Employment Application
The following are requirements for employment:
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Washington State Driver’s License or Washington State ID Card
Auto Insurance if Transporting Clients
Legal Social Security Card
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Current CPR
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2 Positive References before hire
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Cleared Background Checks
We will need to make copies of these items before any interview will be considered
Beneficial In-Home Care
1235 E Wheeler Road
Moses Lake, WA 98837
(509) 764-0004 Fax (509) 765-0755
www.bihc.biz
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Thank you for your interest in employment with Beneficial In-Home Care, Inc. We screen our
applicants by skill level and availability, and then compare them with our client’s needs at that
time. Due to the high volume of applications, our human resources department will contact you
if we have a need for your services and schedule an interview. If we do not have a current
position to place you in, you may be contacted in the future. All applications are kept in an
active file up to 90 days for further consideration. After this period of time, you are welcome to
re-apply again with our company. We are an equal opportunity employer.
Washington is an At-Will State, meaning an employer can terminate an employee at any time
for any reason, except an illegal reason, or for no reason without incurring legal liability.
Likewise, an employee is free to leave a job at any time for any or no reason with no adverse
legal consequences.
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CAREGIVER JOB DESCRIPTION
DEFINITION:
The Caregiver is an employee who provides personal care and related services in the home of the clients. Caregiver’s are
compassionate people who provide important services to clients to help maintain their independence. This is a Part-time
position that can lead into Full-time.
QUALIFICATIONS:
 High school graduate or GED equivalent
 Minimum 18 years of age
 Current Washington NAR/NAC license, or willing to obtain HCA credential within 200 days of employment
 Prior to employment, pass WATCH and DSHS background checks
 Washington State driver’s license or state ID and legal Social Security Card
 Proof of auto insurance if transporting clients
 In-home care or care facility experience preferred
 Proof of up-to-date CPR or Friends and Family CPR card. Must provide copy of current certificate or card.
 Ability to communicate and follow directions
 At least two positive references before hire date. Reference letters will be accepted.
RESPONSIBILITIES:
Under the direction of the office staff, the caregiver may be instructed to provide the following Activities of Daily Living:
 Helps client to maintain good personal hygiene, personal care (transfers, toileting, bathing), assist with
medications. Keep the client as independent as possible and without taking away their dignity.
 Able to lift up to 50 lbs unaided
 Transporting to appointments, grocery shopping, etc.
 Assist in maintaining a healthy and safe environment.
 Plans and prepares nutritious meals and does shopping when necessary.
 Provide basic emotional and psychological support to client; remain professional at all times without crossing
boundaries.
 Establishes a relationship with the client, which conveys trust and confidentiality.
 Regular documentation on progress, changes, or concerns with your client or your client’s surroundings.
*Documentation is required twice a month on each regular client that you see*
 Provide care in compliance with the Plan of Care developed for each client
 Notify the Case Manager when there is a change in the client’s condition, good or bad.
 Keeping a consistent schedule and being on time. Communicating all scheduling changes with the Scheduling
Department.
 Fill out an incident report when there is an injury on the job, whether it is a client injury or a caregiver injury.
This form must be filled out in the office within 72 hours of the incident.
 Knowledge of HIPPA, confidentiality, ER preparedness, infection control, and universal precautions.
 Mandatory reporter of any known or suspected abuse or neglect.
 Exempt employees are responsible for license renewal and continuing education
 Non-exempt employees must complete 5 hours of Orientation & Safety Training before they are allowed to work
and 70 Hour Core Basic Training within 120 days of being hired and be Home Care Aide certified by 200 days
from hire date.
 Must be in compliance with state requirements with Continuing Education classes on a yearly basis.
 Knowing Beneficial In-Home Care policies, and abiding by these guidelines.
By signing below I am acknowledging that I have received, read, understand, and will comply
with the caregiver job description.
Signature:
Revised 3/18/14 KH
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Date:
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EMPLOYMENT APPLICATION
BENEFICIAL IN-HOME CARE, INC.
1235 E Wheeler Road
Moses Lake, WA 98837
Phone: (509) 764-0004 | Fax: (509) 765-0755
NOTICE: Qualified applicants will receive consideration for employment without discrimination because of
age, color, race, marital status, national origin, religion, sex, sexual orientation, or the presence of a physical,
mental, or sensory handicap.
