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Section 2 - General Information |
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Number |
Question |
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1 |
How did you hear about ABC? |
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2 |
Have you ever applied to or worked for Always Best Care before? |
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Yes No |
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3 |
Any friends or relatives working for Always Best Care? If yes, state name(s) and relationship. |
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4 |
Are you at least 18 years old? (required) |
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Yes No |
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5 |
If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? (required) |
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Yes No |
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6 |
If hired, can you provide documentation that you have completed a physical examination within the last 2 years? (required) |
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Yes No |
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7 |
If hired, can you provide documentation that you have completed a TB test within the last 2 years? (required) |
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Yes No |
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8 |
How many years of experience do you have working in "Home Care"? (required) |
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9 |
Are you available to work in a home where smoking occurs? (required) |
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Yes No |
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10 |
Are allergic to pets? If yes, please list pets: (required) |
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11 |
Available to work with senior clients? |
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Male Female |
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12 |
Are you capable of reading, speaking, and understanding English as a part of your job performance? (required) |
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Yes No |
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13 |
If you speak any other languages other than English, please list: |
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14 |
Are you able to perform the following functions? |
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Level 1: Meal preparation, light housekeeping, laundry, change linens, errands/appointments, etc. |
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Level 2: Dressing, ambulating, bathing, grooming, assist with exercise, etc. |
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Level 3: Transfers, feeding, incontinence care, emptying catheter/ostomy bag, safety supervision, oxygen, swallow protocol, long-term chronic care, etc. |
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Dementia/Alzheimer's Care |
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Hospice Care (End of Life Care) |
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15 |
If hired, what is your means of transportation to/from work?: |
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Own Auto Public Transportation Others |
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16 |
What is the minimum amount you need to earn hourly? (required) |
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17 |
Have you ever been convicted of a criminal offense (felony or misdemeanor)? (required) |
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Yes No |
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18 |
If yes, state the nature of the crime(s), when and where convited and disposition of the case(s). |
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19 |
Can you provide up-to-date documentation of a driver's license and auto insurance? (required) |
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Yes No |
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20 |
Do you have any driving violations on your record? (required) |
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Yes No No license |
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21 |
If so, please list: |
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22 |
Is your automobile available for running errands, doctor's appointments, etc? (required) |
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Yes No No car |
| Section 3 - AVAILABILITY |
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Number |
Question |
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1 |
If hired, on what date can you start work? (required) |
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4 |
Are you applying for: Full-time work? (required) |
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Yes No |
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5 |
Are you applying for: Part-time work? (required) |
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Yes No |
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6 |
Are you available to work 12 hour shifts? (required) |
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Yes No |
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7 |
Are you available to work Live-in shifts? (required) |
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Yes No |
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8 |
If yes, what days? |
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9 |
Please select the days and times that you are available: (required) |
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Sunday: |
Monday: |
Tuesday: |
Wednesday: |
Thursday: |
Friday: |
Saturday: |
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Start times: |
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End times: |
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10 |
Check the districts where you are willing to take assignments: (required) |
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Area 1: Daly City, SSF, San Bruno, Millbrae |
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Area 2: Burlingame, San Mateo, Foster City |
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Area 3: Belmont, San Carlos, Redwood City |
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Area 4: San Francisco |
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Area 5: Half Moon Bay, Moss Beach |
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Others (please list): |
| Section 4 - EDUCATION |
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Number |
Question |
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1 |
Name of High School: Years Completed: 1234 |
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2 |
Name of College: Years Completed: 12345678 Major: |
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3 |
Trade School 1: Length of Training: Skill: |
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4 |
Trade School 2: Length of Training: Skill: |
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5 |
Trade School 3: Length of Training: Skill: |
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6 |
Do you have another experience, training, qualifications or skills, which you feel make you especially suited for work at Always Best Care? If so, please explain: |
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| Section 5 - CERTIFICATIONS/LICENSES/CREDENTIALS |
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Number |
Questions |
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1 |
If CPR certified, please provide expiration date: |
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2 |
If First Aid certified, please provide expiration date: |
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3 |
If C.N.A certified, please provide expiration date: |
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4 |
If H.H.A certified, please provide expiration date: |
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| Section 6 - CURRENT EMPLOYER/MOST RECENT EMPLOYER |
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Number |
Question |
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1 |
Employer: (required) |
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2 |
Address: (required) |
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3 |
City: (required) |
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4 |
State: (required) |
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5 |
Zip Code: (required) |
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6 |
Start Date: (required) |
