Caregiver Application Survey
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1
. Please enter your contact information.
Please enter your contact information.
Name:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Email Address:
Phone Number:
*
2
. How long have you provided care for seniors?
How long have you provided care for seniors?
3
. What types of care have you provided for seniors?
What types of care have you provided for seniors?
Bathing
Grooming
Dressing
Toileting
Feeding
Transfers
Companion Care
Meal Preparation
Light Housekeeping
Errands
Other (please specify)
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4
. Can you successfully pass a background check? If you cannot, we cannot hire you.
Can you successfully pass a background check? If you cannot, we cannot hire you.
Yes
No
5
. Do you have reliable transportation and are able to drive clients in your vehicle?
Do you have reliable transportation and are able to drive clients in your vehicle?
Yes I have reliable transportation.
Yes I can drive clients in my vehicle.
*
6
. What type of setting have you provided care in?
What type of setting have you provided care in?
In Home Care Agency
Skilled Nursing Facility
Hospital
Home Health Agency
Assisted Living Facility
Residential Care Home
Other (please specify)
7
. What formal certifications do you have?
What formal certifications do you have?
CNA - Certified Nursing Assistant
CMA- Certified Medical Assistant
No formal certification
8
. What areas can you work in?
What areas can you work in?
Marble Falls
Horseshoe Bay
Northwest Austin
Round Rock
Georgetown
Cedar Park
Leander
Pflugerville
Westlake
South Austin
Jonestown
Lakeway
Other (please specify)
9
. What days are you available to work?
Daytime
Nights
Overnights
Monday
*
What days are you available to work? Monday Daytime
Monday Nights
Monday Overnights
Tuesday
Tuesday Daytime
Tuesday Nights
Tuesday Overnights
Wednesday
Wednesday Daytime
Wednesday Nights
Wednesday Overnights
Thursday
Thursday Daytime
Thursday Nights
Thursday Overnights
Friday
Friday Daytime
Friday Nights
Friday Overnights
Saturday
Saturday Daytime
Saturday Nights
Saturday Overnights
Sunday
Sunday Daytime
Sunday Nights
Sunday Overnights
10
. Are you wiling to take Part-time Clients or PRN work?
Are you wiling to take Part-time Clients or PRN work?
Yes, I will take part-time clients
Yes, I will take PRN work (work as needed -may be short notice)
No, I am only looking for full time work
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