Uncategorized

NOTE: This application cannot save your progress. Please give yourself adequate time to fill it out completely. If possible, form should be completed on a computer.

Personal Information

First Name*
Last Name*
Phone*
Email*
Address*
Are you legal to work in the United States? yesno
Upload your driver's license or state issued ID

Availability

What nights are you available for NOC shift (8pm-6am)?
SuMTWThFSanone
Can you work swing shift Monday-Friday (2pm-8pm)?
yesno
Can you work day shift Monday-Friday (8am-6pm)?
yesno
Can you work early day shift Monday-Friday (6am-2pm)?
yesno
Can you work weekend shift #1 (Saturday/Sunday 6am-6pm)?
yesno
Can you work weekend shift #2 (Saturday/Sunday 8am-8pm)?
yesno

We operate 24 hours a day 7 days a week, 365 days a year.

Can you work Holidays (required)? yesno
Can you work during spring break/winter vacation? yesno
Do you have any responsibilities that would prevent you from working these shifts on a regular basis? yesno

Work History & Experience

Have you worked as a caregiver before? yesno
How many people with dementia have you cared for?
01-34-67-910+
How many bedbound people have you cared for?
01-34-67-910+
How many people on hospice have you cared for?
01-34-67-910+

Where have you worked?
FamilyIHSSBoard & Care/Small FacilityLarge Facility/Assisted LivingMemory CareAdults with DisabilitiesAdult Residential FacilityKids with DisabilitiesMental Health FacilitySkilled Nursing FacilityHome HealthHospiceHospitalOther
Describe duties:

Direct Care Skills

Please assess your skills in the following areas
Transfers:
very comfortablecomfortableneed training
2 Person Transfers:
very comfortablecomfortableneed training
Hoyer:
very comfortablecomfortableneed training
Changes in Bed:
very comfortablecomfortableneed training
Changes Standing:
very comfortablecomfortableneed training
Toileting:
very comfortablecomfortableneed training
Peri Care:
very comfortablecomfortableneed training
Oral Care:
very comfortablecomfortableneed training
Dressing:
very comfortablecomfortableneed training
Assisted Showers:
very comfortablecomfortableneed training
Bed Baths:
very comfortablecomfortableneed training
Feeding:
very comfortablecomfortableneed training
Passing Meds:
very comfortablecomfortableneed training
Redirecting:
very comfortablecomfortableneed training
Dealing with Behaviors:
very comfortablecomfortableneed training
Engaging in Activities:
very comfortablecomfortableneed training

Food Service Skills

Please assess your skills in the following areas
Following a Recipe:
very comfortablecomfortableneed training
Judging How Much Food to Prepare:
very comfortablecomfortableneed training
Following Food Safety Protocols:
very comfortablecomfortableneed training
Puree Diets:
very comfortablecomfortableneed training
Minced Moist Diets:
very comfortablecomfortableneed training
Soft Chopped Diets:
very comfortablecomfortableneed training

Sanitary Skills

Please assess your skills in the following areas
PPE Usage:
very comfortablecomfortableneed training
Sanitizing Dishes:
very comfortablecomfortableneed training
Cleaning Biological Matter:
very comfortablecomfortableneed training
Sanitizing Surfaces:
very comfortablecomfortableneed training
Maintaining Clean Environment:
very comfortablecomfortableneed training
Making Beds:
very comfortablecomfortableneed training
Doing Laundry:
very comfortablecomfortableneed training

Personal Skills

Please assess your skills in the following areas
Multitasking:
very comfortablecomfortableneed training
Verbal Communication:
very comfortablecomfortableneed training
Written Communication:
very comfortablecomfortableneed training
Finding Something to Do:
very comfortablecomfortableneed training
Resolving Conflict:
very comfortablecomfortableneed training
Able to Take Direction/Feedback from Coworkers:
very comfortablecomfortableneed training
Show Up to Work on Time:
very comfortablecomfortableneed training
Use Technology (Phone/Computer Apps):
very comfortablecomfortableneed training

Certifications

Please select current or previous certifications, if any
HHACNAHCAMed TechMedical AssistantAdministratorCPRBLSFirst Aid
Other Certifications:

References

Please enter name, contact info, and relationship for several references

Statement of Interest

Tell us why you are interested in working here.