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7 |
End Date: (required) |
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8 |
Position/Title: (required) |
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9 |
Supervisor's Name/Title (required) |
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10 |
Supervisor's Phone: (required) |
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11 |
Reason for Leaving: (required) |
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12 |
May we contact? (required) |
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Yes No |
| Section 7 - SECOND MOST RECENT EMPLOYER |
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Number |
Question |
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1 |
Employer: (required) |
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2 |
Address: (required) |
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3 |
City: (required) |
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4 |
State: (required) |
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5 |
Zip Code: (required) |
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6 |
Start Date: (required) |
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7 |
End Date: (required) |
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8 |
Position/Title: (required) |
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9 |
Supervisor's Name: (required) |
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10 |
Supervisor's Phone: (required) |
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11 |
Reason for Leaving: (required) |
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12 |
May we contact? (required) |
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Yes No |
| Section 8 - THIRDMOST RECENT EMPLOYER |
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Number |
Question |
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1 |
Employer: (required) |
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2 |
Address: (required) |
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3 |
City: (required) |
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4 |
State: (required) |
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5 |
Zip Code: (required) |
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6 |
Start Date: (required) |
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7 |
End Date: (required) |
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8 |
Position/Title: (required) |
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9 |
Supervisor's Name/Title: (required) |
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10 |
Supervisor's Phone: (required) |
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11 |
Reason for leaving: (required) |
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12 |
May we contact? (required) |
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Yes No |
| Section 9 - PROFESSIONAL REFERENCE - 1 (No Friends/Relatives) |
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Number |
Questions |
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1 |
Name: (required) |
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2 |
Company: (required) |
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3 |
Phone: (required) |
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4 |
Position: (required) |
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5 |
Professional Relationship: (required) |
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| Section 10 - PROFESSIONAL REFERENCE - 2 (No Friends/Relatives) |
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Number |
Question |
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1 |
Name: (required) |
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2 |
Company: (required) |
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3 |
Phone: (required) |
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4 |
Position: (required) |
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5 |
Professional Relationship: (required) |
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| Section 11 - PROFESSIONAL REFERENCE - 3 (No Friends/Relatives) |
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Number |
Question |
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1 |
Name: (required) |
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2 |
Company: (required) |
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3 |
Phone: (required) |
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4 |
Position: (required) |
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5 |
Professional Relationship: (required) |
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| Section 12 - Emergency Contact Information |
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Number |
Question |
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1 |
First Name (required) |
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2 |
Last Name: (required) |
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3 |
Address: (required) |
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4 |
City: (required) |
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5 |
State: (required) |
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6 |
Zip Code: (required) |
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7 |
Phone: (required) |
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8 |
Relationship: (required) |
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| Section 13 - CAREGIVER TEST |
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Number |
Question |
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1 |
Betty Smith is a client who has been discharged from the hospital with a diagnosis of CHF and Diabetes. Which 2 types of food do you need to avoid when cooking her meals? |
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Sweet |
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Sour |
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Salty |
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None of these |
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2 |
Carl has had right hip replacement surgery and is now at home. What precautions are needed when transferring him to and from a wheelchair and a walker? |
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Make sure brakes are locked on wheelchair |
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Avoid twisting of the hips and torso |
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Make sure the walker is locked and placed directly in front of the client |
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All of the above |
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3 |
Sarah was discharged home from the hospital with left sided CVA. She is to have her foods prepared for her that are pureed and her liquids are to be thickened. While supervising her meals, what are 2 important observations to make? |
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She is enjoying her meal |
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Her swallowing |
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Her plants need watering |
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Pocketing of food on her affected side |
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4 |
Sarah is also under aspiration precautions, what does this mean? |
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She sweats a lot |
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She stops breathing |
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She may inhale her food into her lungs |
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5 |
Charles came home from the hospital 2 days ago, this is your second day of caring for him. You are in the laundry room, when suddenly you hear a thud. You run toward the bathroom only to see that he has fallen in the hallway. You would: |
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Grab him underneath the arms and assist him to standing position |
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Grab him underneath the arms and assist him to a sitting position on the floor |
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Ask him if he is able to get up by himself and if he cannot, you do not move him. You call 911 then call the office. |
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6 |
Which of the following foods are high in sodium? |
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Corn Chips |
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Soda |
