Application form for Employment with Kokua Care
Personal Info.
Job Name : _________________________________________________________
First Name : _____________________________________________________ Middle Initial: _______________
Last Name : ________________________________________________
Present Mailing Address: ____________________________________________________________
  ____________________________________________________________
City: _____________________________
State: _____________________________
Zip Code: _______________
Home Phone : _____________________________
Cell Phone _____________________________
E-mail address:
(if any)
_____________________________
Do you wish to work: Full Time?     Part Time?     Fill In?
 
Specify what hours you are available on each day. The amount of work we can assign depends on your flexibility:


Sun Mon Tue Wed Thu Fri Sat

What are would you prefer to work?
(Please check all areas you would consider. The amount of work we can assign depends on your flexibility.)

NO PREFERENCE      
WEST: Waianae Makakilo Kapolei Ewa Beach
CENTRAL: Wahiawa Mililani Waipahu Pearl City Aiea
NORTH: Waialua Haleiwa Waimea
WINDWARD: Laie Hauula Kaneohe Kailua Waimanalo
EAST: Hawaii Kai Niu Valley Aina Haina
TOWN: Kalihi Honolulu Manoa Waikiki Kahala


Date available for work: ______________(Month) / ____ (Date) / _________ (Year)
Other Skills: ___________________________________________________________
Professional Licenses: ___________________________________________________________
   


Education & Work History
  Name, City, State Degree/Certificate Graduated?
High School: _______________________________ __________________
Yes   No
College: _______________________________ __________________
Yes   No
Nursing School: _______________________________ __________________
Yes   No
Technical Training: _______________________________ __________________
Yes   No
   
Employment History:
Include information pertaining to patient care, starting with the most recent.
Employer: ______________________________________________________
Title: ______________________________________________________
City: ______________________________________________________
State: ________________________________
Telephone: ________________________________
Date Started: _____________ (Month) / ____ (Day) / _______(Year)
Date Ended : _____________ (Month) / ____ (Day) / _______(Year)
Reason for Leaving: ______________________________________________________
Employer: ______________________________________________________
Title: ______________________________________________________
City: ______________________________________________________
State: ______________________________________________________
Telephone: ______________________________________________________
Date Started: _____________ (Month) / ____ (Day) / _______(Year)
Date Ended : _____________ (Month) / ____ (Day) / _______(Year)
Reason for Leaving: ______________________________________________________
 
Employer: ______________________________________________________
Title: ______________________________________________________
City: ______________________________________________________
State: ______________________________________________________
Telephone: ______________________________________________________
Date Started: _____________ (Month) / ____ (Day) / _______(Year)
Date Ended : _____________ (Month) / ____ (Day) / _______(Year)
Reason for Leaving: ______________________________________________________
 
May we call your former employers? :
If no, please explain:
Yes   No
____________________________________________

Please describe your most recent hospital, home care, or medical related experience:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________


Caregiver Questionaire
Questionnaire:
Have you been fired in the last ten years?
If yes, please explain:
 
Yes   No
____________________________________________
 
Have you been employed or attended school using any other name?
If yes, please indicate names previously used:
 
Yes   No
____________________________________________
 
Do you have the legal right to be employed in the United States?
 
Yes   No
____________________________________________
 
Have you ever been convicted, pled guilty or no contest, or forfeited bond on bail for any crime other than traffic violations? :
 
Yes   No
____________________________________________
 
As a caregiver, you may be required to manually lift or transfer a patient. The average weight may be 150 lbs. Will you be able to do that?
If no, please explain
 
Yes   No
____________________________________________
 
Do you have any employment restrictions resulting from a non-compete or confidentiality agreement?
If yes, please explain:
 
Yes   No
____________________________________________
 
Are you willing and able to drive for our clients using their car?
 
Yes   No
Are you willing and able to drive for our clients using your car?
 
Yes   No
If Yes please provide insurance information:
 
____________________________________________
 
How did you hear about us?
 
____________________________________________
   
What Would Do? Professional Response Section
Please answer the following questions to the best of your knowledge.
1. You are with a client who has mild dementia and their care-plan states that they should not be left alone.
The client tells you to leave 15 minutes before her spouse plans to be home. She insists that she will be fine,
and becomes agitated when you tell her that you need to stay until her husband returns. What would you do?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
2. Your client has high blood pressure medication that is only to be taken if his diastolic pressure is over 100.
His blood pressure is 146/82. Do you give him his medication?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
3. Your client asks you to work outside of your normally scheduled hours, and wants to pay you in cash.
What would you do?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
4. Your client, Mrs. Kauhane has some old jewelry that she wants to give to you. She insists that her children do not
want the jewelry, and because you have been so kind to her, she wants you to have it. What do you do?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
5. A client that you only visit once a week has some redness around the tailbone area. This client is not very mobile,
and usually spends his day sitting in a recliner, watching TV all day. What would you do?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
6. Your client is bed bound, and has had a BM. You have changed his Depends, and now are preparing to give him
a bed bath. As per Universal Precaution Guidelines, what should you do before giving him his bath, or performing any
other personal care or ADL’s?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
 
7. Your client has a cold, but refuses to take his cough syrup. What do you do?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
8. Your client slipped and fell while you were on shift. What do you do?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
9. Your client has diabetes and is on insulin. You have been trained to take his blood sugar, and when you test his
BS, it is unusually low. What do you do?
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
 
Agreement:
Please read the following statements carefully and indicate you have done so by entering your name and today's date
in the fields below:
   
"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 providers of
reference information, as well as Kokua Care LLC ufrom all liability for any damage that may result from utilization of
such information."
Name: (First MI. Last)

________________________________________________
Date Today:

________________________
All documents below must be provided before being interviewed with our company.
 
  • Current CPR card
  • Current First Aid card
  • Current TB clearance
  • Professional License (if applicable) (RN, LPN, CNA certificate)
   
If you are offered a position with Kokua Care proof of work eligibility must be presented.
   
  • Identifying Document (i.e. driver's license or ID card)
  • Employment Eligibility (i.e. US Social Security card
   
You will be placed on conditional employment with our company until the following background checks have been
completed.
   
  • Original Criminal Abstract
  • Original Driving Abstract (only if you drive)
  • Adult Protective Services (APS) Central Registry Check
  • Child Welfare Services (CWS) Central Registry Check
   
Thank you for your interest in Kokua Care