Pennsylvania Questionnaire

Extended Stay Live-in care Questionnaire

This Caregiver Profile Sheet is used for us to get to you know you better.
Your Name

First NameLast Name
Cell Phone
Cell Phone
Your email address
Optional
MY LOCATION

CITYSTATE
I got this Questionnaire from:

Ellee ( Ellington) Text me the LinkDirectly from the TravelingCare365.com WebsiteI don't remember
I am willing to submit to a Nationwide fingerprint Criminal Background Check

NoYesI am not sure
I am willing to submit to a Pre-employment Drug Test ?

NoYes
I'm aware that the Gross Pay Rate is $1065 for a 7 day week

YesThis pay rate is Not Enough for Me
Our recruiting team works 7 days a week and is available to offer travel suggestions, travel options and alternatives so that caregivers arrive at their destinations as planned. Part of your recruiter's job will be to schedule your arrival date and time at the agency. The office will be anticipating each person's arrival on that day.
Are you legally Authorized to work in the USA

NoYes
I have two forms of valid Identification

NoYes
PLEASE CHECK ONE ( Please note that you certificate status will not determine your eligibility)

I am an HHAI am a CNAI passed the Adult Residential Licencing ExamNone of the above
Number of years working as a Caregiver?

0 - No Experience0 - 12 - 56 - 12Over 13
I understand that its Live-In Work Only

Yes, and I am able to do Live-in assignmentsBut I cannot do Live-In
How long I am available to work on assignments:

I can work 2 - 3 weeks and return home for a break.I Can Stay on assignment and available for continued extended stay Live-In Opportunity ( At Least 8 Weeks)I can do extended stay (several weeks at a time) but less than 8 weeks at a time.
I am Currently

UnemployedWorking but I want more workWorking but Would like to Change Jobs
Are you Okay with bathing a Female Client

NoYes
Are you Okay with bathing a Male Client

NoYes
Would you Work with a Client that Smokes

NoYes
Regarding working in a home with PETS ( TRY TO ONLY CHOOSE 1 ANSWER )

Okay with Cats or DogsOkay only with CatsOkay only with DogsOk with cats and small dogs onlyWill Not work in a home with Pets
Is there any type of Assignment that you would Refuse to Accept ?

NoYes
Regarding the Clients Living arrangement. I am Okay with a Client-

That lives aloneWho lives with their partnerThat lives with other family members
Do you have a Driver's License

NoYes
Do you have a Vehicle (Car NOT Required)

NoYes
Regarding Cooking and or Meal Preparation

I am a Good Cook, can follow instructions and cook what the clients asks forI am an Average Cook but can learn quickly to follow instructionsI do not like to cook, someone else should cook for the client
I was instructed by my recruiter that I must bring Scrubs ( Medical Uniforms) and Closed Toe footwear. Exp: Sneakers, Medical Work Shoes or Crocks.

NoYes
How did you hear about this Job ? Name of the Person who Referred you?
Name and their Phone Number
Are there any type of clients you would refuse to work with ? PLEASE EXPLAIN.
Professional Reference
Name and Telephone Telephone Number
Are you available to start work immediately

NoYes
If not, please provide an estimate of when you would be available to start

MonthDayYear
Date
Should be Empty:

Extended Stay Live-in care Questionnaire