Apply for Home Health Aide/Caregiver

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

Summary
Title:Home Health Aide/Caregiver
ID:1001
Department:Choices
Location:Shelby County
Contact Information
* Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
Email:
Referred By:
Attachments
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
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Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Personal Home Aide
Please answer each question truthfully and to the best of your ability. All job references will be checked before hiring considerations.
* Are you authorized to work in the United States for any employer?
Yes
No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?:
Yes
No
* Have you ever been convicted of a felony or a misdemeanor in the past 7 years?
Yes
No
First Choice require the following checks be performed on each applicant before hire: Criminal, Felony, Probation, Sexual Registry, Abuse Registry, Fraud, and Meth. To the best of your knowledge, would your name be found on any of the following screenings?
Yes
No
If Yes, please explain.:
What type of hours are you seeking?
1st Shift (Days)
2nd shift (Afternoons)
PRN (As Needed)
Weekends Only
* What days and hours are you available to work?:
What days and hours are you available to work?:
Date available to begin work:
* List positions you would like to be considered for.:
Certified Nurse Assist (have valid certificate for proof)
Experienced Personal Care Attendant
Clerical
How did you hear about First Choice?
If referred by a current employee, or have a relative working here, please list his/her name and position::
Desired salary range
Would you be able to as a PRN until a permanent assignment is available if hired?
Yes
No
Are you currently employed?
Yes
No
May we contact your present employer?:
Yes
No
What is your Date of Birth?
Do you have a vehicle? If yes, you will be required to provide proof of insurance.
Yes
No
Do you have valid car insurance and able to provide us with a copy of your insurance card?:
Yes
No
* When can you start?
How many years of experience do you have in the home care field?
less than a year
2-5 years
over 5+ years
* What is the highest level or equivalent completed:
Elementary
High School
College
If College, was degree attained?:
Yes
No
Are you a current student?
Yes
No
* If so, what are your current school hours?:
Yes
No
Do you understand and agree that this position may require you to work on holidays and inclement weather?
Yes
No
* Summarize special skills and qualification acquired from employment or other experiences that may qualify you to work for this company.
Please list last 3 employers and contact information to include Name of Company, Address, Phone Number, and Supervisor Name.
Have you had a current TB skin test?
No, but I will agree to have one done for a fee of $20.00.
Yes and I can provide you with a copy of my recent screening
Have you ever worked for a another personal support, home health, or hospice agency? If so, please list them below.
Can you provide us with a copy of BOTH of the following documents before consideration of hire?
Social Security Card and Current Drivers License
Yes
No
Are you CPR certified? Do you have a CPR card?
No
Yes, and I have a copy of my CPR card
No, but I will agree to attend a class and receive my certification for $40.00.
Upon hire, First Choice requires all employees to attend new hire orientation and new hire training class. Failure to attend will not qualify you for hire or termination. Also, after one year of employment, you must attend at least 12 hours of ongoing training. Do you agree to the terms of this policy?
Yes
No
First Choice has a dress code policy that will require you to purchase a First Choice uniform shirt or wear clean matching scrubs that you already own. Do you own any matching scrubs?
Yes
No
Have you ever been discharged from a previous job? If yes, please explain.
Please list any recent certifications or training classes that you have attended in the past year.
In summarizing your overall experience in this field, which of the following individuals would you say "I consider myself a specialty in this area".
Elderly (Total Care/ Bed Bound)
Elderly (Homemaker, Companionship, Light duty Personal Support)
All ages (Total Care/Bed Bound including Paraplegics)
Mentally Ill patients (DMRS or DIDS trained)
Alzheimer Patients
HHA Skills Checklist
Please check the skills that fit your abilities.
* Cared for Handicapped adults
Yes
No
* Cared for Alzheimer's clients
Yes
No
* Cared for HIV clients
Yes
No
* Cared for terminally ill clients
Yes
No
* Cared for Quadriplegic Clients
Yes
No
* Cared for Geriatric clients
Yes
No
* Cared for Children w/Disabilities
Yes
No

Please indicate the number of years experience in each setting below

* Hospital
* Nursing Home
* Client's home

Please check each skill area below using the following number system to indicate your experience:

Safe transfer technique and positioning of clients:

* in Bed:
(1) Independent (requires no instruction)    (2) Have had experience, but needs instruction    (3) No experience
* into wheelchair:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* ambulation:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* hover lift:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* with walker:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Cane:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience

Personal Care

* Oral Care:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Blood Pressure:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Respirations:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Temperature:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Use Bed Pan:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Shower or Bath:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Infection Control:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Nail/Skin Care:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* CPR:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
Charting
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Medication Assistance:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Temperature:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience

Household

* Shopping:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Bed Making:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Keep Area Safe:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Errands:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Handling Clients Money and Receipts:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Laundry:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Home Maintenance:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Prepare Meals:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Prepare Special Diet Meals:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Follow Physical Therapy plan:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Catheter Care:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
* Meal Planning:
(1) Independent (requires no instruction)
(2) Have had experience, but needs instruction
(3) No experience
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.

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