Application for Employment in Yuma

Application for Employment
Date
MonthDayYear
Date
Personal Information
Full Legal Name*
First NameMiddle InitialLast Name
Present Address*
City*
State*
Zip*
Phone*
Position Applied For*
Type a question*
Full timePart timeHourlyLive In
Referred by
AdvertisementEmployeeOther
Name of the person who referred
Are you Over 18?*
YesNo
Are you eligible to work in this country?*
YesNo
Have you ever been convicted of a crime that would prevent you from working for this company?*
YesNo
If yes, please explain
Do you drive?*
YesNo
If yes, please enter Driver License #
State
Do you have auto insurance?
YesNo Provider
SSN#*
Date of Birth*
MonthDayYear
Date
Email*
example@example.com
License Issuing Authority or Board
Licensure and Certification
License #
License Issue Date
MonthDayYear
Date
License Expiration Date
MonthDayYear
Date
Only for Register Nurse position - Malpractice Insurance Policy Details
Malpractice Insurance Carrier Name
Malpractice Insurance Carrier Address
Additional Qualifications And Education Details
Can lift 20 pounds or greater?*
YesNo
High School*
YesNo
Location
College*
YesNo
Location
Post Graduate*
YesNo
Location
Employment History
Please list all employers
Name of Employer
From
Approximate Date
To
Approximate Date
Phone
Address
Street Address
Street Address Line 2
CityState
Zip Code
Supervisor
Job Title
Reason for Leaving
Duties
Name of Employer
From
To
Phone
Address
Street Address
Street Address Line 2
CityState
Zip Code
Supervisor
Job Title
Reason for Leaving
Duties
Name of Employer
From
To
Phone
Address
Street Address
Street Address Line 2
CityState
Zip Code
Supervisor
Job Title
Reason for Leaving
Duties
References
Please list all employers
Name*
Address
Street Address
Street Address Line 2
CityState
Zip Code
Phone*
Name*
Address
Street Address
Street Address Line 2
CityState
Zip Code
Phone*
Name
Address
Street Address
Street Address Line 2
CityState
Zip Code
Phone
Signature
Clear
Applicant’s Statement Regarding Caregiving History
I attest that I, the applicant, have never abused, neglected, sexually assaulted, exploited or deprived any person nor have I subjected any person to serious injury as a result of intentional or grossly negligent misconduct.
Waiver and Release of Information
I understand and agree that any consequential omissions or misrepresentations made by me on this application will be sufficient cause for cancellation of this application and/or termination by Homewatch CareGivers if I have been employed. I understand that any offer of employment will be at the will of Homewatch CareGivers and that the company reserves the right to terminate my employment at any time, with or without prior notice and that I am free to resign at any time with or without prior notice. I understand that no representative of the company has the authority to make any assurances to the contrary.
I, hereby authorize Homewatch CareGivers to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I also release Homewatch CareGivers and its representatives from all liability from any damage that may result from furnishing the same to you. This includes a criminal background history, workers’ compensation investigation and/or Social Security check. This may also include random drug testing.
I also understand that any offer of employment may be conditioned upon satisfactory completion of a physical exam or medical evaluation.
Date
MonthDayYear
Date
Background Authorization
Please list all employers
AUTHORIZATION FOR BACKGROUND CHECKS
I instruct and authorize Homewatch CareGivers of Morris (the "Company") to obtain a consumer
report(s) (or background check report(s on me, including any investigative consumer reports and anyconsumer credit reports.* I also agree that a copy of this form is valid like the signed original. The consumer reporting agency (CRA) ADP Screening and Selection Services, Inc. (ADP SASS) will conduct the background check and prepare the background check report for the Company. ADP SASS is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached by phone at 800-367-5933, or at
www.adpselect.com. I understand that, as allowed by applicable law, the Company may rely on this
authorization to order additional background check reports, including investigative consumer reports and any consumer credit reports* (1) during my employment or time as a volunteer or independent contractor, as applicable, and (2) from any CRA other than ADP SASS without asking me for my authorization again. I understand the Company may order background check report(s) under my legal name and any other names I may have used.
I also instruct and authorize the following persons, agencies, and entities to disclose to ADP SASS and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. As allowed by law, such disclosures may contain the following information pertaining to me: credit history*; public records; a Social Security number verification; driving records; military service; credentials/certifications; worker's compensation injuries; and verification of prior employment and
*I understand that I am instructing and authorizing the Company to obtain a consumer credit report only to the extent permitted by law. If I reside or anticipate being employed in New York City, I
understand that I am not being asked to authorize a consumer credit report by signing this document.
By signing below, I understand that I am agreeing to the terms contained in this document.
If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of
Please print your full legal name:
Signature (Month/Day/Year)
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Today's Date
MonthDayYear
Date
Skill Sets
Please list all employers
Please check the title/skill set that best describes the job(s) you are applying for:
HomemakerCompanionPersonal Care AideCHHA Certified Home Health AideCNALPNRN
CPR Expiry Date
First Aid Expiry Date
Please check all skills with which you have experience with and are comfortable performing
Client PositioningSkin CareAssistance in BathingBed PanColostomy CareRange of Motion ExerciseBed BathAssistance in AmbulationAssistance in DressingOxygen AdministrationPatient TransferringAssistance in ToiletingCatheter CareHoyer Lift Transfer
Check the following conditions/diagnosis with which you have experience and job skills to care for a client:
Alzheimer'sAmputeeBrain TumorAIDSDecubitus UlcerSpeech ImpairmentCancerStroke Left SideDementiaArthritisVentilator DependentDiabetesChemotherapyQuad or Paraplegic CareAlcoholismHearing ImpairmentIntravenous TherapyIncontinenceFractured HipCongestive Heart FailureOsteoporosisHepatitisKidney DialysisCataract RemovalVisual ImpairmentShinglesMalnutritionPneumoniaParalyzedParkinson'sHospice
