Homecare Worker Application

Office Use Only

Personal Information

Street Address

Mailing address: (If different than street address)

Your phone number(s)

Specific Client – Employer – New Homecare Workers Only

Have you already agreed to work for a particular client-employer?

If yes, please include the name of the individual :

Orientation and Certified Training

Have you attended a homecare worker orientation?

If yes, where did you take it?

Date, If Known

Have you attended a live-in orientation?

If yes, where did you take it?

Date, If Known

Are you CPR certified? ( You must present your card(s) )

If yes, when does it expire?

Are you first aid certified?

If yes, when does it expire?

Transportation

What kind of transportation do you use to get to work? (Check all that apply)

Are you willing to: (Check all that apply)

Transport an employer in your car?

Drive an employer’s car?

Escort an employer on public transportation?

Escort an employer in their car?

Language - In Order of Ability

What languages, including Sign Language, do you speak and/or read?

Availability to Work

Are you currently looking for work?

Check all work types you are willing to consider:

Would you be willing to assist with evacuation and in-home services in the event of a natural disaster?

Work Schedule

Check the days/times you are available for work. If you are available at all times check here

Weekday Mornings Afternoons Evenings Nights
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays

Services and Work Experience

Check all of the services below that you are “willing” to provide. In addition, if you have “experience” in any of these tasks, please check the “experience” column. You must be physically able to perform all the services you check in this section. DO NOT check any tasks where you have physical limitations (such as lifting, bending or stooping) that would prevent you from performing any of these services.

Activities of Daily Living Willing Experience
Ambulation
Bathing
Bladder Care
Bowel Care
Cognition
Dressing
Feeding
Grooming
Personal Hygiene
Positioning
Toileting
Transferring

Services and Work Experience (continued)

Check all of the services below that you are “Willing” to provide. In addition, if you have “Experience” in any of these tasks, please check the “Experience” column. You must be physically able to perform all the services you check in this section. DO NOT check any tasks where you have physical limitations (such as lifting, bending or stooping) that would prevent you from performing any of these services.

Self – Management Tasks Willing Experience
Giving or setting up medications
Housekeeping
Laundry
Meal preparation
Shopping
Transportation
Health – Related Procedures Willing Experience
Bowel program
Feeding Tube
Home dialysis
Injections
Ostomy care (e.g., colostomy, ileostomy)
Oxygen management
Suctioning
Tracheotomy care
Urinary catheter care
Ventilator care
Wound care

Additional Information

Your Gender :

Do you Smoke?

Do you want to receive quit smoking information and/or materials via E-mail?

Are there employers you are NOT willing to work with or services you are NOT willing to provide?

Geographical Location

Where are you willing to work? (Select a maximum of three counties.)

Counties :

Cities:/areas within the counties :

Abuse Investigation

Have you ever been investigated for abuse, neglect or domestic violence?

If yes, please explain :

Applicant Certification

Furthermore, I understand it is my responsibility to keep my availability information updated, and I must review my information in the RRS at least one time every 60 days to continue to be referred for new jobs.

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