Weekend Caregiver

1. Please fill in the following demographic information:

Please fill in the following demographic information: Name:
City/Town:
ZIP:
Email Address:
Phone Number:

2. Are you available for weekend work (Saturday AND Sunday) on a consistent basis?

Are you available for weekend work (Saturday AND Sunday) on a consistent basis? Yes	No
Other:

3. How long have you worked in healthcare? (Non Volunteer)

How long have you worked in healthcare? (Non Volunteer) 0-1 Year

2-3 Years

3-5 Years

5+ Years

4. Are you a CNA?

Are you a CNA? Yes

Yes, but it has expired

No, but I have other formal training. (Fill in comment box)

Please specify other formal training:

5. What types of clients are you the most comfortable caring for?

What types of clients are you the most comfortable caring for? Companion Type Client Care (Standby Assist, Basic Assist, ADLs, etc.)

Assisted Living Type Client Care (Hands on Assist, ADLs, Memory Care, Continence Care)

High Care (Total Care, Continence Care, Bed Bath, Transfer Assist, etc.)

6. Have you worked with or are you currently working with any other in-home care agencies?

Have you worked with or are you currently working with any other in-home care agencies? No

Yes (If Yes, please list agencies below)

Other Agencies:

7. Please describe why you have chosen to be a caregiver to the elderly.

Please describe why you have chosen to be a caregiver to the elderly.

8. Please describe the highest needs client that you've cared for (the types of things you helped with):

Please describe the highest needs client that you've cared for (the types of things you helped with):

9. Please decribe a time you have gone 'above and beyond' for a client. This could be anything that you did that was outside your scope of duties to benefit the client.

Please decribe a time you have gone 'above and beyond' for a client. This could be anything that you did that was outside your scope of duties to benefit the client.

Check out our sample surveys and create your own now!

form {display:none;} #jserror {text-align:center;margin-top:50px;}Javascript is required for this site to function, please enable.