Check the home medical equipment you are experienced with:
WalkerWheelchairHospital BedOxygen TankBlood Pressure KitHoyer LiftThermometerGait BeltPosey Belt
Check the job responsibilities you will do in addition to Eldercare
Formal CookingMenu PlanningFamily CookingFancy CookingTray ServiceSpecial Diet CookingPlain CookingLaundryLaunder Linens OnlyHousekeepingIroningShoppingClean HomeThermometerClean Client's Room/Bath Only
Employee Signature
Clear
Date
MonthDayYear
Date
Caregiver Skills Test
Please list all employers
Supervisor
1. A caregiver should do which of the following to ensure great quality care?
Ask for guidance on job related issues.Attend in-service education requirements.Manage their schedule in an efficient way.All of the above.
Date
MonthDayYear
Date
2. The purpose of a caregiver’s documentation is to provide a written record of:
Conflicts between coworkers.Care delivered.Medication given.Personal opinion of the client’s condition.
4. The following describes a good caregiver:
Being reliable.Being healthy.Being honest.All of the above.
5. Repetitive motions can cause injury. Which item below could cause injury to the caregiver because of repetitive motion?
Holding a ball.Bending down to pick up something.Crossing your legs.Brushing your teeth.
6. Caregivers must be aware of using proper body mechanics. “Body mechanics” refers to:
The proper way in which the body is used to perform a physical task.Transferring from a bed to a chair.Positioning a client safely.Taking a course on automobiles.
7. The safe way to transfer a client from the bed to a chair is to:
Keep your knees locked.Position the client a full arm’s length away.Use your leg muscles to lift not your back.Place your feet close together.
8. A caregiver should realize that client’s rights are considered:
Something to be ignored.Both a human privilege and a legal protection.Important to only doctors and nurses.Illegal.
9. If the caregiver notices a change in the client, the FIRST reaction would be to
Call the police.Tell other caregivers.Report to the supervisor or Homewatch CareGivers office.Keep changes quiet so as not to upset anyone else.
10. When a client complains about chest pains and is very pale and clammy, what is the FIRST thing a caregiver should:
Wait to see if it goes away.Call the supervisor immediately.Give mouth-to-mouth.Call the local emergency medical service.
11. When entering the room of a client who is blind, the caregiver should:
Turn on the light as he/she enters.Touch the client gently on the arm.Greet the client and identify him or herself. Walk quietly into the room before he or she speaks.Walk quietly into the room before he or she speaks.
12. The caregiver brings a breakfast tray to a bed bound client and sees that the client has been incontinent, what should the caregiver do FIRST?
Ask the client if you can clean him/her up after breakfast.Give the client his/her breakfast.Clean and change the client first.Report it to your supervisor.
13. To communicate with the client who is hard of hearing, the caregiver should:
Talk to the client in a loud, high voice. yway.Face the client and speak clearly.Repeat everything two or three times.Do not worry about communicating if the client cannot hear you anyway.
14. A client insists on giving a caregiver a financial loan to “tide him/her over”. The caregiver should:
Take the loan and thank the client politely.Promise to pay the client back.Explain that a caregiver cannot borrow money from a client for any reason.Call the police and report the client.
15. When caring for a client who is incontinent of urine or on complete bed rest, the main goal of care is to:
Limit the client's fluid intake.Prevent skin breakdown.Turn the client every 8 hours.Establish regular bowel habits.
16. A client slaps a caregiver while receiving care. The caregiver should respond with which statement?
"How would you like it if I slapped you?""I'll pretend that it did not happen, but don't ever do it again!""I am going to leave right now.'"Why did you slap me?
17. A client has left-side weakness due to a stroke. After assisting the client to a chair the caregiver should position the:
Weak arm in a downward position.Weak arm on a pillow.Strong leg crossed over the weak leg.Body weight shifted toward the weak side.
18. Which one of these actions would be appropriate for a caregiver when it is time for a client to take medications?
Give the client the bottle of pills and remind him/her that it is time to take their medication.Pour the pills into the client's hand.Count the pills before giving them to the client.Put the pills in the client's mouth.
19. Confidentiality is a very important part of the caregiver’s job. A visitor asks the caregiver if the patient has cancer. Which one of these responses should the caregiver make?
"If she wanted you to know, she would tell you."Yes, but she is doing well.""I don't know.""You'll need to speak to the client about it."
20. Which action is important for safety in the home?
Keeping the shades pulled down.Putting electrical cords across the floor so the client can see them.Dimming the house lights to a low setting.Make sure throw rugs are secure.
21. When disposing of soiled attends (diapers) the caregiver should put them in the following:
A hamper.A red hazardous bag.The toilet.A plastic trash bag and take to dumpster.
22. Which action is an example of universal precautions?
Using gloves when providing personal care for the incontinent client.Cleaning the table after a meal.Washing the client's car.Throwing dirty linen in the trash.
23. When assisting a client with a shower the caregiver should:
Have the client use a towel bar for support.Adjust the water temperature to the comfort of the caregiver.Stay close in case client needs assistance.Keep the bathroom door open.
24. When transporting a client to an appointment the caregiver should:
Talk on cell phone.Keep car somewhat clean.Practice safety at all times. .Run personal errands on the way
25. When making a home visit, which of the following actions should a caregiver take when no one answers the door?
Make a phone call to the client's home.Obtain help from the police.Ask for another assignment.Take the day off.
Should be Empty:

Application for Employment

Personal Information

Licensure and Certification

Additional Qualifications And Education Details

Employment History

References

Background Authorization

Skill Sets

Caregiver Skills Test