| Full Name: (Required) | |
| Phone: (Required) | |
| Email: | |
| Do you have reliable transportation? | yes no |
| Are you available weekends? | yes no |
| What shift are you available? | |
| Do you have two forms of ID with you today? | yes no |
| Have you ever been convicted of a crime? | yes no |
Do you have any functional limitations that would prevent you from performing the work for which you are applying? | yes no |
| Have you ever been injured? | yes no |
Which of the following certifications, if any, do you have? | CPR HHA CNA Other |
Which of the following skills, if any, have you been trained in (but not certified)? | CPR HHACNAOther |
Which of the following groups have you had experience taking care of in the past? | Adult Elderly Adolescents
Children Infants |
What in your past experience makes you qualified for this position? | |
Please answer the following questions: |
Are you trained in carrying out the duties of transferring a person to and from a bed, chair, or portable potty? | yes no |
Can you work live-in assignments? | yes no |
| If so, how many days per week? | |
Is there anything in the qualifications for this job that you cannot or will not perform? | |
Are you looking for long term or short term employment? | |
Can you monitor and document changes in behavior? | yes no |
How would you handle a patient who wanders? | |
What is your training with a person with memory loss? | |
Does smoking or drinking bother you? | yes no |
Do you smoke? | yes no |
Are you capable of preparing a meal if needed? | yes no |
Are you allergic to cats or dogs, or do you dislike any animals?
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| Would you on any occasion bring someone with you on a job assignment? | yes no |
| Do you have any problems understanding written or oral requests? | yes no |
| Would you be willing to agree upon a trail period for training and getting acquainted? | yesno |
The attached checklist allows you, the applicant, the opportunity to identify skills acquired throughout your work experience. It also allows the interviewer to ask specific questions about your home care background and skills. The checklist is used as a tool for exploring your experience Skills |
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Informed Consent Form Application Policies - We do not interview everyone who applies.
- This is not a job offer. We may not interview you today. We may call you another day for an interview.
- We will call you if we want to interview you
- We are an Equal Opportunity Employer.
I have read, understand and agree to cooperate with these policies. I also understand that the information I provide about myself on application forms, on tests, and during interviews will be used in making hiring decisions, and I consent to it being used for this purpose. |
| Signature (type name): | |
| Date: | |
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