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Employment Application

Personal Information:

Name:
Email Address:
Cell Phone: Home Phone:
Current Address:
Mailing Address:
Position you are applying for:
Hourly Live-In Date you can start:
How did you hear about Innovative Healthcare Consultants?

Legal History:

Have you had any moving traffic violations? Yes No
Please describe:
Have you ever been convicted of a misdemeanor? Yes No
If yes, what, when and where?

Have you ever been convicted of a felony? Yes No
If yes, what, when and where?

NOTE: No applicant will be denied employment solely on the grounds of conviction of a criminal offense.The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position applied for may however be considered.

Job Related Skills:Describe any training you have had that applies to service and/or care for the elderly/or disabled.

What interests you most in working with older adults?

What do you find most difficult in working with older adults?

Please describe your education and training with assisting clients that require transferring.

In Home Provider Information

If called for an interview, you will be asked at that time to bring in the following documents:

Valid Drivers License or State ID Card
Social Security Card
Recent DMV Record of your driving record
Proof of valid auto insurance
Proof of a negative result from a recent TB Test (within one year) or Chest X-ray (within five years)
Copies of all your professional licenses
A copy of your CPR Certification, if you are certified.

I authorize investigation of all statements contained in this application. I understand that falsification, misrepresention, or omission of requested facts will result in immediate dismissal or removal of my application from consideration. I authorize Innovative Healthcare Consultants to secure information about my experience, releasing all parties from any liability that may arise.

I understand that having a pre-employment investigation conducted is a condition of my employment and that although I may be offered and begin working for the company, Innovative Healthcare Consultants reserves the right to terminate me from the position if information discovered during my pre-employment investigation makes me unsuitable to continue in that position.

I understand that all offers of employment are conditioned on the provision of satisfactory proof of identity and legal authority to work in the United States.

I understand that Innovative Healthcare Consultants is an at-will employer. Employment at-will may be terminated with or without cause and with or without notice at any time by either the employee or Innovative. Nothing shall limit the right to terminate employment at-will. The terms and conditions of employment, including its at-will nature, may only be modified in a writing signed by the employee and by the CEO.

I certify that I have read and understand the forgoing, and to the best of my knowledge and belief the information on this form is true and correct.

INSTRUCTIONS: In order for your application to be properly evaluated, it is essential that all of the following questions be answered carefully and completely. If you need more space for your answers, please attach a separate sheet. Please feel free to add any additional information which will help us in placing you where you are best qualified. Please type or fill out in ink. Read all parts of this application carefully. Incomplete applications will not be processed. Applications will be considered for three months from date of receipt. This is not an employment contract. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT DISCRIMINATION BECAUSE OF GENDER, MARITAL STATUS, PREGNANCY, RELISION, RACE, AGE,CREED, NATIONAL ORIGIN, PRESENCE OF DISABILITIES, SEXUAL ORIENTATION, ANCESTRY, OR ANY OTHER STATUS PROTECTED BY LAW. TESTING FOR THE PRESENCE OF ILLEGAL DRUGS IN YOUR BODY MAY BE REQUIRED PRIOR TO EMPLOYMENT.

Signature:

Date:

Health Questions:

Date of last TB test or x-ray:

Results: Yes No

Please read the following job descriptions for In-Home Care Provider:

An in-home provider is a paraprofessional who provides assistance in and support for living in a home setting. The primary responsibility of the employee is to provide supervision and safety to the client. The provider may perform personal care and home management services that enable the elderly, ill or person with disabilities to livein a home setting.

Additional responsibilities of an in-home provider may include:

Supervision of the clients safety
Feeding and dressing the client
Housekeeping tasks such as light housework, laundry, purchasing and preparing food
Personal hygiene tasks including assisting with bathing, grooming, toileting and dressing/undressing
Assisting clients with hands on or supervision of ambulation and transfers
Helping with prescribed exercises and assisting with medication reminding and monitoring
Transportation as needed to doctor's appointments, grocery store and errands and outings
Respite for the primary caregiver and companionship for the client

Do you feel that you have any physical limitations that will prohibit you from accomplishing the tasks associated with the job?

Yes No

Initials:

If yes, please explain:

Availability:

Please indicate the type of work you would prefer: Full Time Part Time Days Nights Live-in (24 hr. shifts)
Approximately how many hours per week do you wish to work?

List the days and hours you wish to work:

What areas in San Diego or Riverside County are you willing to work?

NOTE: Innovative Healthcare will do everything possible to accommodate your scheduling needs, but we cannot guarantee that we will be capable of providing the hours requested.

Services:

Please check the services you are willing to provide:

Supervision Companionship Meal Preparation Walking/Standing assistance
Dressing Assistance Personal Care (showering, incontinence, etc) Feeding Laundry
Transportation Light Housework Transfers to and from wheelchair, bed, etc.
Do you have any reservations providing services to a client with a pet(s)? Yes No
Do you smoke? Yes No
Are you willing to work with a client who smokes? Yes No

Employment History

List all employment including business and caregiving for the last 5 years. Start with your current or last position.

Company/Client Name: Position Held:
Address:
Phone:
From: To:
Supervisor’s Name: Reason for Leaving:

Fill in your name, sign and date below. The bottom portion is for verification of your previous employer.

I, authorize the release of information to Innovative Healthcare Consultants for employment purposes.

Signature:

Date:

To be filled in by previous employer:

has applied to Innovative Healthcare Consultants.

We would appreciate you completing this form:

Dates of employment:

Job Title:

Would you rehire this applicant? Yes No

Signature:

Comments:

Make Application Printer-Friendly

Make Application Editable
Please fax your application to (760) 731-1490 or mail to:

Innovative Healthcare Consultants
557 E. Alvarado St.
Fallbrook, CA 92028

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