THIS AGENCY IS AN EQUAL OPPORTUNITY EMPLOYER
Date: ______________
Full-Time 
Position Desired: ___________________
Part-Time 
On-Call 
Name: _________________________________________
Phone: ( _____ ) ___________________________
Email Address: __________________________________
Cell:
( _____ ) ___________________________
Current Address: _____________________________________________________________________________
(STREET ADDRESS)
_______________________________________________________________________
(CITY, STATE, ZIP CODE)
Where is your birth City & State? _________________________________________________________
Referred By: _____________________________________________
Emergency Contact: _______________________________________
Relationship: _____________________
Phone ( _____ ) ___________________________________________
EDUCATION
Name of School
City/State
Years Completed
Degree
Major
High School/GED
Other
Have you ever been convicted of a crime or been released from prison? Yes  No 
If yes, explain the year of the incident and the charge:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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EMPLOYMENT RECORD
Are you currently employed?
Yes 
No 
When could you start? ______________________________
If you have ever taken care of an elderly parent, grandparent, or child; you have “life experience” and that qualifies as
work history.
PRESENT/ MOST CURRENT EMPLOYER:
Name: ___________________________________________
Phone: ( ____ ) ___________________________
Address: ____________________________________________________________________________________
(STREET ADDRESS, CITY, STATE, ZIP CODE)
Position Title: ___________________________ _____________ Immediate Supervisor____________________
Employment Dates: From _____________ To ______________ Reason for leaving: _______________________
Job Duties: __________________________________________________________________________________
PREVIOUS EMPLOYER:
Name: ___________________________________________
Phone: ( ____ ) __________________________
Address: ____________________________________________________________________________________
(STREET ADDRESS, CITY, STATE, ZIP CODE)
Position Title: ___________________________ _____________ Immediate Supervisor____________________
Employment Dates: From _____________ To ______________ Reason for leaving: _______________________
Job Duties: __________________________________________________________________________________
PREVIOUS EMPLOYER:
Name: ___________________________________________
Phone: ( ____ ) __________________________
Address: ____________________________________________________________________________________
(STREET ADDRESS, CITY, STATE, ZIP CODE)
Position Title: ___________________________ _____________ Immediate Supervisor____________________
Employment Dates: From _____________ To ______________ Reason for leaving: _______________________
Job Duties: __________________________________________________________________________________
PLEASE LIST 2 PERSONAL REFERENCES:
Name: _______________________________________ Phone: ( ____ ) __________________________
Name: _______________________________________ Phone: ( ____ ) __________________________
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Attestation Regarding Relationship to Agency Clients
I, __________________________________________________________, attest as follows:
(Print employee name)
I understand that as an employee of this agency I am obligated to notify agency personnel if the client to whom I
am or will be providing in-home care services (Medicaid-MPC-Copes-Respite or DDA) is a family member of
mine.
I understand that by falsifying this document I am committing “Medicaid Fraud”
 To the best of my knowledge, I am not a family member to any client of this agency to whom I provide
care as an employee of this agency.
 I am a family member of _______________________________, a client of this agency to whom I
provide care as an employee of this agency.
 A am not working with any family members here at Beneficial In-Home Care, but I am reporting the
name to make the office staff aware and will not schedule me to work with any of my family members.
The family name is: __________________________________________________
Family member is broadly defined to include, but is not limited to: a parent, child, sibling, aunt, uncle, cousin,
grandparent, grandchild, grandniece or grandnephew, spouse, or such relatives when related by adoption or
marriage or registered domestic partnership. (For example, family member would include relationships such as
step-children, parents-in-law or step-grandparents.)
I am aware that if I fail to notify the office of any family members being a client here, and I work any
shifts with them: I may be prosecuted by law and have to pay back Beneficial In-Home Care for time I
have worked with the client, and possible termination.
Signature:
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Date:
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AVAILABILITY
NAME: __________________________________________
DATE: __________________
* Are you available for late night shifts anywhere between 8p and 1a? Yes  No 
If yes, which nights of the week would you be willing to do late night shifts?
Sat  Sun  Mon  Tue  Wed  Thu  Fri 
* Are you available for any overnight shifts? Yes  No 
If yes, which nights of the week would you be willing to do overnight shifts?
Sat  Sun  Mon  Tue  Wed 
Thu 
Fri 
* Are you available for 24 hour shifts? 8 hours of sleep is required for the caregiver within every 24-hour shift. (You do not
actually move in with the client.) Yes  No 
If yes, which days of the week would you be willing to work live-in shifts?
