Application for Employment
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
Basic Information
How did you hear about us?
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Applying for:
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Full Time Hourly
Part Time Hourly
24 Hour Live-in
Name
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First Name
Middle Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
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Please enter a valid phone number.
Cell Phone Number
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Please enter a valid phone number.
Email
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example@example.com
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Certifications
Are you a CNA or Certified Caregiver?
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Yes or No
For how long?
CNA/ Caregiver License Number & Expiration Date
License Number
Expiration Date
Are you CPR Certified?
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Yes
No
Expiration Date?
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Month
-
Day
Year
Date
Are you First Aid Certified?
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Yes
No
Expiration Date?
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-
Month
-
Day
Year
Date
Do you have a Fingerprint Clearance Card?
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Yes
No
Fingerprint Card Number & Expiration Date
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Fingerprint Card Number?
Expiration Date
Do you have experience with any of the following?
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Parkinson's
Alzheimer's
Dementia
Hospice Care
Diabetes
Other conditions with experience?
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How may years of Caregiving experience do you have overall?
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Other Qualifications
Highest Level of Education?
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Have you ever been convicted of a crime?
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Yes
No
Do you have a Valid TB Test in the last 12 months?
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Do you have a current Driver's License?
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Yes
No
Expiration Date?
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-
Month
-
Day
Year
Date
Do you have reliable transportation?
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Yes
No
Do you have current auto insurance?
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Yes
No
Expiration Date?
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How far are you willing to commute?
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Are you willing to transport client in their vehicle?
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Yes
No
Do you have a valid TB Test in the last 12 months?
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Yes
No
Are you an experienced cook?
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Yes
No
Do you have experience with Hoyer Lifts?
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Yes
No
Can you lift and transfer a client?
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Yes
No
With assistance up to what weight?
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Do you smoke?
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Yes
No
If Yes, how often?
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Are you agreeable to random drug testing?
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Yes
No
Have you or any family members been employed with us before?
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Previous Employment History
First Most Recent Employer Company Name:
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Are you currently employed here?
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May we contact?
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Yes
No
City/State
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Phone Number
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Please enter a valid phone number.
Supervisor's Name?
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Dates Employed?
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Job Title
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Hourly/Salary Wage?
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Pay Type?
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Duties Performed?
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Reason for Leaving?
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Second Most Recent Employer Company Name?
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Are you currently employed here?
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May we contact?
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Yes
No
City/State?
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Phone Number
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Please enter a valid phone number.
Supervisor's Name
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Dates of Employment?
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Job Title
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Hourly/Salary Wage?
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Pay Type?
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Duties Performed?
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Reason for Leaving?
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Third Most Recent Employer Company Name?
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Are you currently employed here?
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May We Contact?
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Yes
No
City/State?
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Phone Number
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Please enter a valid phone number.
Supervisor's Name
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Dates Employed
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Job Title
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Hourly/Salary Wage?
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Pay Type
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Duties Performed?
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Reason for Leaving?
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Are you available for 24 hour Live-in?
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Yes
No
How many hours a week preferred?
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Please indicate the times you are available to work
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Daytime Hours Available
Night Time Hours Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Note: All night shifts require the Caregiver to stay awake.
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Please initial above that you understand the above statement.
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Skills Assessment
This basic skills checklist is a tool to be used in your clinical experience to guide you in determining what skills you and what experiences you have performed in the past. This basic skills checklist is a tool to be used for placing you with clients that meet the needs you have experience with. Please select only one of the options that best describes the amount of experience you have with the skills listed below.
Daily Patient Care
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N/A or 0
3-6 Months
6-9 Months
1-2 Years
2-4 Years
4+ Years
Bathing (Bed bath, sitz)
Oral Care
Feeding Patients
Positioning Patients
Intake/Output
Vital Signs (BP, Pulse, Respiratory Rates)
Bed Operation
Range of Motion
Daily Weight
Medication Reminders
Procedures/Equipment
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N/A or 0
3-6 Months
6-9 Months
1-2 Years
2-3 Years
4+ Years
Gait Belts
Hoyer Lift
Bath Lift
Total Transfer from bed to chair
Monitor for skin breakdown
Elimination - Peri Care & applying barrier cream to buttock
Change adult briefs
Empty Catheter
Blood glucose monitoring
Infection Control Procedures
Oxygen therapy (nasal cannula, face mask)
Documentation
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N/A or 0
3-6 Months
6-9 Months
1-2 Years
2-4 Years
4+ Years
Reading Care Plans
Daily Flow Sheets
Patient Education Materials
Incident Reports
Emergency Procedures
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N/A or 0
3-6 Months
6-9 Months
1-2 Years
2-4 Years
4+ Years
CPR/First Aid
Heimlich Maneuver
Disruptive Patient
Seizure Precautions
Anaphylactic Reaction
Other
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N/A or 0
3-6 Months
6-9 Months
1-2 Years
2-4 Years
4+ Years
Post Mortem Care
Fall Prevention
Alzheimer's Disease
Parkinson's Disease
Dementia
Stroke
Seizure
Cancer
Hospice
Diabetes
Pediatric Experience
Meal Preparations for Diabetics, renal disease etc
Any additional experiences that will help place you with a client?
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Disclosure to Employment Applicant Regarding Procurement of a Verification of Employment
Pleasebe advised that we may also obtain an investigative report includinginformation as to your character, general reputation, personal characteristics,and mode of living. This information maybe obtained by contacting your previous employers or references supplied byyou. Please be advised that you have theright to request, in writing, within a reasonable time, that we make a completeand accurate disclosure of the nature and scope of the informationrequested. Such disclosure will be madeto you within 5 days of the date on which we receive the request from you orwithin 5 days of the time the report was first requested. By your signature below, you hereby authorize us toobtain the information from your previous employers in order to consider youfor employment.
Name
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First Name
Middle Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
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Last 4 digits of Social Security Number?
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Do you have any restrictions?
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Cats
Dogs
No Smokers
No Driving
Other
Submit
Should be Empty: