Application for Direct Support Worker Employment

PERSONAL INFORMATION

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Is this address different from your mailing address? *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date of Birth *

Social Security Number (SSN) *

Email Address *

Primary Phone *

Type of Phone Number *

Can you receive text messages through this number? *

Secondary Phone *

Type of Phone Number *

Can you receive text messages through this number? *

Do you have access to a GPS capable and web-enabled smart phone? *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.

Gender *

Driver's License Number *

Driver's License State *

I hereby voluntarily consent to and authorize Leading Home Care 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. *

EDUCATION & TRAINING

High School

Number of Years Attended

Graduated? *

College/Technical Program

Number of Years Attended

Graduated? *

Special Training/SkillsIf listing multiple skills, please use a comma to separate each.

Are you a licensed CNA? *

Are you certified in CPR and First Aid? *

Please check-off if you have experience in any of the following.

Daily Activities (e.g., Bathing, etc.)Care for ElderlyBehavior ManagementCare for Physically or Mentally Disabled

PREVIOUS EMPLOYMENT

List last three employers, starting with the most recent.

Company Name #1 *

Job Title *

Start/End Date *

Pay Rate *

Reason for Leaving *

Company Name #2

Job Title

Start/End Date

Pay Rate

Reason for Leaving

Company Name #3

Job Title

Start/End Date

Pay Rate

Reason for Leaving

EMPLOYMENT QUESTIONNAIRE

Are you currently employed? *

Are you eligible to work in the U.S.? *

Are you at least 18 years or older? *

Do you have access to a personal vehicle that you are able to drive for work? *

Are you afraid of and/or allergic to pets/animals? *

Are you a smoker? *

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? *

If no, please explain. *

Have you ever been convicted of a felony? *

If yes, what was the felony and when did it occur. *

Do you have any work restrictions that Leading Home Care should know about? *

If yes, please explain. *

Have you worked for Leading Home Care previously? *

If yes, please provide when. *

Do you know anyone who works for Leading Home Care? *

If yes, please list their name. *

Employment Location *Please select the location that you are applying for to be a Direct Support Worker.

Sunday Hours *

Monday Hours *

Tuesday Hours *

Wednesday Hours *

Thursday Hours *

Friday Hours *

Saturday Hours *

How soon are you available to begin working? *

Please provide the name of the Leading Home Care client that referred you. *

Please provide the name of the Leading Home Care employee that referred you. *

Please provide how you heard about Leading Home Care. *

Signature *

Date *

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