Sat  Sun  Mon  Tue  Wed  Thu  Fri 
* Each employee is required to work at least one 4-hour shift on a weekend per month. What is your weekend availability?
Every weekend 
Every other weekend 
One weekend per month 
We need to know what days and hours you are available to work. Please be specific with the hours for example, write the earliest time
you would be available & the latest time that you want to be working:
SATURDAY
SUNDAY
MONDAY
TUESDAY
* Do you have another job or schooling? Yes  No 
WEDNESDAY
THURSDAY
FRIDAY
What days/hours:
___________________________________________________________________________________________
* Please circle the areas of town that you are willing to work in: ~ Moses Lake ~ Othello ~ Warden ~ Soap Lake ~
Othello ~ Ephrata ~ Quincy ~ Royal City ~ Mattawa ~ Ritzville ~ Lind ~ Other _____________________________________
* How many hours per week do you wish to be working? ____________________________________________________
* Mark all age groups that you are willing to work with: 0-11 years  12-18 years  20 years & over 
* Have you worked with hospice clients before? Yes  No 
* Are you comfortable working with hospice clients? Yes 
No 
* Are you willing to work with? Light Care Clients  Total Care Clients 
* Do you prefer to work with? Male  Female  Either 
* Can you transport your clients? Yes  No 
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* Do you: Ride bus  Have car  If you have a car, is it in good running condition? Yes  No 
Do you have car insurance: Yes  No  Expiration of auto insurance: ___________________________________
* Do you have a valid Washington State driver’s license? Yes  No  Expiration date: ______________________
If no, do you have a valid Washington State Identification Card? Yes  No  Expiration date: ________________
* Have you been trained on the Hoyer? Yes  No 
If yes, when and where have you been trained? _________________________________________________________
* Do you smoke? Yes  No 
* Our clients often need help with nutritional home-cooked meals and light house cleaning. Are you able and willing to assist
with these activities? Yes  No 
* Our clients often need help with personal care. This can be tasks related to basic personal care, such as: bathing,
dressing, toileting and grooming, etc. Are you able and willing to assist with these activities? Yes  No 
* Are you ok to work with a client that smokes? Yes  No 
* Are you allergic to pets? Yes  No 
If yes, what pets? _____________________________________________
* Are you ok to work with clients with pets? Yes  No 
* Would you like to be receiving a text rather than a phone call from (only) On-Call/After hour staff?
Yes  No  If Yes, what number is best? _________________________________________________________
* Would you like us to contact you through your email? Yes  No 
Email Address: __________________________________________________________________________________
* Do you have any lifting restrictions that could limit your ability to perform the job for which you have applied for with or
without reasonable accommodation? Yes  No 
If yes, please explain: _____________________________________________________________________________
* Do you have a current CPR card?
Yes  No  If yes, what is the expiration date? ________________________
* Have you ever had a positive T.B. skin test? Yes  No 
If yes, we will need proof that you are clear of Tuberculosis (ex. Chest x-ray, documentation, etc.)
* Do you have a current Nursing Assistant License (Registered/Certified)? Yes  No  Expiration date: _________
Has your Nursing Assistant license ever been suspended or revoked? Yes  No 
If yes, please explain: _____________________________________________________________________________
* Have you had Fundamentals of Caregiving Certification? Yes  No  When? ____________________________
* Do you speak another language and/or use sign language? If yes, which language(s) __________________________
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BENEFICIAL IN-HOME CARE, INC.
DISCLOSURE OF EMPLOYMENT
Please answer the question below to the best of your ability.
YES
NO
1) Have you ever been convicted of any crime against children
or other persons?
2) Have you ever been convicted of any crime relating to financial
exploitation of a vulnerable adult?
3) Have you ever been convicted of crimes relating to drugs as
defined in RCW 43.43.830?
4) Have you ever been found in any dependency action under
RCW 13.34.040 to have sexually assaulted or exploited any
Minor or to have physically abused any minor?
5) Have you ever been found by a court in a domestic relations
proceeding under Title 26 RCW to have sexually abused or
exploited any minor or to have physically abused any minor?
6) Have you ever been found in any disciplinary board final
decision to have sexually or physically abused or exploited
any minor or developmentally disabled person or to have
abused or financially exploited a vulnerable adult?
