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:

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

College:

_______________________________

__________________

Yes

Nursing School:

_______________________________

__________________

Yes

Technical Training:

_______________________________

__________________

Yes

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

____________________________________________

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

____________________________________________

Have you been employed or attended school using any other name?
If yes, please indicate names previously used:

Yes

____________________________________________

Do you have the legal right to be employed in the United States?

Yes

____________________________________________

Have you ever been convicted, pled guilty or no contest, or forfeited bond on bail for any crime other than traffic violations? :

Yes

____________________________________________

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

____________________________________________

Do you have any employment restrictions resulting from a non-compete or confidentiality agreement?
If yes, please explain:

Yes

____________________________________________

Are you willing and able to drive for our clients using their car?

Yes

Are you willing and able to drive for our clients using your car?

Yes

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