Thank you for contacting Home Instead Senior Care, the world’s most trusted source of non-medical companionship and home care services. We provide companionship, meal preparation, light housekeeping, laundry, errands and incidental transportation to the seniors in our community. We are looking to employ individuals who have a positive work history, compassion for seniors and are extremely dependable. Our employees enjoy part time work and a starting wage of $7.00 per hour.
If being a Home Instead CAREGiver interests you, you should be aware that we conduct criminal background and driving record checks and require the names and telephone numbers of personal and employment references along with a valid drivers’ license and proof of auto insurance.
Please complete the following application & interview questions. These can be e-mailed to
Christi West at
EMPLOYMENT APPLICATION
INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.
1. Please read "APPLICANT NOTE" BELOW.
2. Complete all sides of this form.
3. If more space is needed to complete any question, use comments section on the back.
4. Print clearly. Incomplete or illegible applications may not be processed.
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of gender, marital status, pregnancy, religion, race, age, creed, national origin, presence of disabilities, sexual orientation, genetic screening or testing information, refusal to submit to a genetic test, ancestry, AIDS or HIV status, and on any other status protected by law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.
PERSONAL INFORMATION
TODAY'S DATE: ______SOCIAL SECURITY NUMBER: ______-______-______
NAME: ______
Last FirstMiddle Maiden Name
CURRENT ADDRESS: ______
Street City State Zip Code
PREVIOUS ADDRESS: ______
Street City State Zip Code
HOME PHONE#: (______) ______WORK PHONE# :(______) ______
CELL PHONE#: (______) ______ALTERNATE PHONE# :(_____) ______
E-Mail Address______
EMERGENCY CONTACT: ______
NamePhone #Relationship
OTHER NAMES OR SOCIAL SECURITY NUMBERS PREVIOUSLY USED:
______
Last FirstMiddle Social Security Number
______
Last FirstMiddle Social Security Number
How did you hear about Home Instead Senior Care? ______
Why are you interested in employment with Home Instead Senior Care? ______
______
AVAILABILITY
Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.
Please complete all areas of availability:
When are you available to begin work? ______
____Part-Time (less than 30 hours/week) Hours/Week Requested: _____
____Mornings ____Afternoon_____Evenings ____Overnights
____Weekdays ____Weekends
Please indicate the days of the week as well as the earliest and latest times that you are available for work.
Shifts / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / SundayShift 1
From:
To:
Shift 2
From:
To:
PREFERENCES
Please indicate all areas in which you are willing to work:
___ Allen Co ___ Auglaize Co ___ Hancock Co ___ Hardin Co ___ Mercer Co ___ Putnam Co
___ Seneca Co ___Sandusky Co ___ Van Wert Co ___Wood Co
Have far are you willing to drive to an assignment? _____miles
Please indicate all of the services, which you are willing to provide:
___Companionship ___Meal Preparation ___Assistance Walking/Standing ___Dementia/Alzheimer’s Care ___Personal Assistance
___Light Housekeeping (vacuum, dust, clean floors, counters) ___Laundry ___Change Linens
___Transportation* ___Errands*
*In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle check and proof of insurance will be required.
Are you willing to provide service to a client with a pet? ___ No ___ Yes
(If yes, which ones: ___Cats ___Dogs)
Are you willing to provide service to a client that smokes? ___ No ___ Yes
Do you use tobacco products? ___No __Yes
Are you willing to work with … ___ Male and Female clients ___ Male clients only
___ Female clients only
Are you certified in any of the following: ___ First Aid ___ CPR ___ CNA ___ HHA ___Alzheimer’s ___STNA
Do you enjoy/ or have interest in: ____ Television/Movies ___ Sports ___ Arts & Crafts ___ Music
___ ScrapBooking___Church Activities ___ Fine Arts & Theater ___ Sewing ___ Reading
___ Nature ___ Other interests or hobbies:
______
JOB RELATED SKILLS
Describe any training or life skills you have that apply to caring for a senior.
Describe any work history you have that would apply to caring for a senior.
What do you like (or think you would like) most about working with older adults?
What do you like (or think you would like) least about working with older adults?
Have you ever worked in a nursing home or assisted living facility? If so, in what manner?
EDUCATION
Please circle highest grade completed:
Grade School: 6 7 8 High School: 9 10 11 12 College: 13 14 15 16 16+
School Type / School Name / City, State / Major/Subject / # Yrs Attended / GraduateHigh School / Y / N
Vocational/Technical / Y / N
College/University / Y / N
WORK HISTORY
Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.
