EMPLOYMENT APPLICATION for HOME CARE WORKER
Personal Information
Name
First _____________________________________________________2ndInitial___________
Last: _______________________________________________________________________
Address
Street: ____________________________________________________Apartment:_________
City: _________________________________State:______________ Zip:_________________
Phone
Home: _______________________________Cell: _________________________________
Other: ____________________________________________________________________
Electronic
Email Address: ____________________________________________________________________
Date of Birth
Day: ___________ Month:______________________ Year: __________________
SSN
Social Security Number: ______________________________________________
Gender
Male:_______Female: ________
Language
What languages do you speak? _____________________________________________________
______________________________________________________________________________
Emergency Contact
Name & Phone Number of Person to contact in the event of an emergency:
Local: ________________________________________________________________________
Out-of-Area: ___________________________________________________________________
Education
Formal
Diploma: _________________________________________________________________
Certificate: _______________________________________________________________
Degree: __________________________________________________________________
Other: ___________________________________________________________________
Other: ____________________________________________________________________
Informal
Do you have current First Aid Certification (State Level): _________Expiry Date:_______________
Do you have current CPR? _______ Expiry Date: _____________________________________
Have you taken a Food Safety course? _______________________________________________
Other: ____________________________________________________________________
(Specify)
Other: ____________________________________________________________________
(Specify)
Restrictions
Work
Limitations
List any work limitations that you may have and briefly describe:
Hearing: ___ Yes ____ No __________________________________________________
Speech: ___ Yes ____ No __________________________________________________
Lifting: ___ Yes ____ No ___________________________________________________
Health: ___ Yes ____ No____________________________________________________
Physical: ___ Yes ____ No____________________________________________________
Emotional: ___ Yes ____ No____________________________________________________
Other: ___ Yes ____ No ____________________________________________________
Availability for Work
Hours & Days Available for Work
_______Full-time _________ Part-time ___________ Short-notice ___________Split Shift
Indicate Days and List Hours Available for Work:
____Sunday: From: ____________________________ To: ______________________
____Monday: From: ____________________________ To: ______________________
____Tuesday: From: ____________________________To: _____________________
____Wednesday: From: _____________________________To: ______________________
____Thursday: From: _____________________________To: ______________________
____ Friday: From: _____________________________To: ______________________
____Saturday: From: ____________________________ To: ______________________
What is the minimum number of hours you will work in one day? ________________
What is the maximum number of hours you will work in one day?________________
Type of Work Seeking
Type of Position(s) Preferred
_______ Home Maker ______ Personal Care _____ Companion ________ Live-In
________ Other: ________________________________________________________________
(Specify)
Live-in care usually requires that you to in a client’s home continuously for 3-4 days at a time every week. Indicate which shifts you will accept:
____Weekdays (Monday a.m. to Friday a.m.) _______Weekends: (Friday a.m. to Monday a.m.)
Clients Not Willing/Able to Work With
_____ Dementias/Alzheimer’s _____ Physical Disabilities
_____ Smokers _____ Pets
_ _____ Females
_____Behavioral Disorders _____ Males
_____ Elderly (over 65) _____ Client use of marijuana for medicinal purposes
_____ Children _____ HIV Positive/Aids
_____ Other: ____________________________________________________________
(Specify)
Duties Not Willing/Able to Perform
_____ Bathing ____ Housekeeping
------- Grooming ____ Laundry
____ Oral Care ____Meal Preparation
____ Dressing ____Shopping
____ Bowel Care ____ Transportation
____ Bladder Care ____ Medication Reminding
____ Feeding ____ Friendly Reassurance Phone Call/Home Visit
____ Ambulation ____ Other _______________________________
Experience
Indicate which of the following you have experience in:
_____ Bathing/Showering ____ Housekeeping
------- Grooming ____ Laundry
____ Personal Hygiene ____Meal Preparation
____ Dressing ____Shopping
____ Bowel Care ____ Transportation
____ Bladder Care ____ Medication Reminding
____ Feeding ____ Friendly Reassurance Phone Call or Home Visit
____ Ambulation -------- Socialization
____ Toileting ____ Other _______________________________
(Specify)
Assignment
Location
Are you restricted in the geographical location you are willing/able to work? ___Yes ___No Explain: _______________________________________________________________________________
Transportation
Type
______Private Vehicle _____Bus _____Bike ________Other: ___________________________
(Specify)
Driver’s License
Do you have a valid Driver’s License?: ___________________
Transporting Clients
Are you willing to transport clients in your private vehicle? _______________________________
Do you have adequate vehicle insurance? ____________________________________________
Are you willing to drive a client’s vehicle? _____________________________________________
Are you willing to escort a client in their own vehicle? ____________________________________
Are you willing to escort a client on public transportation? _________________________________
Comments: _____________________________________________________________________
Abuse Investigation
Have you ever been investigated for abuse, neglect or domestic violence? If “yes”, explain:
___Yes___No _______________________________________________________________
______________________________________________________________________________
Reference Information
Work Related
#1
(Last Position)
Company Name ________________________________________________________________
Address: ______________________________________________________________________
Telephone No. & Email Address: ___________________________________________________:
Supervisor’s Name_____________._________________________________________________
Position Held: __________________________________________________________________
Length of Employment: ___________________________________________________________
Reason for Leaving: _______________________________________________________________
Work Related
#2
(2ndLast Position)
Company Name ________________________________________________________________
Address: ______________________________________________________________________
Telephone No. & Email Address: ___________________________________________________:
Supervisor’s Name_____________._________________________________________________
Position Held: __________________________________________________________________
Length of Employment: ___________________________________________________________
Reason for Leaving: _______________________________________________________________
Work Related
#3
(3rdLast Position)
Company Name ________________________________________________________________
Address: ______________________________________________________________________
Telephone No. & Email Address: ___________________________________________________:
Supervisor’s Name_____________._________________________________________________
Position Held: __________________________________________________________________
Length of Employment: ___________________________________________________________
Reason for Leaving: _______________________________________________________________
Personal
#1
Name ________________________________________________________________________
Address: ______________________________________________________________________
Telephone No. & Email Address: ___________________________________________________:
Nature of Friendship (friend, co-worker, family etc.)_______________________________________
(Other than relative.)
Personal
#2
Name ________________________________________________________________________
Address: ______________________________________________________________________
Telephone No. & Email Address: ___________________________________________________:
Nature of Friendship (friend, co-worker, family etc.)________________________________________
Other than relative.)
I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Insert your company/agency name and I hereby release and discharge any of the above and Insert your company/agency name from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary
I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check
If further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.
________________________________________ _______________
Applicant’s Signature Date
Work Remotely
Job Types: Full-time, Part-time
Pay: $12.00 - $14.00 per hour
Medical Specialty:
Education:
- High school or equivalent (Preferred)
Experience:
- Home Care: 1 year (Preferred)
License/Certification:
- CNA (Preferred)
- Certified Home Health Aide (Preferred)
Work Location: In person
