Application Form

PERSONAL INFORMATION

Full Name:

Address:

Emergency Contact


EMPLOYMENT DESIRED

Position(s) Applying For:

Will You accept Employment Of:


EDUCATION/TRAINING

Graduate? YesNo

Graduate? YesNo

Graduate? YesNo

Professional Licenses and/or Certifications

Professional Organization Membership, Volunteer or Community Service or Other Qualifications Related to the Position for Which You Are Applying:


EMPLOYMENT HISTORY - Begin With Most Recent

First

Address:

Dates of Employment:


Second

Address:

Dates of Employment:


Third

Address:

Dates of Employment:


Fourth

Address:

Dates of Employment:


Fifth

Address:

Dates of Employment:


REFERENCES

List 3 Individuals (Not Related to You) Who Are Familiar With Your Work-Related Skills.


Have You Ever Been Charged or Convicted of a Crime? YesNo

If Yes, Please Provide Details.


AVAILABILITY INFORMATION

Please Select the Shifts You Are Available for Each Day.


Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Do You Have Your Own Transportation?
YesNo

Do You Have Current Auto Insurance?
YesNo

Please Indicate Areas You Will Be Available to Work:

Pierce County:

King County

Do You Have Any Physical Limitations That Would Prevent You From Doing Any Aspect of This Job? YesNo

If Yes, Please Explain:


PERMISSION FOR RELEASE OF EMPLOYMENT HISTORY AND REFERENCES

I, _________________, do hereby authorize A&B Homecare and its representatives to conduct my reference check with all and any of the previous employers listed on my completed employment application form, submitted resume and on completed Personal Reference Check form.

I hereby authorize and release A&B Homecare and its representatives conducting my reference checks and persons/organizations providing past employment information and references on my behalf from any liabilities whatsoever which may occur as a result of the said employment records, recommendations or any other communications pursuant of this authorization.

Furthermore, I understand that this information will be placed in my personnel file as part of my employment record.

I swear that all statements in this application are true and correct. I understand that false information may be cause for dismissal.


SKILLS CHECKLIST AND PREFERENCE RECORD

SKILL/PROCEDURE
ELIMINATION

Bedpan:

Urinal:

Bedside Commode:

Incontinence/Diapers:

Perineal Care:

Texas/Condom Catheter:

Urinary Catheter Care:

Change Ostomy Bags:

Measure Intake/Output:

PERSONAL CARE

Tub Bath or Shower:

Use of Shower Chair:

Bath at Sink:

Bed Bath:

Shampoo/Set/Comb Hair:

Mouth & Denture Care:

Shaving Client:

Nail Care:

Dressing/Undressing:

Care of Eyeglasses:

Care of Hearing Aid:

HOUSEKEEPING

Make Unoccupied Bed:

Make Occupied Bed:

Laundry:

Vacuum/Dust/Mop:

Clean Kitchen/Bath:

Clean Living Area:

NUTRITION

Menu Planning:

Grocery Shopping:

Meal Preparation:

Regular Diet:

Soft or Blended Diet:

Bland / Low Residue:

Diabetic Diet:

Low Fat Diet:

Low Sodium Diet:

Low Cholesterol Diet:

High Fiber Diet:

Feeding Clients:

Storage of Leftovers:

AMBULATION/TRANSFER

Use of Walker or Cane:

Use of Wheelchair:

Use of Hoyer Lift:

Use of Trapeze:

Assist with Walking:

Use of Gait Belt:

Transfer Bed to Chair:

Transfer Wheelchair to Bed, Toilet, Chair, etc.:

Positioning Clients on Side, Back, etc.:

Range of Motion Excercises:

Use of Hospital Bed:

INFECTION CONTROL

Handwashing:

Universal Precautions:

Isolation Techniques:

Bio-Medical Waste:

EMPLOYEE INFORMATION - Do You

Drive:
YesNo

Smoke:
YesNo

Speak Other Language:
YesNo

Have Lifting Restrictions:
YesNo

SELECT THOSE CLIENT YOU PREFER NOT TO CARE FOR:

SELECT CLIENT CONDITIONS YOU HAVE TAKEN CARE OF BEFORE:

LIST OTHER SKILLS HERE:

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