Employment Inquiry Form

Name

Phone

Who referred you to this agency?

Do you have a valid DL?

Yes No

Do you maintain automobile insurance?

Yes No

Do you have dependable transportation?

Yes No

How many miles are you willing to drive to get to an assignment?

Our staff is considered PRN. What position are you applying for?

PCA CNA

COVID Vaccination?

Yes No

Available hours:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

We require all employees to work at least 1 - 2 weekend shifts per month. Availability on weekends:

Saturdays Sundays No Weekends

Are you available for overnight stays?

Yes No

Are you able to stay awake all night on an overnight shift?

Yes No N/A

How long have you worked with the elderly/disabled?

What types of hands on transfer experience do you have?

Gait Belt Slide Board Hoyer Lift Sit to Stand Lift

Can you lift at least 25 pounds?

Yes No

Will you work around:

Cats Dogs

Can you provide pet care?

Yes No

Can you cook?

Yes No

What can you cook?

Alzheimer/Dementia Experience?

Yes No

Parkinson Experience?

Yes No

Oxygen Experience?

Yes No

Feeding Tube Experience?

Yes No

Have you ever worked in a nursing home or hospital?

Yes No

If yes, how long?

Have you worked for a home care agency before?

Yes No

If yes, how long?

No smoking is allowed while at a shift. Will this be a problem?

Yes No

Can you work around smokers?

Yes No

Are you able to perform all the required duties of the position for which you have applied?

Yes No

If hired, we will need to run a criminal history check and a motor vehicle check. Is there anything that may prevent you from getting this job even if an attorney has told you it was deferred?

Contact Us

We’d love to hear from you, contact us to schedule an appointment today!

Your Choice for Compassionate Care! We offer superior home care from compassionate and qualified caregivers.

Office Hours

MONDAY-FRIDAY

9 a.m.—5 p.m.

SATURDAY – SUNDAY

by Appointment

Currently serving Arlington, Mansfield, Grand Prairie, Cedar Hill, Fort Worth & Mid Cities.

Contact Us

ADDRESS:

801 E. Abram Street, Arlington, Texas 76010

PHONE:

817-277-8606

FAX:

817-277-8607

EMAIL:

qualitycare@atmoorehealthcare.com

We answer phones after hours for emergencies.

Website by Arlington Web Designer Red Spot Design

Employment Inquiry Form

Contact Us

Office Hours

MONDAY-FRIDAY

9 a.m.—5 p.m.

SATURDAY – SUNDAY

by Appointment

Contact Us

ADDRESS:

801 E. Abram Street, Arlington, Texas 76010

PHONE:

817-277-8606

FAX:

817-277-8607

EMAIL:

qualitycare@atmoorehealthcare.com

Social Media

Facebook

Youtube

Instagram

Google Plus

We answer phones after hours for emergencies.