Date: 5/22/2015

Application Form

Franchise 195

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License Number
Mobile Phone
Email *

Section 1 - APPLICANT DATA

Number Question Effective Date Expiration Date
1 Position Applied for: (required)  
     
2 Date Available to Start Work? (required)  
     
3 Type of Employment desired: (required)  
 
 
 
 
 
5 Have you previously applied for or worked at Comfort Keepers? (required)  
     
6 If your answer to the question above was yes, what date did you last apply?  
     
9 Are you able to provide proof of eligibility to work in the United Status? (required)  
     
10 Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? (required)  
     
11 If your answer to question above was no, please describe the functions that cannot be performed.  
 
12 (Note: We comply with ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical exam and to skill and agility tests.) (required)  
     
13 Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (required)  
     
14 If Yes to 13 above, state nature of crime, when and where convicted and disposition of case (convictions for misdemeanor marijuana-related offenses that are more than 2 years old need NOT be listed). (required)  
 
15 If required for this position, do you have a valid driver's license? (required)  
   
16 Confirm any prior DMV violations  
     
17 How did you hear about us? (required)  
 
 
 
 
 
18 Do you have reliable transportation? (required)  
     

Section 2 - EDUCATIONAL BACKGROUND

Number Question Effective Date Expiration Date
1 High School (required)  
 
 
 
2 Date above degree obtained?  
     
3 College Graduate  
 
 
 
 
4 Date above degree obtained?  
     
5 Business or Trade  
 
6 Date above degree obtained?  
     

Section 3 - EMPLOYMENT HISTORY

Number Question Effective Date Expiration Date
1 Most Recent Employer 1 - Company Name (required)  
     
3 Employer 1 - City (required)  
     
4 Employer 1 - State (required)  
     
5 Employer 1 - Zip Code (required)  
  (Numeric Answer Only)    
6 Employer 1 - Your Job Title (required)  
     
7 Employer 1 - Name and Title of Immediate Supervisor (required)  
     
9 Employer 1 - Reason for leaving (required)  
     
10 Employer 1 - Start Date (required)  
     
11 Employer 1 - End Date (required)  
     
12 Employer 1 - Start Salary (Hourly) (required)  
  (Numeric Answer Only)    
13 Employer 1 - End Salary (Hourly) (required)  
  (Numeric Answer Only)    
14 Employer 1 - May we contact for reference/verification? (required)  
 
 
 
15 Employer 1 - Summarize the nature of the work performed and your job responsibilities: (required)  
 
16 Employer 2 - Company Name (required)  
     
18 Employer 2 - City (required)  
     
19 Employer 2 - State (required)  
     
20 Employer 2 - Zip Code (required)  
  (Numeric Answer Only)    
21 Employer 2 - Your Job Title (required)  
     
22 Employer 2 - Name and Title of Immediate Supervisor (required)  
     
24 Employer 2 - Reason for Leaving (required)  
     
25 Employer 2 - Start Date (required)  
     
26 Employer 2 - End Date (required)  
     
27 Employer 2 - Start Salary (Hourly) (required)  
  (Numeric Answer Only)    
28 Employer 2 - End Salary (Hourly) (required)  
  (Numeric Answer Only)    
29 Employer 2 - May we contact for reference/verification? (required)  
 
 
30 Employer 2 - Summarize the nature of the work performed and your job responsibilities: (required)  
 
31 Employer 3 - Company Name (required)  
     
33 Employer 3 - City (required)  
     
34 Employer 3 - State (required)  
     
35 Employer 3 - Zip Code (required)  
  (Numeric Answer Only)    
36 Employer 3 - Your Job Title (required)  
     
37 Employer 3 - Name and Title of Immediate Supervisor (required)  
     
39 Employer 3 - Reason for Leaving (required)  
     
40 Employer 3 - Start Date (required)  
     
41 Employer 3 - End Date (required)  
     
42 Employer 3 - Start Salary (Hourly) (required)  
  (Numeric Answer Only)    
43 Employer 3 - End Salary (Hourly) (required)  
  (Numeric Answer Only)    
44 Employer 3 - May we contact for reference/verification? (required)  
 
 
45 Employer 3 - Summarize the nature of the work performed and your job responsibilities: (required)  
 
46 Please provide any comments, skills or qualifications below (including an explanation of any gaps in employment):  
 

Section 4 - REFERENCES-Business and Professional References

Number Question Effective Date Expiration Date
1 Reference 1 - Full Name (required)  
     
2 Reference 1 - Telephone Number (required)  
     
3 Reference 1 - Years Known (required)  
  (Numeric Answer Only)    
4 Reference 1 - Title and Position (required)  
 
 
 
5 Reference 2 - Full Name (required)  
     
6 Reference 2 - Telephone Number (required)  
     
7 Reference 2 - Years Known (required)  
  (Numeric Answer Only)    
8 Reference 2 - Title and Position (required)  
 
 
 
9 Reference 3 - Full Name (required)  
     
10 Reference 3 - Telephone Number (required)  
     
11 Reference 3 - Years Known (required)  
  (Numeric Answer Only)    
12 Reference 3 - Title and Position (required)  
 
 
 

