| Questionnaire: |
 Have you ever been convicted…,
if yes, please explain |
Yes
No
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Have you been fired in the last ten years?
If yes, please explain: |
Yes
No
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Have you been employed or attended school using any other name?
If
yes, please indicate names previously used: |
Yes
No
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Do you have the legal right to be employed in the United States?
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Yes
No
(If hired, you will be required to provide identification to prove eligibility for employment): |
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| Have you ever been convicted, pled guilty or no contest, or forfeited bond on bail for any crime other than traffic violations? : |
Yes
No
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As
a caregiver, you may be required to manually lift or transfer
a patient. The average weight may be 70 lbs. Will you be
able to do that?
If
no, please explain |
Yes
No
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Do you have any employment restrictions resulting from a non-compete or confidentiality agreement?
If
yes, please explain: |
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Are you willing and able to drive for our clients using their car?
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| Are you willing and able to drive for our clients using your car? |
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Yes please provide insurance information: |
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| How did you hear about us? |
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| 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? |
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| 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? |
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| 3. Your client asks you to work outside of your normally scheduled hours, and wants to pay you in cash. What would you do? |
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| 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? |
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| 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? |
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| 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? |
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| 7. Your client has a cold, but refuses to take his cough syrup. What do you do? |
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| 8. Your client slipped and fell while you were on shift. What do you do? |
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| 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? |
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| Please tell us about yourself. In the space below, please tell us a little bit more about you. Please include any hobbies or activities that you enjoy in your spare time, as well as any additional training or skills you may have. |
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| 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: |
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| "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)
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Date Today:
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| All documents below must be provided before being interviewed with our company. |
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- Current CPR card
- Current First Aid card
- Current TB clearance
- Professional License (if applicable) (RN, LPN, CNA certificate)
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| If you are offered a
position with Kokua Care proof of work eligibility must be
presented. |
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- Identifying Document (i.e. driver's license or ID card)
- Employment Eligibility (i.e. US Social Security card
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| You will be placed on conditional employment with our company until the following background checks have been completed. |
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- Original Criminal Abstract
- Original Driving Abstract (only if you drive)
- Adult Protective Services (APS) Central Registry Check
- Child Welfare Services (CWS) Central Registry Check
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| Thank you
for your interest in Kokua Care |
Enter Security Code:
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