Employment Application - Caregiving Experts

Are you authorized to work in the United States? *

Yes

No

Do you have a car? *

Yes

No

PLEASE NOTE, IF YOU DO NOT HAVE A CAR, WE ARE UNABLE TO PROVIDE EMPLOYMENT AT THIS TIME.

Are you a smoker? *

Yes

No

Will you work with a smoker? *

Yes

No

Will you work with dogs? *

Yes

No

Will you work with cats? *

Yes

No

Describe what makes you a good caregiver *

School or formal training

Year certified as CNA *

Year, make and model of car *

Insurance Carrier *

Start Time *

End Time *

24 Hours *

Yes

No

Overnight *

Yes

No

CURRENT EMPLOYER

Are you currently employed? *

Yes

No

Employer Type *

Private Party

Agency or Facility

Name of person you report to *

Address of current employer *

Phone number of person you report to *

Date started with this employer *

Job Title *

Salary *

Name of Agency or Facility *

Address of current employer *

Supervisor *

Phone number of person you report to *

Date started with this employer *

Job Title *

Salary *

PREVIOUS EMPLOYER #1

Employer Type *

Private Party

Agency or Facility

Name of person you reported to *

Address of previous employer *

Phone number of previous employer *

Date started with this employer *

Date ended with this employer *

Reason for leaving *

Job Title *

Salary *

Name of Agency or Facility *

Address of previous employer *

Supervisor *

Phone number of previous employer *

Date started with this employer *

Date ended with this employer *

Reason for leaving *

Job Title *

Salary *

PREVIOUS EMPLOYER #2

Employer Type

Private Party

Agency or Facility

Name of person you reported to

Address of previous employer

Phone number of previous employer

Date started with this employer

Date ended with this employer

Reason for leaving

Job Title

Salary

Name of Agency or Facility

Address of previous employer

Supervisor

Phone number of previous employer

Date started with this employer

Date ended with this employer

Reason for leaving

Job Title

Salary

ORIGINATION

How did you find out about Caregiving Experts? *

Name of Newspaper *

Name of Friend/Relative *

Where did you receive the flyer? *

Name of school *

Please explain *

CAREGIVING EXPERTS EMPLOYMENT TEST

Please answer each of the questions below by choosing one of the answers from the drop down menu options.

1. Parkinson’s, multiple sclerosis (MS), and Lou Gehring’s disease (ALS) have the following in common: *

2. A Gait belt is: *

3. You can pick up medication for the client at the pharmacy. *

4. When you are with a client: *

5. Alzheimer’s is a type of dementia. *

6. If a client with dementia wants to do something inappropriate: *

7. Caregivers must be aware of using proper body mechanics. “Body mechanics” means: *

8. The safe way to transfer a client from the bed to a chair is: *

9. A caregiver should realize that client’s rights are considered: *

10. When a client complains about chest pains and is very pale and clammy a caregiver should: *

11. When entering the room of a client who is blind, the caregiver should: *

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? *

13. To communicate with the client who is hard of hearing, the caregiver should: *

14. When caring for a client who is incontinent or on complete bed rest, the main goal of care is to: *

15. A client slaps a caregiver while receiving care. The caregiver should respond with which statement? *

16. When it is time for a client to take his/her medication the caregiver should? *

17. Confidentiality is a very important part of the caregiver’s job. A visitor asks the caregiver if her client Mrs. Smith has cancer. How should the caregiver respond? *

18. Which action is an example of universal precautions? *

19. When transporting a client to an appointment or shopping the caregiver should: *

20. The caregiver arrives at the client’s home, but no one answers the door. What should the caregiver do? *

ACKNOWLEDGEMENT AND RELEASE *

I AGREE

I acknowledge that the responses provided by me to the questions above and the statements made by me in this online employment application are complete and true to the best of my knowledge and belief. I understand that any misrepresentation or omission of facts provided in this application may result in denial of my application or cause for dismissal at any time during my employment. I authorize Caregiving Experts and/or its representatives to investigate all statements contained in this online employment application, including, but not limited to work references, criminal background history, educational history and motor vehicle and driving records. I also authorize all individuals, groups, companies, organization and law enforcement agencies to release any information regarding my background and agree to release any said individuals, groups, companies, organization and law enforcement agencies from liability of any kind for any damage whatsoever for providing this information. I UNDERSTAND THAT THIS ONLINE APPLICATION IS NOT A CONTRACT OF EMPLOYMENT, NOR IS EMPLOYMENT BEING OFFERED.

*

I agree to receive SMS or emails for the provided number/email above. You may opt out at any time

APPLICANT INFORMATION

WORK AVAILABILITY

CURRENT EMPLOYER

PREVIOUS EMPLOYER #1

PREVIOUS EMPLOYER #2

ORIGINATION

JOB SKILLS YOU HAVE EXPERIENCE WITH

CONDITIONS/DIAGNOSIS YOU HAVE EXPERIENCE WITH

JOBS YOU CAN DO

EQUIPMENT YOUR ARE FAMILIAR WITH

CAREGIVING EXPERTS EMPLOYMENT TEST