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Oranges |
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Celery |
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Milk |
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Chicken noodle soup |
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7 |
You are caring for Gertrude who has Dementia. She insists there is an intruder stealing jewelry from her bedroom. What do you do to calm her? |
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Tell her that her mind is playing tricks on her |
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Tell her you are going to go into the bedroom apprehend the intruder and get rid of him |
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Change the subject |
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8 |
Harold came home from the hospital with a Foley catheter. You are asked to empty it every 8 hours or when 2/3 full. What observations will you be making of his urine to ensure safety? |
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Color |
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Presence or absence of blood |
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Clarity |
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Amount |
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All of the above |
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9 |
Sylvia has been your client for a week now, she is always complaining of constipation. You know that she has had a bowel movement everyday you have been there. She suddenly complains of severe, acute abdominal pain and doubles over. You: |
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You make her some warm prune juice |
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Tell her she should probably take a pain medication |
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Call 911, and then call the office |
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10 |
You are caring for a 45 year old woman who is an alcoholic. She especially drinks excessively on the anniversary of her son's death. You are caring for her on that very day. What do you do to help her cope? |
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Lock all the liquor in the cabinet |
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Dump it all down the drain |
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Encourage her to talk about her grief, remain with her at all times even though she is drinking, and call the office |
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Start mixing up drinks for both of you since this case if very depressing |
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11 |
You are caring for a man who is confused (usually very pleasant), he suddenly becomes very belligerent and is verbally abusive. When serving his dinner he strikes you on the arm accusing you of poisoning his food. What do you do? |
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Ignore him |
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Calmly reassure him and call the office |
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Strike him on his arm |
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12 |
Your client is an 85 year old elderly woman. She has a 90 year old husband who can no longer care for her. He request that you fix meals for both of them. You would: |
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Say, "Of course I will" |
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Tell them this will be an extra charge |
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Tell him you are only there to prepare meals for his wife |
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13 |
Sally has been home from the SMF for 2 weeks now. She really feels the need to get out. She asks if you will drive her to her favorite restaurant for lunch. She wants you to drive her car. You: |
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Say, "Of course I will" |
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Call the office to get approval and have this added to her care plan, explaining to the client that additional paperwork may need to be done regarding insurance and transportation. |
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Say, "No I cannot do that for you" |
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14 |
Betty is a client you are caring for. Her daughter Kelly is visiting after work one day and asks you if you could stay 2 extra hours. what do you do? |
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Say, "Yes" |
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Call the office with the request and have Kelly talk to the manager or staff to authorize this. |
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Tell her you will if she pays you cash |
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15 |
You are working as a live-in caregiver. You have been caring for Gertrude a 91 year old woman. Lately she's been staying up until 3 a.m. and she used to go to sleep at 10 p.m. She wanders around the house and jabbers constantly. You are now getting four hours of sleep per night if you are lucky. You are the best of friends but you are very weary and feel yourself becoming sick. She has been telling you she has a very limited income. What should you do? |
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Keep going to the assignment hoping her sleep schedule will return to normal |
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Call her family to see if they can help |
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Call the office |
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16 |
You are caring for Zelda. You have noticed that she has become increasingly more agitated each day and today she is very agitated and nervous. She has a prescription for both Xanax and Valium available. Zelda agrees she needs help calming herself and asks you to giver her whichever medication you think will work the best. What do you do? |
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Give her one of the meds |
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Explain to her you are not allowed to administer meds and call the office |
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Give her both of the meds to be on the safe side |
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17 |
You have cared for Bob for 6 months now. You are very close with the whole family. It's the holidays and as you leave your shift they hand you a card. You open it, not only have they given you a Christmas card but have also included $200 cash. You: |
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Graciously accept the Christmas card, you have earned it! |
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Call your manager, you cannot accept gifts |
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Tell the family thank you, but do not tell my manager |
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18 |
While giving Jane her shower you notice that her perineal area is very red, inflamed and sore. What should you do? |
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Call the office |
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Call the family and notify them of the condition |
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Look for the proper ointment to apply |
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19 |
You have just started with a new client. While preparing him for bed you notice there is bruising on his arms and legs. What do you do? |
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Ask the client what happened |
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Ignore the bruising |
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Call the office and let them know APS needs to be notified |
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20 |
When cleaning the perineal area you should always clean: |
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Back to front |
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Does not matter |
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Front to back |
| Section 14 - SIGNATURE |
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Number |
Question |
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1 |
By entering my name and today's date and submitting this form, I am indicating that I am electronically signing this form and have read and understand the content, intent and terms of this application. (required) |
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