A Better Solution Home Care
Application for Employment
Today’s Date:
Personal Information
Name (Last, First, MI):
Street Address:
City, State, Zip:
Home phone number:
Cell phone number:
E-mail address:
DOB:
Social security number:
Driver’s license number:
Employment Desired
Position applied for:
Date available for work:
How did you hear about A Better Solution?
Write in
desired hours
in the columns
to the right
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Or check a preferred
shift:
All
24-hr. shifts
Overnights
Check all locations you’re willing to work:
Stanwood/Camano
N. Snohomish Skagit All
SEATTLE office Serves: Seattle Area Eastside S. Snohomish County All
Education
School Name
Course/Major
Total
Years
Date
Degree/Diploma
High School
College
Technical
Training
Other (specify)
List any certifications, classes or other education not listed above which may help qualify you for this
position (Example: Fundamentals of Caregiving, NAC, NAR, etc.):
1
Employment History
List below all present and past employers over the past 10 years, starting with your most recent
employer. Account for all periods of unemployment. You must complete this section even if attaching
a resume. May we contact your current employer?
Yes
No
1. Employer
Start
Date
End
Date
Address:
Essential job functions of final
position:
1.
City, State, Zip:
Starting
Wage
Ending
Wage
Phone number:
2.
3.
Fax number:
Supervisor(s):
4.
Job position(s):
Email address of supervisor:
Reason(s) for leaving:
What value did you add to this company?
2. Employer:
Start
Date
End
Date
Address:
Essential job functions of final
position:
1.
City, State, Zip:
Starting
Wage
Ending
Wage
Phone number:
2
3.
Fax number:
Supervisor(s):
Job position(s):
E-mail address of supervisor:
4.
Reason(s) for leaving:
What value did you add to this company?
2
3. Employer:
Start
Date
End
Date
Address:
Essential job functions of final
position:
1.
City, State, Zip:
Starting
Wage
Ending
Wage
Phone number:
2.
3.
Fax number:
Supervisor(s):
4.
Job position(s):
E-mail address of supervisor:
Reason(s) for leaving:
What value did you add to this company?
4. Employer:
Start
Date
End
Date
Address:
Essential job functions of final
position:
1.
City, State, Zip:
Starting
Wage
Ending
Wage
Phone number:
2.
3.
Fax number:
Supervisor(s):
Job position(s):
E-mail address of supervisor:
4.
Reason(s) for leaving:
What value did you add to this company?
Additional Information
If hired, can you provide proof of citizenship or proof of your legal right to work in the U.S.?
Have you ever been convicted of a felony? Yes No If Yes, please explain:
Yes
No
Are you able to perform all of the essential functions of the job for which you are applying with or
without reasonable accommodation? Yes No
If hired, do you have a reliable and insured means of transportation to and from work?
Yes
No
3
References
List below three persons not related to you who have knowledge of your work performances within
the last five years, and whom you have known for at least 1 year:
Name:
Occupation:
Address:
Telephone:
Relationship and years acquainted:
Name:
Occupation:
Address:
Telephone:
Relationship and years acquainted:
Name:
Occupation:
Address:
Telephone:
Relationship and years acquainted:
Additional Space to Expand on Any Points
By signing this application I verify that all information given is true and complete to the best of my
knowledge. I also acknowledge that if hired, A Better Solution Home Care will perform a mandatory
criminal background check and I herein give my permission for them to do so.
________________________________________________
Signature
_________________
Date
4
A Better Solution Home Care
Reference Release
In signing this release, I give A Better Solution Home Care (ABS) permission to contact any of my
former and current employers to obtain a reference check. I understand that this process is
required to become an employee of ABS and that they may obtain this information via phone, fax, email, or mail.
I also acknowledge that ABS will be asking of any employer to give a fair assessment of my skills in
relationship to the position I am applying for today, with the understanding that they are not
required to comply with this assessment. If in the event they refuse to assess my skills, they will be
required to provide my beginning and ending dates of employment, my position with the company,
and whether or not I am eligible for rehire.
_______________________________________________
Applicant
____________
Date
5
A Better Solution Home Care
Consistent Scheduling System
_____________________________________________
_________________
Name
Date
In order to provide quality services to our clients, you are required to fill out a consistent
schedule so that we may schedule efficiently.
Please select the amount of hours you would prefer to work and initial accordingly:
Up to 20 hours per week
* Up to 1 weekend per month
Initial: _______
21-30 hours per week
* Up to 2 weekends per month
Initial: _______
31+ hours per week
* Up to 3 weekends per month
Initial: _______
* Please note: Working in home care often means having to cover weekend shifts. If you are
absolutely unable to cover weekends with no exception please indicate so in the schedule
below by crossing those days out. Understand that the less you are available to work, the
fewer hours you are likely to get. You may never have to cover weekends.
Fill in your maximum availability below. If there are any days that you absolutely cannot
work, cross those days off. This schedule should reflect your weekend commitment listed
above:
Monday
Tuesday
Wednesday Thursday
Friday
Saturday
Sunday
Please note: we are not asking for your “ideal” schedule. We would like you to enter the
earliest time you are able to start a shift to the latest you can work on each day. If your
availability varies from week to week, please let us know.
Can we call you on your day off?
Yes
No
Your Signature: ________________________________________
Scheduler: _____________________________________________
Home Care Supervisor: __________________________________
6
Skills Inventory Checklist
Name: __________________________________
Date: _____________
Please use this form to rate yourself on a scale of “Very skilled”, “Moderately skilled”, or “Unskilled”
for each caregiving task. Check one for each task.
