Touch of Class
Application
(Attendant)
Touch of Class requires each new employee to attend orientation prior to work placement. All new
employees will be paid for the orientation training upon completion of the 90-day adjustment period.
REQUIREMENTS BEFORE HIRING CONSIDERATION:

Drug Testing:
Touch of Class will only hire and maintain
drug-free employees
CPR certificate must be up-to-date (must be American Red
Cross or American Heart Association) No Internet
CPR Certification:
Touch of Class will notify you one month in advance of the expiration date of your CPR certification. This
must be updated or you will be ineligible to work.
COPIES OF THE FOLLOWING DOCUMENTATION MUST BE ATTACHED TO THE
EMPLOYMENT APPLICATION BEFORE IT IS PROCESSED:
1.
2.
3.
4.
Current Valid Texas Driver's License, or Texas ID Card
Social Security Card or Certified Birth Certificate
Practicing License if required for position
Copy of high school or college diploma if required for position
Touch of Class is an Equal Employment Opportunity employer. Applications are considered for all
positions without regard to race, religion, sex, national origin, age, family status, veteran status, disability
or any other legally protected status. Touch of Class is a drug-free workplace.
THIS APPLICATION CANNOT BE PROCESSED UNLESS IT IS COMPLETELY
FILLED OUT AND INCLUDES THE REQUIRED DOCUMENTATION STATED ON
THE FRONT PAGE OF THIS PACKET.
Date of Application:
/
/
Name:
(Last)
(First)
Social Security #:
(Middle Initial)
Phone #: (
)
_____
Cell#(___)_______________________
Other Phone #(__)_________________
Date of Birth:____________
Address:
(Street)
Position Applied For:
Days Available:
Hours Available:
(City)
(State)
(Zip Code)
Full-time?
[ ]Y [ ] N
Part-time? [ ]Y [ ] N
1. Are you eligible for employment in the United States? [ ] YES [ ] NO
( I understand that if I am hired, I will be required to provide proof of identity and legal work authorization.)
2. Have you ever had a criminal conviction? [ ] YES [ ] NO
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Touch of Class
If yes, please explain:
3. Some positions may require drug screening. Do you consent to the testing prior to
or if needed after employment with TOC? [ ] YES [ ] NO
4. Will you work overtime if asked? [ ] YES [ ] NO
beginning work
If you answered NO to questions 1 or 4, please explain:
EDUCATION:
Level
Grade
High Sch.
GED
College
Trade/Voc
Type
(List any education, training or courses that support
the qualifications for this position.)
School / Location
Graduate?
[]Yes []No
[]Yes []No
[]Yes []No
[]Yes []No
[]Yes []No
Please list any professional licenses and / or certifications:
Agency or State Issued By
Date Issued
Number
EMPLOYMENT EXPERIENCE:
(Start with your present or most recent job.
Include military service assignments and volunteer activities.)
Employer:
Address:
Phone:
Supervisor:
Job Title:
Dates of Employment: From: Mo./Yr.
To: Mo./Yr.
Starting Hourly/Salary Rate:
Ending Hourly/Salary Rate:
Work Performed:_________________________________________________________
Reason for Leaving:
May we contact your present employer? [ ] Yes [ ] No
Employer:
Address:
Phone:
Supervisor:
Job Title:
Dates of Employment: From: Mo./Yr.
To: Mo./Yr.
Starting Hourly/Salary Rate:
Ending Hourly/Salary Rate:
Work Performed:_________________________________________________________
Reason for Leaving:
May we contact your former employer? [ ] Yes [ ] No
Employer:
Address:
Supervisor:
Phone:
Job Title:
Revised 11.2011
Degree
Touch of Class
Dates of Employment: From: Mo./Yr.
To: Mo./Yr.
Starting Hourly/Salary Rate:
Ending Hourly/Salary Rate:
Work Performed:_________________________________________________________
Reason for Leaving:
May we contact your former employer? [ ] Yes [ ] No
NUMBER OF MONTHS YOU HAVE WORKED
WITH PEOPLE WITH DISABILITIES:
Briefly, explain your experience:
_____
Experience working with children: yes/ no/ N/a: If yes, describe type of
experience, and age group and what you feel is important when working with
children.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
PERSONAL REFERENCES:
(References listed below may not be present or
past employers, or family members.)
Reference Name:
Address:
Position:
Years Known:
Phone #:
Reference Name:
Address:
Position:
Years Known:
Reference Name:
Address:
Position:
Years Known:
Phone #:
Phone #:
I attest that the information provided on this application is true and correct. Any misrepresentation
or falsification will result in immediate termination.