MOST RECENT EMPLOYER
Are you currently working for this employer? ___ Yes ____ No If yes, may we contact? ___Yes ____ No
______(_____)______
Company Name City State Phone Number
From ______to______
Dates Employed Job Title Supervisor's Name
______
Duties
$______per ______
Salary (Hour, Week, Month) Reason for Leaving
SECOND MOST RECENT EMPLOYER
______(____ )______
Company Name City State Phone Number
From ______to______
Dates Employed Job Title Supervisor's Name
______
Duties
$______per ______
Salary (Hour, Week, Month) Reason for Leaving
THIRD MOST RECENT EMPLOYER
______( ____ )______
Company Name City State Phone Number
From ______to______
Dates Employed Job Title Supervisor's Name
______
Duties
$______per ______
Salary (Hour, Week, Month) Reason for Leaving
BACKGROUND
As a condition of employment all employees must be “Bondable”.
List states and counties of residence for the past seven years:
______
StateCountyStateCounty
______
StateCounty StateCounty
Have you had any movingtraffic violations? ___No ___Yes please describe: ______
Have you ever been convicted of a felony? ___No ___Yes Misdemeanor? ___No ___Yes - Please describe below
Incident City/ State Result
1
2
REFERENCES(Do not include relatives)
Please complete all six references. Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance.
Full Name / Phone Number / Best Time of Day to Call / Relationship / Number of Years Known1) / H ( )
W ( ) / AM / PM
AM / PM
2) / H ( )
W ( ) / AM / PM
AM / PM
3) / H ( )
W ( ) / AM / PM
AM / PM
4) / H ( )
W ( ) / AM / PM
AM / PM
5) / H ( )
W ( ) / AM / PM
AM / PM
6) / H ( )
W ( ) / AM / PM
AM / PM
CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, 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 also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
______
APPLICANT SIGNATUREDATE
Serving
Allen, Auglaize, Hancock, Hardin, Mercer, Putnam, Sandusky, Seneca, Van Wert & Wood Counties
RELEASE AUTHORIZATION
Name:
(Last)(First)(Middle Initial)
Maiden/Previous Name(s)
Home Address:
(City, State, Zipcode)
Social Security Number: Date of Birth:
Driver’s License Number: State Issuing:
Authorization to Secure Consumer Investigative Report
I authorize Home Instead Senior Care to make whatever inquiries it may deem necessary in connection with my application of employment. As part of such inquiries, the Company has my permission to contact persons who may have information regarding my suitability for employment and to secure consumer reports (including investigative consumer reports).
I authorize and instruct any person or agency contacted to participate or conduct inquiries at its request,
to compile information, and to furnish any information obtained as a result of such inquiries.
I further authorize the Company, in its sole discretion, to furnish copies of this authorization and my application to any person and/or consumer-reporting agency in connection with above purposes.
Disclosure Statement
Information contained in reports obtained by Home Instead Senior Care in accordance with above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that Home Instead Senior Care completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing to the personnel department within a reasonable period of time after your application for employment is received.
I hereby acknowledge that I have read the above disclosure statement and have understood it.
______
(Signature)(Date)
Application Interview
Name______Date______
1. What attracted you to apply for a job with Home Instead Senior Care?______
______
2. What experiences have you had working with the elderly? ______
______
3. What do you feel are some of the challenges you may face caring for an elderly client? ______
______
______
4. Relate an experience you have had in your life that will help you to be a good CAREGiver. ______
______
5. Cooking for the elderly can sometimes be challenging. What would you do especially to meet their needs? ______
______Do you enjoy cooking?______Cleaning?______
6. How would you handle incontinence accidents which may occur? ______
______
7. What three characteristics about yourself do you feel are the most important in caring for the elderly? (1)______
(2)______
(3)______
8. What type of person would you find most difficult to provide care? ______
______
9. Suppose you are working in a client’s home and you notice a diamond ring lying near the sink. What would you do? ______
______
10. How would you rank yourself on a scale from 1-10 (10-high)
being on time ______as a conversationalist ______dedicated to your job ______
being organized ______following directions ______on improving yourself______
as a caring person ______choice of attire for work ______cleanliness ______
11. As a CAREGiver, you may be asked to provide transportation. Do you have a reliable vehicle? Y/ N
If yes, can you provide proof of insurance for the vehicle? Y / N
12. Define dependability:______
______
______
13. On a scale of 1-10, with 10 being the highest, how would you rate your dependability? ______
Can you meet our dependability standards? Y / N How? ______
14. When someone assigns you a schedule, how conscientious are you about keeping it? ______
______
______
15. What type of situations would cause you to call and change your work schedule or cancel an assignment?
______
______
16. Is there anything further that you would like to share about yourself? ______
______
______