Section 5 - AVAILABILITY

Number Question Effective Date Expiration Date
1 Are you available to work on Mondays? (required)  
 
 
 
 
 
2 Are you available to work on Tuesdays? (required)  
 
 
 
 
 
3 Are you available to work on Wednesdays? (required)  
 
 
 
 
 
4 Are you available to work on Thursdays? (required)  
 
 
 
 
 
5 Are you available to work on Fridays? (required)  
 
 
 
 
 
6 Are you available to work on Saturdays? (required)  
 
 
 
 
 
7 Are you available to work on Sundays? (required)  
 
 
 
 
 

Section 6 - COMPANION CARE

Number Question Effective Date Expiration Date
1 Please list 3 healthy meals you can prepare with the ingredients: (required)  
     
2 Are you able to transfer between 25-100 pounds? (required)  
     
3 Are you able to transport a client? (required)  
     
4 Are you able to perform light housekeeping? (required)  
     
5 Are you able to work in a smoker's home? (required)  
     
6 Are you able to work with a client's pets (dogs, cats, birds, etc)? (required)  
     
7 Are you able to utilize computerized maps (MapQuest, Google Maps, etc.)? (required)  
     
8 Can you speak conversational English? (required)  
     
9 What do you like about caring for the elderly? (required)  
     
10 Are you able to work in a multi-level home? (required)  
     
11 Will you work with clients who have Dementia? (required)  
     
12 Are you able to drive a client IN YOUR CAR while on the job? (required)  
 
 
 
13 Are you able to drive the client’s car on the job? (required)  
 
 
 
14 Please list your experience working with dementia clients: (required)  
     
15 Please list any allergies (ie. nuts, pets, etc.).  
     

Section 7 - CAREGIVING EXPERIENCE

Number Question Effective Date Expiration Date
1 Have you had a TB Test? (required)  
 
 
 
2 Date of most recent TB Test Results?  
     
3 Have you had an MMR Immunization? (required)  
 
 
 
4 Date of Immunization-MMR?  
     
5 Have you had Immunization - V-Zoster? (required)  
 
 
 
6 Date of Immunization - V-Zoster?  
     
7 Have you had Immunization - Hep B? (required)  
 
 
 
 
8 Date of Immunization - Hep B?  
     
9 Do you have Live-Scan Fingerprints? (required)  
 
 
 
10 Date of Live-Scan Fingerprints?  
     
11 Can you provide us a vaccination record within the last year? (required)  
 
12 Do you have any other training or licensing, i.e, CPR? Please list: (required)  
     
13 Are you a C.N.A.? (required)  
     
14 How much experience do you have with transfers? (required)  
 
 
 
 
15 How much experience do you have with bed baths? (required)  
 
 
 
 
16 How much experience do you have with bathing/showering? (required)  
 
 
 
 
17 How much experience do you have with feeding cients? (required)  
     
18 How much experience do you have with changing adult diapers? (required)  
     
19 Have you worked with bed pans before? (required)  
     
20 How much experience do you have with dementia/Alz? (required)  
 
 
 
 
21 Have you worked with Hospice clients? (required)  
     
22 What is a Hoyer lift? (required)  
 
23 When a client is walking upstairs or downstairs where should the caregiver stand? (required)  
 

Section 8 - PERSONAL CARE

Number Question Effective Date Expiration Date
1 Are you able to assist a client with bathing and grooming? (required)  
     
2 Are you able to change adult diapers and/or briefs? (required)  
     

Section 9 - STANDARD INTERVIEW QUESTIONS

Number Question Effective Date Expiration Date
1 This job requires regular and reliable transportation. How would you meet this job requirement? (required)  
 
2 This job requires that you follow the chain of command and adhere to Company Policies and procedures. Describe what you would do in the following situations while working in a client’s home (start at question 3):  
     
3 A client or a client’s family member asks you to give an insulin injection. How do you respond? (required)  
 
4 It’s 8:30am, your shift starts at 9:00am, and your car won’t start. What would you do? (required)  
 
5 What would you do if a client asks you to stay late or come early for your next shift? (required)  
 
6 The children of a client want you to perform a service outside of your job description/covered service: (required)  
 
7 Clients are often forgetful, think you are someone else, accuse you of wrong doing or get temperamental. How would you handle a difficult situation like this? (required)  
 
8 What qualities and attributes do you have that you feel make you a good caregiver? (required)  
 
9 Why do you want to work for Comfort Keepers? (required)  
 
11 Where do you see yourself in 2 years from now? (required)  
     
12 What would you do if you witnessed a caregiver being rough with a client? (required)  
 
13 What needs to be cleaned in the bathroom and with what supplies? (required)  
 
14 Describe how to empty a bedside commode: (required)  
 
14 Describe how to give a proper sponge bath: (required)  
 
15 How would you work with a client who is visually impaired?  
 
23 When should you wash your hands? (required)  
 
24 When should you empty the trash during your shift? (required)  
 
25 Do you have a smart phone and/or internet access? (required)  
     
26 What cell phone carrier do you use at this time? This info is needed if you are hired (ie. ATT, Verizon, Cricket etc). (required)  
     



I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.