Personal Information
Name *
Name
Date available to start
Date available to start
Contact Phone Number *
Contact Phone Number
Address
Address
Referred by a current family/client?
Desired number of hours
$
Availability
Provide specific, precise times
Which age group(s) would you be most comfortable working with?
Education
*
Expiration Date
Expiration Date
Expiration Date
Expiration Date
Employment/Volunteer History
list present or most recent employer first, include all employment, military and volunteer service
Phone Number
Phone Number
Employment start date
Employment start date
Employment end date
Employment end date
May we contact your present employer?
Phone Number
Phone Number
Employment start date
Employment start date
Employment end date
Employment end date
Phone number
Phone number
Employment start date
Employment start date
Employment end date
Employment end date
How did you hear about Trinity In-Home Care
Employment Questionnaire
Are you over 18 years of age? *
Do you have reliable transportation? *
Do you have a valid Driver's License? *
Are you willing to provide care to clients outside of Lawrence? *
If so, which areas?
Are you willing to provide personal care (bathing, catheter care, changing brief)? *
Are you willing to assist with housekeeping? *
Are you willing to provide sleeping overnight support? *
Are you willing to support clients in activities (going to the library or bowling)? *
Are you able and willing to provide physical assistance (lifting, transfering)? *
Have you been trained on how to transfer clients? *
Are you willing to go shopping for a client? *
Are you willing to provide meal assistance (cooking, feeding, clean up)? *
Are you willing to assist a client that has challenging behaviors (biting, hitting, yelling)? *
Are you able to assist client with exercise and physically demanding activities (sports)? *
Are you allergic to smoke? *
Are you allergic to pets/animals? *
Do you have any restrictions on the days of the week you can work? *
If offered employment, can you submit verification of your legal right to work in the United States of America? *
Have you been convicted of a misdemeanor or felony? (A conviction may be relevant if job-related, but does not necessarily ban you from employment) *
Have you been convicted, tried, or accused of abuse, neglect, or exploitation in the past? *
please read and sign
Date completed *
Date completed
Equal Employment Opportunity Commission Information
This section is optional.
Gender
Race/Ethnicity