7) Have you ever been found by a court in a protection proceeding
Under chapter 74.34 RCW, to have abused or financially
Exploited a vulnerable adult?
I swear under penalty of perjury that the above answers are correct and true.
Signature:
Revised 3/18/14 KH
Date:
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If you answered yes to any of the question on the front page, please give an explanation:
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I swear under penalty of perjury that the above explanation is correct.
Signature
Revised 3/18/14 KH
Date
_________
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Reference Check
To Verifying Employer: _____________________________________________________________________________
Employer Please Fax back to (509) 765-0755
We are preforming a background investigation on the person listed below and request your assistance in confirming the following record of
employment.
Requested from:
Beneficial In-Home Care, Inc.
1235 E Wheeler Road
Moses Lake, WA 98837
Phone: (509) 764-0004 HR ext. 3315
Fax: (509) 765-0755
Concerning:
Applicant Name: ___________________________________________
If a Social Security Number is needed please contact Alex Colin at (509) 764-0004
I hereby authorize Beneficial In-Home Care, Inc. to solicit from _________________________________ the information stipulated
above concerning my previous employment experience. I further authorize the above name previous employer to respond to all listed
items truthfully and without reservation. By signing this request I hereby release both Beneficial In-Home Care and the above named
previous employer from all claims and liabilities from the release of such information.
________________________________________________________________
Applicant Signature
____________________
Date
Has this person ever been in your employ? Yes
No (circle one)
Dates of Employment: From: ________________ To: __________________
Job Title: _______________________________________________________
Rate of Pay: ___________________ Hourly / Salary (circle one)
Reason for Leaving: [ ] Voluntary [ ] Discharge [ ] Laid Off [ ] Other_______________________________________
Is this person eligible for rehire? Yes
No (circle one)
If NO, is this due to: [ ] Job Performance [ ] Violation of Company Policy [ ] Lack of Notice [ ] Attendance Issues [ ]
Other –PleaseExplain:____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Overall, how would you consider this applicants job performance?
[ ] Below Average [ ] Average [ ] Above Average [ ] Outstanding
Please comment on Job Performance:__________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Would you rehire this person?: Yes
No (circle one)
If you have any questions regarding this form or need additional information, please contact Human Resources at
(509)764-0004.
Print name:______________________________________________
Title: _________________________________
Signature of Employer: _________________________________________________________
Revised 3/18/14 KH
Date:_____________
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Reference Check
To Verifying Employer: _____________________________________________________________________________
Employer Please Fax back to (509) 765-0755
We are preforming a background investigation on the person listed below and request your assistance in confirming the following record of
employment.
Requested from:
Beneficial In-Home Care, Inc.
1235 E Wheeler Road
Moses Lake, WA 98837
Phone: (509) 764-0004 HR ext. 3315
Fax: (509) 765-0755
Concerning:
Applicant Name: ___________________________________________
If a Social Security Number is needed please contact Alex Colin at (509) 764-0004
I hereby authorize Beneficial In-Home Care, Inc. to solicit from _________________________________ the information stipulated
above concerning my previous employment experience. I further authorize the above name previous employer to respond to all listed
items truthfully and without reservation. By signing this request I hereby release both Beneficial In-Home Care and the above named
previous employer from all claims and liabilities from the release of such information.
________________________________________________________________
Applicant Signature
____________________
Date
Has this person ever been in your employ? Yes
No (circle one)
Dates of Employment: From: ________________ To: __________________
Job Title: _______________________________________________________
Rate of Pay: ___________________ Hourly / Salary (circle one)
Reason for Leaving: [ ] Voluntary [ ] Discharge [ ] Laid Off [ ] Other_______________________________________
Is this person eligible for rehire? Yes
No (circle one)
If NO, is this due to: [ ] Job Performance [ ] Violation of Company Policy [ ] Lack of Notice [ ] Attendance Issues [ ]
Other –PleaseExplain:____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Overall, how would you consider this applicants job performance?
[ ] Below Average [ ] Average [ ] Above Average [ ] Outstanding
Please comment on Job Performance:__________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Would you rehire this person?: Yes
No (circle one)
If you have any questions regarding this form or need additional information, please contact Human Resources at
(509)764-0004.
Print name:______________________________________________
Title: _________________________________
Signature of Employer: _________________________________________________________
Revised 3/18/14 KH
Date:_____________
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