can you substitute for absent staff?

  • All shifts vary in length and time of day.

  • EMPLOYMENT - List below last three employers, most recent first.

  • Rows

  • PERSONAL REFERENCES - List 3 people NOT related to you that would provide you a personal reference.

  • Rows
  • I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for in this application can be cause for dismissal.
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Brown County Developmental Services is an equal opportunity employer dedicated to a policy of non-discrimination in employment on any basis including race, creed, color, age, sex, religion or national origin.
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