Employment Inquiry Form Name Phone Email 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? Weekday Available hours: Monday Tuesday Wednesday Thursday Weekend Available hours: Friday Saturday Sunday We require all employees to work at least 1 - 2 weekend shifts per month. Availability on weekends: 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? If so, please explain: SUBMIT
