* 1. Please fill in the following:

* 2. What is your gender?

* 3. How long have you worked as a LPN?

* 4. Which of the following best describes your home care work experience? (Check all that apply.)

* 5. Are you enrolled as a Medicaid Provider (i.e. Do you have both a Medicaid Provider and National Provider Identification number)?

* 6. Please answer the following:

  Yes No Sometimes/Unsure
I smoke cigarettes
I'm able to bend, lean, kneel, push and pull
I'm able to lift more than 80 lbs
I am willing to perform light housekeeping tasks
I have a working cellular phone
I use text messaging
I have regular access to email

* 7. What type of transportation would you use to get to/from work? (Check all that apply.)

* 8. Which of the following categories best describes your current employment status?

* 9. Which of the following days and times are you available and/or willing to work? (Check all that apply.)

  Mornings (7a - 1p) Evenings (4p - 8p) Overnights (10p - 7a)

* 10. Please take this opportunity to tell me something about yourself and/or why you're interested in this job.