Home Care Have Experience

Face to Face Interview

Name of Applicant: Position: DCW_

Phone: E-Mail 1. How many years’ experience do you have in Home Care? 2. Do you have an active CNA or HHA certification? Yes No 3. Do you have any experience with assisting with baths/showers? Yes No 4. Do you have any experience transferring clients? Yes No 5. Do you have experience with a Hoyer/Sara/sit-to-stand lift, gait belt and/or transfer board? Yes No

6. Do you have experience with bed bound care such as repositioning, bed baths, bed pans and changing sheets? Yes No

7. Do you have experience with assisting a client with toileting and incontinent care? Yes No 8. Do you smoke? Yes No

9. Do you mind if your client smokes? Yes No

Interviewer Name (Print): Date: Signature:

Sol Maria Cintron

484-***-**** *******************@*****.***

8

Application for Employment - SarahCare Home Care Agency Application for Employment

SarahCare is an equal opportunity employer. We do not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on any basis protected by local, state or federal law, including a person’s age, gender, sexual orientation, race, creed, national origin, religion, disability, or veteran status. Applicants for positions with the Company must completely fill out this application to be considered for employment unless otherwise noted. No applicant will be considered for employment solely on the basis of this application. This application will remain active for 60 days only. If you are not contacted by a representative of this Company within 60 days and still wish to be considered for a position, you must fill out and submit a new application. Please type or print the information requested. Personal information Date

Name Social Security #

Present address

Street City State Zip

Cell Phone # Date of Birth

NOTE: We only ask for Date of Birth to run your background check. We do not require this question be answered. Are you employed now? If so, may we contact your present employer? Yes No Will you travel if required? Yes No Do you have a reliable means of transportation? Yes No Have you lived in Pennsylvania for more than 2 years? Have you ever been convicted of ANY crime in the past? Yes No NOTE: A conviction will not necessarily disqualify you from employment. If you answered yes to the above question, please explain: Education Name of School

# of years

Completed

Did you

Graduate?

Subjects

Studied

Academic

Currently Attending

Last Completed

Date

Month and Year Name of Employer

Salary

Job Title

Reason for

Leaving

From

To

From

To

04/03/2025

Sol Maria Cintron

225 E Lancaster 19607

Avenue

Shillington PA

484-***-**** 01/01/1947

No

Yes

Saint Theresa Academy Yes

Application for Employment - SarahCare Home Care Agency References: Give the names of three persons not related to you to whom you have known at least 1 year Name Address Phone Years acquainted

SarahCare often has clients whose primary language is other than English. List any foreign language(s) you speak, read or write, and check the box that best describes your skill level. Language Read and write Read and speak Speak only

In case of

emergency, notify

Full Name Relationship Phone #

INITIAL Conditions of Employment – Please Read Carefully and Initial A condition of employment includes the applicant or employee agreeing to a PPD test, Criminal History Investigation, Reference Check, Child Abuse Clearance, Competency Exam and Drug Screening. I authorize SarahCare to contact my references to investigate my past employment and professional activities. I also agree to release from liability all persons and companies providing this information. I understand and acknowledge that any offer of employment is conditional upon SarahCare being completely satisfied with the information provided as a result of this reference check. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from SarahCare’s service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, SarahCare reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of SarahCare has the authority to make any assurances to the contrary. Signature of Applicant Date

S C

Sol

Maria

Cintro

n

S C

04/03/2025

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