Application for Direct Support Worker Employment

Application for Direct Support Worker
LHCL is an Equal Opportunity Employer and employment is on an at-will basis. Applicants must pass all required screenings and background checks as regulated by State & Federal guidelines before an offer of employment is made.
Please select a location*
Name*
First Middle Maiden Name Last
Gender*
Date of Birth*
MM
DD
YYYY
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Permanent Address (if different from Mailing Address)
Street Address Address Line 2 City State ZIP Code
Email Address*
Social Security Number*
The State of Louisiana requires that Direct Support Workers utilize mobile devices to access the LaSRS Electronic Visit Verification (EVV) program to clock in and out for shifts with clients who participate in Medicaid programs.
Do you have access to a GPS capable and web-enabled smart phone?
- Yes
- No
Primary Phone*
This number is for a*
- Home Phone
- Cell Phone
Can this number receive text messages?*
- Yes
- No
Secondary Phone
This number is a
- Home Phone
- Cell Phone
Can this number receive text messages?
- Yes
- No
Driver’s License Number*
Driver’s License State*
State
I hereby voluntarily consent to and authorize Leading Health Care of Louisiana, Inc. to obtain a report verifying the validity of my driver’s license, and I authorize all persons and organizations that may have information relevant to this research to disclose such information.*
- Yes
- No
Education
High School
Number of years attended
Graduated?
- Yes
- No
College or University
Number of years attended
Graduated?
- Yes
- No
Subjects Studied/Major
Technical Program / Other
Number of years attended
Graduated?
- Yes
- No
Subjects Studied/Major
Special Training/Skills:
Previous Employment
List last three positions, starting with the most recent
Job 1
Company Name
Job Title
Start Date
End Date
Pay Rate
Reason for Leaving
Job 2
Company Name
Job Title
Start Date
End Date
Pay Rate
Reason for Leaving
Job 3
Company Name
Job Title
Start Date
End Date
Pay Rate
Reason for Leaving
How did you hear about Leading Health Care?*
- Now Hiring Sign
- Online Job Board
- Job Fair
- Social Media
- Referred by employee
- Referred by client
- Other
Referred by employee:
First Last
Referred by client:
First Last
Other:
Employment Questionnaire
Are you currently employed?*
- Yes
- No
Are you eligible to work in the US?*
- Yes
- No
Are you at least 18 years or older?*
- Yes
- No
Have you ever been convicted of a felony or misdemeanor, pled no contest to a felony or misdemeanor, or are you under indictment for a felony or misdemeanor charge?*
- Yes
- No
When did it occur?*
Based on the Job Description are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?*
- Yes
- No
Do you have any work restrictions that LHCL should know about?*
- Yes
- No
Please explain*
Have you worked for LHCL previously?*
- Yes
- No
Do you know anyone who works for LHCL?*
- Yes
- No
What is their name?
First Last
Do you have access to a personal vehicle that you are able to drive for work?*
- Yes
- No
Are you a licensed CNA?*
- Yes
- No
Are you certified in CPR and First Aid?*
- Yes
- No
Are you afraid or allergic to pets/animals?*
- Yes
- No
Do you smoke?*
- Yes
- No
Availability
Please list your complete hours of availability for each day. Include all available day and night hours.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How soon are you available to begin working?
Date Format: MM slash DD slash YYYY
What areas are you able to work or travel to?
Please check-off if you have work experience in the following:
- Bathing/Dressing/Activities of Daily Living
- Behavior(s)
- Elderly Care
- Care for Physically or Mentally Disabled
Authorization*
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application shall be grounds for termination.
- Yes
- No
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
_________________________________________________

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Application for Direct Support Worker Employment

Application for Direct Support Worker

Education

Previous Employment

Job 1

Job 2

Job 3

Employment Questionnaire

Availability