Apply for Caregiver

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Caregiver
ID:1003 - A
Location:The Woodlands, TX
Department:Client Services
Resume
Resume:
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Application
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No

PREVIOUS CAREGIVER EXPERIENCE

Give your full employment record, starting with your current or most recent employment

Less than 1 year   1-3 yrs   4-5yrs   5+yrs   10-20yrs   20 & up yrs
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

Yes   No

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No

REFERENCES

Please provide three references (not relatives).

Reference 1

*
*
*
*

Reference 2

*
*
*
*

Reference 3


EMERGENCY CONTACT

First Emergency Contact

Second Emergency Contact

Third Emergency Contact

AUTHORIZATION

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize All Around Care to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause and with or without notice. I understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the administrator of the facility.

I understand that I am required to abide by all rules and regulations of the company.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigation report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I understand that AAC is licensed by DADs and must follow all background checks that they require.

All-Around Care has a non-compete agreement with caregivers and clients. The Client or Client Representative agrees not to hire caregivers privately for 90 days after this agreement has ended. Caregivers agree not to do business directly with any individual or business entity that All-Around Care has introduced to them or by entering into employment with such individuals or businesses for 90 days after this agreement has ended.

Availability
Are you willing to work on short notice during normal working hours?
Yes
No

Please check off the days you are available to work below. If you cannot work the entire shift, indicate what times you are available that day.

Day Shift 8:00AM-8:00PM
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Night Shift 8:00PM-8:00AM
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Interview Sheet
Name:
Date:

Our procedure for hiring: Application, Reference checks, CHH, NAR, EMR, and other background checks when applicable, Verification of qualifications for applied job, and Testing to confirm job knowledge when applicable.

1. How many years' direct experience caregiving?
a. With an agency?
b. With a private client?
2. Occasionally you will be required to work after your normal shift. Is this a problem?
Yes
No
Comments:
3. Do you have experience with Hoyer Lifts?
Yes
No
Comments:
4. You will be required to work on call, one weekend of the month. Is this a problem?
Yes
No
Comments:
5. You will be required to work within a 20-mile radius of the office. Is this a problem?
Yes
No
Comments:

True or Flase

A client has the right to participate in planning their care
True
False
HIV/AIDS can be spread by casual contact, hugging, and/or shaking hands.
True
False
It is important for you to wash your hands when taking care of clients.
True
False
Taking out the trash daily is not the caregiver's responsibility.
True
False
A bed-bound client should be repositioned every 6 hours.
True
False
You should ask clients a lot of questions while they are eating their meal.
True
False
Medication assistance means you give the client a reminder.
True
False
You must have a current Texas Driver's License and proof of valid auto insurance to provide transportation to clients.
True
False
If you suspect a client is being mistreated (i.e. abuse, neglect, and/or exploitation), you should keep it to yourself.
True
False
If a client does not want their hair brushed during a visit, but it is on their care plan, you should restrain the client and brush their hair.
True
False
Other notes and relevant info from interview:
Interviewer Signature:
Date:
Preferences
Please choose the answer that best describes yourself.
I enjoy working in a team.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I keep my cool when I am angry or frustrated.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel comfortable saying 'no' to people.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I would describle myself as a confidential person.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I can find something positive in even the most difficult situations.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I work persistently until my task is complete.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I pay careful attention to small details when I am completing a task.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I show up when I say I will.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I find it difficult to prioritize my tasks.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I make a conscious effort to follow the rules and regulations at work.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I take precautions so that I can prevent accidents from occurring.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I consider how others will be affected by my words and actions.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I do tasks carefully even if no one else will ever see the result.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
People know that they can count on me.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I strive to get along and cooperate with other people involved in a patient's care.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My work suffers when I have problems in my personal life.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I make myself available to others when they need help.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am supportive and encouraging.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am a very patient person.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Pick ONE that best describes you.
I am usually early
I am usually on time
Sometimes I am late
I am usually late
Skills and Preferences
What type of care are you willing to give?
Elderly Care
Companion Care
Hospice Care
Illness Care
Disabilities Care
Respite Care
Please Check any of the following you are willing to work with.
Driving a Client
Client Who Smokes
Males
Females
Client having dogs
Client having cats
Cleaning
Cooking
Hoyer Lift
Flexible Hours
Short Notice
Weekends
Talkative Client
Quiet Client
Hospice
Wheelchair

Which of these skills have you had experience in and feel you could perform for a client?

Level 1
Companion Care
Meal Assistance/Feeding
Cleaning/Laundry
Errands/Shopping
Transportation/Escorts
Level 2
Medication Assistance
Ambulation with Assistance
Transferring with Assistance
Bathing/Grooming with Assistance
Toileting with Assistance
Level 3
Total Grooming
Ambulation
Transferring
Complete Bath
Toileting Needs
Level 4
RN Delegated Tasks
Hospice Care
Alzheimer/Dementia
Parkinson's Disease
Cancer

*Rn delegated tasks only with Administrator approval and RN approval delegating tasks. Training given.

SPECIALIZED TRAINING

Please list any certifications you hold (CNA,CPR, LVN, RN, etc.)
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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