Caregiver Employment Attributes

CAREGIVER EMPLOYMENT ATTRIBUTES

Personal Information

Date of Birth:   Gender:

Position Information

Reporting Manager:   Requested Start Date:

Full-time    Part-time    PRN / On-call

Day    Evening    Night    Weekend

Caregiver Specific Attributes

Years of direct caregiving experience:   Primary care settings worked in:

Medication administration (oral/topical)    Dementia / memory care    Mobility assistance / transfers   

Wound care / dressing changes    Catheter care    Oxygen therapy / nebulizers

I possess a valid driver's license   License number:   State:

Able to lift up to (lbs):   Able to stand/walk for (hours):

Certifications, Training & Health

CPR certified   Expiration:

First Aid certified   Expiration:

Most recent TB test date:   Result:

Employment History (most recent first)

Job Title:   From:   To:

Job Title:   From:   To:

Education & Professional Development

Professional References

Legal Disclosures & Authorizations

At-Will Employment: I understand that, unless a separate written agreement signed by an authorized representative specifies otherwise, my employment relationship is at-will. Either I or the employer may terminate the employment relationship at any time, with or without cause or notice.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to protected class status. Reasonable accommodations for qualified individuals with known disabilities will be considered in accordance with applicable law.

Background and Reference Checks: I authorize the employer to verify the information provided on this form, contact previous employers and professional references, and obtain criminal background checks and consumer reports as permitted by law. I understand that any offer of employment may be conditioned on satisfactory completion of these checks and, where applicable, drug and health screenings.

Consent to Contact: I consent to the employer contacting prior employers and references for purposes of evaluating my application.

Criminal Convictions: Have you ever been convicted of a felony or a crime involving moral turpitude?   Yes    No

Confidentiality and Client Privacy: I agree to maintain the confidentiality of client information obtained during performance of my duties. Unauthorized disclosure of protected health information or other confidential information is grounds for disciplinary action, up to and including termination.

Applicant Certification: I certify that all information provided on this form is true, complete, and correct to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may result in denial of employment or, if employed, discipline up to and including termination. I understand that employment is contingent upon satisfactory completion of any required checks, verification, and compliance with employer policies.

Applicant Authorization: By checking here, I expressly authorize the foregoing verifications, background checks, and release prospective employers and references from liability for providing truthful information.

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