Personal Care
Very Skilled
Moderately
Skilled
Unskilled
Moderately
Skilled
Unskilled
Moderately
Skilled
Unskilled
Shampooing Hair
Shaving
Oral Hygiene
Denture Care
Dressing
Showering
Tub Bathing
Sponge Bathing
Bed Baths
Bathing with Hoyer Lift
Skin Care
Pressure Ulcers
General Wound Care
Foot Care
Diabetes Care
Blood Glucose Monitoring
Peri Care
Range of Motion
Toileting
Very Skilled
Urinary Incontinence
Urinary Problems
Bowel Incontinence
Bowel Problems
Transfers to
Toilet/Commode
Use of Bedpan/Urinal
Catheter Care
Stoma care
Changing Briefs
Ambulation
Very Skilled
Wheelchair
Walker
Cane
Hoyer Lift
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Ambulation Continued
Very Skilled
Moderately
Skilled
Unskilled
Very Skilled
Moderately
Skilled
Unskilled
Very Skilled
Moderately
Skilled
Unskilled
Very Skilled
Moderately
Skilled
Unskilled
Very Skilled
Moderately
Skilled
Unskilled
Very Skilled
Moderately
Skilled
Unskilled
Very Skilled
Moderately
Skilled
Unskilled
Lift Chairs
Transfer: Standby/Assist
Transfer: Full Assist
Transfer/Gait Belt
Turn/Reposition
Medications/Treatments
Reminders
Administer
Oxygen
Special Needs
Behavior Monitoring
Wandering Prevention
Fall Prevention
Difficult Behaviors
Developmental Disabilities
Dementia Care
Eating Assistance
Meal Planning
Meal Preparation
Special Diets
Dysphasia
Traveling/Transporting
Travel to Medical Services
Essential Shopping
Community Activities
Recreation
Home Management
General Housekeeping
Deep Cleaning
Making Fires
Gardening
Personal Financing
Other Tasks Not Listed
Please return to:
Stanwood Applicants
A Better Solution Home Care
10003 270th St NW Ste A
Stanwood WA 98292
Fax: 360-629-4658
Email: sandi@abettersolutionhc.com
Seattle Applicants
A Better Solution Home Care
12810 NE 178th ST Ste 234
Woodinville, WA 98072
Fax:425-481-9426
taunya@abettersolutionhc.com
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Home Caregiver
Applicant name: _________________________________
Date: ____________________
Please complete these questions using additional paper if needed.
Do you have dependable childcare, and back-up plan?
Do you have reliable transportation?
Do you have car insurance?
I. Job Skills/Problem Solving Scenarios
1. You walk into the client’s home for your very first shift with them. The house is extremely
dirty and they client seems that way too. Right away he tells you that his sister will be
coming by to bathe him on a regular basis and he doesn’t want you to worry about that part
of your job- even though it’s on your Plan of Care to do this. He just wants you to do
everything else on the Plan. What would you do?
2. You are assigned to work with a client who you are unable to communicate verbally with.
You are clear that she doesn’t like the meals you have been preparing because she keeps
giving the food back to you. How would you figure out how to prepare meals that she likes?
What are some resources you could use to help you with this?
3. You are a member of a three caregiver care team and you notice that at least one of the
other caregivers isn’t doing the dishes and laundry on their shift. It would seem like they’re
leaving it all up to you. How do you think you would handle this situation?
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4. You have developed a close bond with a client and they have asked for your cell phone
number so they can reach you when they need you to pick up groceries on your way out to
their house before a shift. Would you give them your phone number? Explain:
5. Your client, Ms. Brown, is an elderly woman who has been living alone for 20 years. At the
recommendation of her doctor, she has reluctantly agreed to home care. This is your first
day with her and your supervisor tells you that Ms. Brown may be difficult. As soon as you
walk in the door, she says, “None of you aides know what you’re doing….and I told the
agency not to send anyone else!” How would you attempt to work with this client?
Why do you think she is behaving this way?
6. You’re at a client’s house and they’ve asked you to use your car to run errands for them. You
weren’t expecting having to use your car while on shift and are very short on gas. What do
you do?
What if your client offers to lend you enough gas money to do the chore they’ve requested?
7. It’s your first day with a new male client, who has mild dementia. Within the first couple
hours of your shift, the client makes sexually inappropriate comments to you. How do you
handle this situation?
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8. You are providing 24-hr. care for a long-term client. You have a great working relationship
with the client and their spouse, and it’s apparent they feel the same about you. In a 24-hr.
shift you are required to receive 16 hours of downtime, with 8 hours of labor dispersed
throughout the shift. Your client’s spouse agreed to this rule at the start of services but they
consistently seem to forget about it, as they are always asking you to do different house
chores while you’re taking breaks. How do you handle this?
9. Your client Carol tells you that she leant $25 to another agency caregiver last week and she
hasn’t repaid her- although she wasn’t scheduled to return to the client’s house until the
following day. Carol says “I’m sure she’ll pay me back tomorrow when she’s here.” Is this
ok?
Do you think you should report this or talk to anyone about it?
10. You have a client who has Home Health in place temporarily. The home health nurse tells
you that every time she stops by the client’s home and your co-worker Angel on shift, she is
appalled by the clothes she sees Angel wearing- they’re incredibly inappropriate for a
professional caregiver. What would you do?
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III. Character Questions
1. What would you consider your biggest accomplishment to be?
2. Name one short term goal:
3. How about a long term goal?
4. If you could have 24 hours of uninterrupted time to do whatever your heart desired… what
would you do?
5. One word that best describes you as a person
What unique quality separates you from
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