I agree to undergo initial and random drug/alcohol testing and driver's license checks. If hired, I
will provide proof of identity and legal work authorization.
Applicant Signature:
Date:
Review of application DSA Supervisor:_________________________________
Date:
_________________________________
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Touch of Class
Evaluation of Past Work Experience
Applicant's Name:
Date:
1.
Have you had experience in taking directions from an individual with a disability?
[ ] YES [ ] NO
Explain:
2.
Have you received training to assist with transfers?
[ ] Wheelchair
[ ] Sliding Board
[ ] Dependent Transfers [ ] Vehicle
Maximum weight you can lift: [ ] 0-50 lbs.
3.
Which of the following
with?
[ ] Bathing
[ ] Dressing
[ ] Shopping
[ ] Menu Planning
[ ] Gait/Transfer Belt
[ ] Hoyer Lift Transfers
[ ] 100+ lbs.
independent living skills have you assisted an individual with disabilities
[
[
[
[
] Cooking
[ ] Feeding
] Budgeting [ ] Self-Medications
] Personal Grooming
] Showers/ Roll-in
[ ] G-Tube
[ ] Tutoring
Where and how long did you perform these tasks?
Have you been trained to perform personal tasks and to protect the personal dignity of a person with a
disability? (Explain)
4.
Have you received training in assisting with the following personal care tasks?
Bowel Programs
[ ] Yes [ ] No Bladder Programs
[ ] Yes [ ] No
Care for medically related skin problems
[ ] Yes [ ] No
5.
Have you received training concerning the following subjects?
[ ] Infection control
[ ] CPR [ ] Universal Precautions
[ ] AIDS
[ ] HIV [ ] HBV- Hepatitis B Virus
6.
Have you had training in conflict resolution?
7.
What experience do you have in using adaptive equipment?
8.
What experience have you had in documentation of patient/client information?
9.
Have you trained in fire safety/emergency procedures?
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Touch of Class
11.
Have you had any experience in a supported living environment?
12.
Are you familiar with community resources for people with disabilities?
13.
Please explain any other paid or volunteer experience you have in working with people with
disabilities?
14.
In our program, the participant drives the program and decisions made about their lives. How do
you see yourself as a person who is working with a person with a disability?
15.
What rights do you feel our clients with disabilities have?
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________
Please include any additional information you think would be useful in evaluating your past experience with
the disability community below/and children.
Revised 11.2011
Touch of Class
Employee Physical Profile
I,
, certify that I am able the following physical profile
requirements for my position with Touch of Class.
POSITION:
Habilitation Attendant
Measurement Criteria:
1.
Lifting:
___
Light (must be able to lift 5-20 pounds)
___
Moderate (must be able to lift 20-50 pounds)
_X_
Heavy (must be able to lift weights in excess of 50 pounds)
2.
Pushing:
___
Light (must be able to push light objects such as an empty
wheelchair)
___
Moderate (must be able to push objects such as an occupied
wheelchair)
_X_
Heavy (must be able to push an occupied motorized wheelchair)
3.
Pulling:
___
Light (must be able to pull light objects such as an empty
wheelchair)
___
Moderate (must be able to pull objects such as an occupied
wheelchair)
_X_
Heavy (must be able to pull an occupied motorized wheelchair)
4.
Mobility (Walking):
___
No walking required for this position
___
Moderate walking (routine office movement)
_X_
Continual walking (Courier)
___
Does not have to walk.
5.
Stair Climbing:
___
No climbing
_X_
Must be able to climb stairs
___
Must be able to climb ladders
_X_
Must be able to climb ramps
6.
Standing:
___
Short duration (less than 10 minutes without a break)
___
Moderate duration (10-30 minutes without a break)
_X_
Continual (more than 30 minutes without a break)
7.
Sitting:
_X_
Intermittent sitting
___
Prolonged sitting
8.
Squatting:
___
_X_
9.
Stooping:
___
_X_
10.
11.
Reaching:
Hands:
12.
Other:
_X_
_X_
job
___
_X_
It is not necessary to be able to bend at the knees in order to
perform this job
It is necessary to be able to bend at the knees in order to perform
this job
Ability to bend at the waist is not necessary in order to perform
this job
Ability to bend at the waist is necessary in order to perform this
job
Must be able to reach above shoulder level
It is necessary to have use of both hands in order to perform this
Other physical specifications required to do this job
Must be able to provide maximum assistance when transferring
participants
By my signature, I certify that I am able to perform the above physical requirements in order to perform my
job duties.
Applicant Signature:
Date:
_____
Supervisor’s Review: _________________________
Date: ____________
Revised 11.2011