Application Form – A+ Caregivers | Personal Care Services in Nebraska

Personal Care Worker Employment Application

An Equal Opportunity Employer

Date: Dec 23, 2024

First Section

First Name

Middle Name

Last Name

Cell Phone

Home Phone

E-Mail

How did you hear about us?

Street Address

City

State

Zip Code

Person we may contact in case of emergency

Name

Phone

Date available for Employment

Education

School Name, Major, Dates Attended

1

2

3

Employment Experience One

Employment Experience: Please list job history starting with your current or most recent position, going back 5 years. If your references are incomplete (not listing phone numbers, position, etc.) your application will be discarded.

Company Name

Street Address

City

State

Zip Code

Supervisor’s name and Phone Number

Position

Duties

Starting Day

Leaving Day

Reason for Leaving

May we contact the employer listed above?

Yes

No

If no, please explain:

Employment Experience Two

Company Name

Street Address

City

State

Zip Code

Supervisor’s name and Phone Number

Position

Duties

Starting Day

Leaving Day

Reason for Leaving

May we contact the employer listed above?

Yes

No

If no, please explain:

PCA/Homemaker Employment Application

Proficiency Skills Checklist

Please let us know your experience in the following areas:

Key To Competency Levels

0 - No Experience

1 - Minimal experience, need review and supervision, have performed at least once

2 - Comfortable performing with resource available

3 - Competent to perform independently and safely

4 - Expert, able to act as resource to others

Infection Control

Proper Use of Infection Control/Protection Methods:

Gloves

Gown

Mask /Goggles

Hand Washing

Isolation technique (protecting yourself and/or the client using protective clothing, gloves and/or mask when the client has a infectious disease that can be passed on, or to protect the client when their immune system is low)

Infectious /Hazardous Waste Disposal (what to do with items soiled with body fluids or disposal of hazardous waste)

Safety and Activity

Identifying Safety Hazards (eg. Loose rugs, clutter)

Determining Need for Additional Help

Recognizing Abuse: Substance, Physical, Emotional, Etc.

Maintaining Clean, Orderly Work Area

Proper Body Mechanics (using proper posture and technique when providing cares and during transfers)

Transferring to Bed, WC, Commode, Etc.

Ambulating With or Without Device (walker, cane, wheelchair)

Responding to Safety Hazards

Use of Transfer Belt

1. Do you have experience as a Personal Care Worker?

a. If so, what kind and how long?

b. If not, what kind of experience do you have that would make you qualified for this position?

2. What locations are you interested to work in?

3. What are the days/times you are available? How many hours a week would you ideally like to work?

Upload Additional Document

Maximum file size: 516MB

I agree to allow A Plus Caregivers to contact previous employers and professional references.

I agree to allow A Plus Caregivers to perform necessary screenings applicable to my employment.

I certify that the above information is true and complete to the best of my knowledge.

Applicant's Full Name

Date: Dec 23, 2024