CarePlus Home Health, Inc. Employment Application
Carefully and accurately fill out all fields. When ready, click "Submit" below.
First Name
ex. Nancy
Last Name
ex. Smith
Email Address
ex. name@domain.com
Primary Phone
555-555-5555
Alt. Phone
555-555-5555
Address
suite/Apt# on 2nd line
City, State, Zip
ex. Walla Walla, WA 99216
1. Do you have a car?
Yes
No
2. Are you available to work day shift?
Yes
No
3. Are you available to work live-in?
Yes
No
4. Are you available to work weekends?
Yes
No
5. Can you work less than 5 hours?
Yes
No
6. Are you available on short notice?
Yes
No
7. Have you been convicted of a felony?
Yes
No
8. Do you have hands-on experience dealing with dementia patients?
Yes
No
9. Enter current employment reference (include name, dates of employment, phone number and position held).
10. Enter another employment reference (include name, dates of employment, phone number and position held).
11. Please write your full name if you give us permission to call your references.
12. Under what circumstances is it appropriate to strike or yell at a patient?
13. What would you do if your patient fell while in your care?
14. When is it appropriate to take money from your patients?
15. If your dementia patient gets upset and refuses to take a bath, what do you do?
