Have you already agreed to work for a particular client-employer? Yes No
If yes, please include the name of the individual :
Have you attended a homecare worker orientation? Yes No
If yes, where did you take it?
Date, If Known
Have you attended a live-in orientation? Yes No
Are you CPR certified? ( You must present your card(s) )
Yes No If yes, when does it expire?
Are you first aid certified?
What kind of transportation do you use to get to work? (Check all that apply)
Motor Vehicle Public Transportation Bike/Walk
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?
What languages, including Sign Language, do you speak and/or read?
Are you currently looking for work? Yes No
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? Yes No
Check the days/times you are available for work. If you are available at all times check here
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.
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.
Your Gender : Female Male
Do you Smoke? Yes No
Do you want to receive quit smoking information and/or materials via E-mail? Yes No
Are there employers you are NOT willing to work with or services you are NOT willing to provide?
Where are you willing to work? (Select a maximum of three counties.)
Counties :
Cities:/areas within the counties :
Have you ever been investigated for abuse, neglect or domestic violence? Yes No
If yes, please explain :
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.