Name
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First Name
Last Name
Email
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Phone
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(###)
###
####
Are you over 18 years of age?
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Are you legally eligible to work in the United States?
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Please list all days and hours you are available to work.
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Including days and nights.
How flexible are you to cover shifts and substitute for teammates, outside of your regular work schedule?
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Our night shifts are awake shifts. If applying for a night shift, do you foresee any difficulty remaining awake and alert for the entire shift?
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Do you have reliable transportation?
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Date Available to Start
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MM
DD
YYYY
Expected Salary?
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This position requires working some holidays and may require overtime, weekend work, and staying on shift until your relief arrives. Do you foresee any problems fulfilling these requirements?
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If Yes, please explain.
Days: 7am – 3pm
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Swings: 1pm – 9pm
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NOC: 9pm – 7am
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If you have any plans/appointments in the next three months that would conflict with your work schedule, please provide important information. If not, please write N/A.
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Are you currently employed?
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1. Employer/Company Name
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1. Dates Employed
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1. Supervisor’s Name & Contact Info
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Can we contact this employer?
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2. Employer/Company Name
2. Dates Employed
2. Supervisor’s Name & Contact Info
Can we contact this employer?
3. Employer/Company Name
3. Dates Employed
3. Supervisor’s Name & Contact Info
Can we contact this employer?
School 1
School 2
School 3
Are you restricted from lifting specific weights?
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If so, please specify the weight you cannot lift.
Have you dealt with incontinence (both bowel and bladder) and used incontinence products on any of your previous jobs?
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This job requires you to transfer residents from bed to wheelchair and from wheelchair to bed or toilet or chair. Do you have any physical limitations that would prohibit you from task?
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Do you have experience transferring?
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Have you used a Gait belt?
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Have you used a Hoyer lift?
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Have you assisted in Sit to Stand?
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Would you be able to transfer any person from bed to wheelchair, wheelchair to bed or toilet or chair?
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Please explain:
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Is there any phase of housekeeping that you cannot do or are unwilling to do?
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If Yes, please explain.
How would you describe your housekeeping skills (laundry, cleaning bathrooms, floors, etc.)?
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How would you describe your skills in preparing meals/cooking?
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What other skills/abilities do you have that pertain to this position?
Reference 1
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Reference 2
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Reference 3
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Check the boxes of your current credentials:
What else would you like us to know about yourself?
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Date of Signature
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MM
DD
YYYY
How did you hear about this open position?
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If other, please specify
