PRE-EMPLOYMENT QUESTIONNAIRE Equal Opportunity Employer First Name Middle Name Last Name Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Phone Number Email Are you legally authorized to work in the US? -- Please Select -- Yes No What languages do you speak? Position Type of Employment Desired -- Please Select -- Full-Time (Live Out) Part-Time (Live Out) Full-Time (Live In) On Call Date Available What days can you work? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Desired Wage Amount Type of Wage -- Please Select -- Hourly Weekly Monthly Salary How many hours can you work weekly? -- Please Select -- 4-16 16-26 26-40 Can you work nights? -- Please Select -- Yes No Can you work weekends? -- Please Select -- Yes No Can you work holidays? -- Please Select -- Yes No List any work limitations that you may have Hearing Speech Lifting Health Physical Emotional Other Briefly Describe Clients Not Willing / Able to Work With Dementias / Alzheimer's Smokers Behavioral Disorders Elderly (over 65) Physical Disabilities Pets Females Males Client use of marijuana for medicinal purposes Children HIV Positive / Aids Other Briefly Describe Duties Not Willing / Able to Perform Bathing / Showering Grooming Oral Care Dressing Bowel Care Bladder Care Feeding Ambulation Toileting Hoyer Lift Housekeeping Laundry Meal Preparation Shopping Transportation Medication Reminding Friendly Reassurance Phone Call / Home Visit Other Briefly Describe Indicate which of the following you have experience in Bathing / Showering Grooming Personal Hygiene Dressing Bowel Care Bladder Care Feeding Ambulation Toileting Hoyer Lift Housekeeping Laundry Meal Preparation Shopping Transportation Medication Reminding Friendly Reassurance Phone Call / Home Visit Socialization Assistance with Transfer Other Briefly Describe Mode of Transportation Valid Driver's License -- Please Select -- Yes No Vehicle Insurance -- Please Select -- Yes No Can you provide a driving record? -- Please Select -- Yes No Are you willing to transport clients in your private vehicle? -- Please Select -- Yes No Are you willing to drive a client's vehicle? -- Please Select -- Yes No Are you willing to escort a client in their own vehicle? -- Please Select -- Yes No Are you willing to escort a client on public transportation? -- Please Select -- Yes No Are you employed now? -- Please Select -- Yes No If so, may we inquire of your present employer? -- Please Select -- Yes No Have you ever worked for TSC? -- Please Select -- Yes No If so, where? When? How did you find out about Total Senior Care? Name of School Location Years Attended Course / Degree Name of School Location Years Attended Course / Degree Name of School Location Years Attended Course / Degree Certifications & Credentials: Please check all that apply State ID Card Social Security Card CPR Certification First Aid Certification CNA License Food Safety Course CPR / First Aid Certificate Other Skills and Qualifications Dates Employer Salary Reason for Leaving Position Dates Employer Salary Reason for Leaving Position Dates Employer Salary Reason for Leaving Position Name Address Business / Title Phone / Email Years Known Name Address Business / Title Phone / Email Years Known Name Address Business / Title Phone / Email Years Known Upload your Resume Upload your Credentials Agree I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. Date Send
