At Home Healthcare Employment Application

At Home Healthcare Employment Application
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Earned Certificates
Other/additional training in senior home care
Most recent job held
Begin Date

MonthDayYear
End Date

MonthDayYear
Reason for leaving
Immediate supervisor name and contact #
List additional previous positions (Job title & brief description of duties) held in the home senior care field
Have you already completed a level 2 background screening & are able to provide a copy of the results?

YesNo
References: Name, relationship & contact number
References: Name, relationship & contact number
References: Name, relationship & contact number
Which days are you NOT available for work?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
What times (hours) are you NOT available for work?
How many hours per week are you looking for?

10-2020-3030-4040 or more
We offer multiple services to our seniors. Which of the following are you interested in providing services for?

In home care24 hour in home careOn call in home care1-2 hour companion visitsHouse cleaningHelping with chores outside of the houseOrganization of closets, garages, pantries etc.Packing and moving assistance
How many miles are you willing to travel for work?

5-1010-1515-2020-30
Please use this field to add any additional information about yourself or experience.
Job Related Skills
Language(s) (in addition to English)
Do you drive?

YesNo
License plate #
Car (Year, make, model and color)
2 Door or 4 Door?

2 Door4 Door
Is freeway driving ok?

YesNo
If you do not drive, what will be your primary means of getting to and from work?

BusRidesWalkBike
Are you a smoker?

YesNo
Are you willing to work in a smoking environment? If not, please explain.
Do you prefer male or female clients?

FemaleMaleEither is fine
Do you have pet allergies? If so, kindly specify.
Can you do transfers?

YesNo
If so, how much can you support? (lbs.)
If no, please state reason.
Do you have any physical limitations that would prevent you from performing your duties?

YesNo
If yes, please explain briefly.
Do you have any allergies that may affect your job performance while in a patient's home?

YesNo
If yes, please explain briefly.
Do you have any other training qualifications or skills which you feel make you especially suited to work for us?

YesNo
If so, please explain.
Do you have a CPR card?

YesNo
If yes, date issued

MonthDayYear
Do you have a First Aid Card?

YesNo
If yes, date issued

MonthDayYear
Are you a Certified Home Health Aid?

YesNo
If yes, C.H.H.A. # and exp. date
Are you a Certified Nurse ?

YesNo
If yes, C.N.A. # and exp. date
Other certifications kindly specify.
Medical equipment and experience. Please check all that apply

NoneAlzheimerBoard and CareBP monitoring/pulse/tempCatheterColostomy CareCOPDNebulizerParkinsonStroke PatientDementiaDiabetesFacility/HospitalFeeding tubeGait beltGlucometerOxygen tankRetirement Hotel"Stand-up lift" (ex. SARA lift)G-tubeHip surgeryHospice careHospital bed (elec/manual)Hoyer liftHygiene/bathingMassages/ROM exercisesNon-ambulatory patientsResidential/one-on-one
Other, please specify.
Pre-Employment Test
Full Name

First NameLast Name
Date

MonthDayYear
Postion applying for.
Name two (2) forms of resident abuse.
Give an example of verabl abuse.
Give an example of physical abuse.
If a resident does not eat, you should..

Force food into his/her mouth.Encourage him/her to eat and report to a supervisor.Yell at him/her for not eating.Ignore him/her and take the food away.
You found a resident on the floor, what should you do?

Help him/her to get comfortable.Keep him/her calm and call for help.Leave him/her on the floor and go for help.
True or False
To ambulate, means a resident can walk.

TrueFalse
Temperature of 100.4 is normal.

TrueFalse
A resident with diarrhea loses fluid.

TrueFalse
It is alright to take gratuity (money or gift) from residents.

TrueFalse
Teasing a resident can be verbal abuse.

TrueFalse
Residents should be offered fluids, even if they don't ask for them.

TrueFalse
What is the best prevention against infection?
Name 5 times you SHOULD wash your hands.
If you discover a fire, you should:
Mix and Match

Match the numbers to the corresponding correct letter. Please record answers in the space below.

1. Reddened area

2. Water, jello, ice cream

3. Denture Cup

4. Oral Care

5. Infection Control

a. Teeth

b. Cleanliness

c. Fluid intake

d. Pressure area

e. Denture
Record answers here:
Kindly answer the questions below.
What do you like most about working with seniors/elderly individuals?
What do you find the least desirable about working with seniors/elderly individuals?
Discuss all training with seniors/elderly.
Should be Empty:

At Home Healthcare Employment Application

Job Related Skills

Pre-Employment Test