Direct Care Worker Application

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Direct Care Worker Application

Are you eligible for employment in the United States?
Were you previously employed by PimaCare at Home or Pima Council on Aging?
Were you previously employed as a caregiver?
Have you been convicted of any crime, including sex-related or child/vulnerable adult-abuse related offenses?
Do you currently carry the minimum state-required liability auto insurance?
Referred By
Are you applying to work as a pre-match caregiver? (Current/future client at PCAH)


High School Diploma?


Have you ever completed AZ Direct Care Worker Certification?
Do you have a current CPR/First Aid Certification?
Do you have a current Fingerprint Clearance Card?
Sign Language?

Employment History (Please begin with most recent)

Transportation and Availability

Mode of Transportation (check all that apply)
Available to work on Sundays?
Available to work on Mondays?
Available to work on Tuesdays?
Available to work on Wednesdays?
Available to work on Thursdays?
Available to work on Fridays?
Available to work on Saturdays?

Professional References

May we contact your current employer?
Reference #1
Reference #2
Reference #3
Reference #4

Pre-Employment Questionnaire

A DCW who provides personal care needs:
If you suspect a client is being abused:
You have called paramedics for a medical emergency. When paramedics arriveat the client’s home you should:
Instrumental Activities of Daily Living (IADLS):
For DCWs, it is important to understand that:
I certify that I have provided information that, to the best of my knowledge, is truthful and accurate. I understand that deliberate falsifications or significant omissions will be grounds for denying or terminating employment with PimaCare at Home. I understand that my continued employment depends on Level 1 fingerprint clearance and Central Registry clearance.
I agree to allow PimaCare at Home to contact the people I have listed on this application. I also agree not to hold any of these people liable for damages relating to any truthful information they provide regarding my qualifications for employment at PimaCare at Home.
I understand that nothing in the application creates an employment contract or relationship. I also understand that, if hired by PimaCare at Home, my employment can be terminated at any time, by myself or PimaCare at Home, for any reason not prohibited by law.