Be A Caregiver

Pre-Screening Questionnaire for Potential Caregivers

If you are an experienced caregiver who is interested in placement in our registry, please complete and submit our questionnaire and a member of our staff will review it promptly and be in touch with you.

Please answer all items. Incomplete questionnaire submissions will not receive a response.

Thank you for your interest. We look forward to receiving your information.

How did you hear about us?(*)
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What Is Your Name?(*)
Please type your full name.

What city do you live in?(*)
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Telephone / Cell #(*)
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Date of Birth dd/mm/yyyy
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E-mail(*)
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Are you ok with being 1099/Independent Caregiver?(*)
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Do you have VERIFIABLE caregiving experience?(*)
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What are your pay expectations?(*)
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What is your availability?(*)
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How soon can you start?

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Do you plan to take any time off? If yes, when?
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What are the minimum and maximum number of hours you are willing and able to work?(*)
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Are you able to work 24 hours(*)
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Have you worked 24's
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How Long?
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Are you available to work 12 hours(*)
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Are you willing to be on-call?(*)
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Do you have reliable transportation?(*)
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Do you share your car i.e.carpool?(*)
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Can you pass a background check(*)
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Do you have any tickets? If so, explain
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VALID driver's license?
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Are you comfortable texting?(*)
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Please tell us a little about your qualifications

Do you have any certifications? If so, please list them.
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How long have you been a caregiver?(*)
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How much of this experience is verifiable?
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Have you worked for any of the following?

Agency? If yes, how long?
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Which one?
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Facility? If yes, how long?
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Which one?
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Private? If yes, how long?
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What is the longest time you have cared for a client?(*)
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Do you know how to take vitals?(*)
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Are you able to perform medication reminders?(*)
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Have you worked with:

Cancer Patients
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Parkinson’s patients?
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Alzheimer's patients?
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Dementia patients?
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Diabetic patients?
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Patients who have suffered a stroke?
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Patients who are suffering from HIV?
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Bed Ridden?
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Do you know how to work an oxygen machine?(*)
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Have you worked with a patient while on Hospice?(*)
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If Yes, how long and what did you do for that client?
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Do you have experience lifting?(*)
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Have you had lifting training/certifications?(*)
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Are you able to lift dead weight?
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How much weight can you lift?
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Have you performed the following:

Showering? Check All that Apply(*)
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Bed Baths? Check All that Apply
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Diapering? Check All that Apply
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Can you cook? On a scale from 1-10 with 10 being best, how would you rate your cooking?(*)
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Can you follow a recipe?(*)
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What ONE word would you use to describe yourself as a caregiver?(*)
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Everything will be verified. Do you have anything else you would like to add to this?
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