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Leading Health Care of Louisiana
Senior & Disabled Home Care Services. Louisiana Home Health Care Agency
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Join Our Team
Contact Us
Search:
Home
About Us
Our Services
Our Process
Testimonials
New Headquarters
Meet Our Staff
St. Pierre’s Center for the Arts
Festival De Succes
Quick Links
LT-PCS for Medicaid Recipients
Long Term Care Insurance
Free In-Home Care Resources for Veterans
Join Our Team
Contact Us
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
*
Baton Rouge
Thibodaux
Lafayette
Lake Charles
Pineville
Hammond
Opelousas
New Iberia
Name
*
First
Middle
Maiden Name
Last
Gender
*
Date of Birth
*
MM
DD
YYYY
Mailing Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Permanent Address (if different from Mailing Address)
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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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