Caregiver Job Application form
LAST, FIRST MIDDLE
*
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Phone number
*
Email
*
Address
*
Are you legally authorized to work in the US:?
*
YES
NO
Which position(s) are you interested in?
*
Life Skills Development 1- Companion
Life Skills Development 2- Supported Employment
Supported Living
Personal Support
Respite
Employment desired: [Check All That Apply]
*
Part-Time
Full-Time
Contract
PRN
A minimum of 3 years of caregiving or equivalent skills that are verifiable are required to be employed here. Do you meet this qualification?
*
YES
NO
When are you available to start work?
*
-
Month
-
Day
Year
Date Picker Icon
How many hours can you work weekly?
*
Are you available to work weekends?
*
YES
NO
Are you available to work nights?
*
YES
NO
Would you consider live-in?
*
YES
NO
We require a Level 2 screening to be conducted on ALL staff. Are you willing to obtain this screening in order to provide proof of clearance to work?
*
YES
NO
We require a Local Law Records Check from your county of residence to be conducted on ALL staff. Are you willing to obtain this records check in order to provide proof of clearance to work?
*
YES
NO
Have you ever been convicted of a crime?
*
YES
NO
If yes, explain.
A minimum of a High School Diploma or GED is required to apply. Do you have a minimum of a High School Diploma or GED?
*
YES
NO
The following initial trainings are required to be taking through train.org in order to provide direct care to clients receiving services from this agency. Check all that you have.
*
1) APD - Health Insurance Portability and Accountability Act
2)APD - Requirements for All Waiver Providers
3) APD - Zero Tolerance
4)APD - Direct Care Core Competencies
5)FDOH HIV/AIDS 101 In the News
6)FDOH Bloodborne Pathogens -Part 1
7)FDOH Bloodborne Pathogens -Part 2
8) CPR/First Aid/AED (Red Cross, American Heart Association or HSI)
Do you have a driver’s license?
*
YES
NO
Do you have a car?
*
YES
NO
If no, do you have a reliable way to work?
*
YES
NO
We require a Drivers Record Check on ALL staff who transport clients to be conducted. Are you willing to obtain this records check in order to provide proof of clearance to work?
*
YES
NO
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Companionship
*
No Experience
Some Experience
Good Experience
Excellent Experience
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Meal Preparation
*
No Experience
Some Experience
Good Experience
Excellent Experience
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Light Housekeeping
*
No Experience
Some Experience
Good Experience
Excellent Experience
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Bathing / Showering
*
No Experience
Some Experience
Good Experience
Excellent Experience
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Dressing / Grooming
*
No Experience
Some Experience
Good Experience
Excellent Experience
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Transferring
*
No Experience
Some Experience
Good Experience
Excellent Experience
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Incontinence Care
*
No Experience
Some Experience
Good Experience
Excellent Experience
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience Dementia / Alzheimer’s Care
*
No Experience
Some Experience
Good Experience
Excellent Experience
Please provide the name, title, company name, email address and phone number of 3 non related professional references that we may contact.
*
By typing your name below you acknowledge and confirm the information provided to be true to the best of your knowledge.
*
*
-
Month
-
Day
Year
Date Picker Icon
Submit
Should be Empty: