Direct Care Worker Application

Phone*
Email*
Name*
First Middle Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Are you eligible for employment in the United States?*
- Yes
- No
Were you previously employed by PimaCare at Home or Pima Council on Aging?*
- Yes
- No
If yes, when?*
Were you previously employed as a caregiver?*
- Yes
- No
If yes, when?*
Have you been convicted of any crime, including sex-related or child/vulnerable adult-abuse related offenses?*
- Yes
- No
If yes, please explain:*
Do you currently carry the minium state-required liability auto insurance?*
- Yes
- No
Referred by*
- PimaCare at Home/PCOA Website
- PimaCare at Home/PCOA Employee
- Newspaper
- Other
Which employee?*
Is the employee a relative?*
- Yes
- No
If other, please list:*
Are you applying to work as a pre-match caregiver? (Current/future client at PCAH)*
- Yes
- No
If yes, does your client already have established services through PimaCare at Home?*
- Yes
- No
Client Name:*
First Last
Education/Training
High School or GED (Name of School, City, and State)
High School Diploma?
- Yes
- No
College or University (Name of School, City, and State) if applicable
College or University Degree Awarded or Credit Hours Earned (if applicable)
Graduate or Other (Name of School, City, and State) if applicable
Graduate or Other Degree Awarded or Credit Hours Earned (if applicable)
Certifications/Skills
Have you ever completed AZ Direct Care Worker Certification?*
- Yes
- No
Do you have a current CPR/First Aid Certification?*
- Yes
- No
Expiration Date*
MM slash DD slash YYYY
Do you have a current Fingerprint Clearance Card?*
- Yes
- No
Expiration Date*
MM slash DD slash YYYY
Other License, Degree, Certification, Training, or Skills:
Language Other than English Spoken:
Sign Language?*
- Yes
- No
Computer Programs:
Employment History (Please begin with most recent)
Employer Name #1
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone Number
Job Title
Salary
Reason for Leaving:
Supervisor Name/Title
Supervisor Email/Phone
Employment Start Date
DD slash MM slash YYYY
Employment End Date
MM slash DD slash YYYY
Essential Duties
Employer Name #2
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone Number
Job Title
Salary
Reason for Leaving:
Supervisor Name/Title
Supervisor Email/Phone
Employment Start Date
DD slash MM slash YYYY
Employment End Date
MM slash DD slash YYYY
Essential Duties
Employer Name #3
Address
Street Address City State / Province / Region ZIP / Postal Code
Job Title
Salary
Reason for Leaving:
Supervisor Name/Title
Supervisor Email/Phone
Employment Start Date
DD slash MM slash YYYY
Employment End Date
MM slash DD slash YYYY
Essential Duties
Transportation and Availability
Mode of Transportation (check all that apply)
- Bus Rider
- Own Vehicle
- Borrow Vehicle
- Bicycle
- Walker/On Foot
Available to work on Sundays?*
- Yes
- No
If yes, what times:*
Available to work on Mondays?*
- Yes
- No
If yes, what times:*
Available to work on Tuesdays?*
- Yes
- No
If yes, what times:*
Available to work on Wednesdays?*
- Yes
- No
If yes, what times:*
Available to work on Thursdays?*
- Yes
- No
If yes, what times:*
Available to work on Fridays?*
- Yes
- No
If yes, what times:*
Available to work on Saturdays?*
- Yes
- No
If yes, what times:*
Professional References
May we contact your current employer?*
- Yes
- No
If no, please explain:*
Reference #1*
First Last
Email
Phone
Relationship
Years Known
Reference #2*
First Last
Email
Phone
Relationship
Years Known
Reference #3*
First Last
Email
Phone
Relationship
Years Known
Reference #4
First Last
Email
Phone
Relationship
Years Known
Pre-Employment Questionairre
A DCW who provides personal care needs:*
- Level I training plus Level II plus agency orientation and CPR/First Aid
- Level I (Caregiving Fundamentals) training and CPR / First Aid
- Level I training plus one module at Level II
- Only agency orientation
If you suspect a client is being abused:*
- Finish your shift, then tell your supervisor
- Tell a family member
- Tell your supervisor immediately
- Ignore it; it’s none of your business
You have called paramedics for a medical emergency. When paramedics arriveat the client’s home you should:*
- Hand the paramedics the client’s service plan and all medical documents
- Tell the neighbors why the paramedics are there
- Answer relevant questions asked by paramedics
- Notify ALL the client’s family members
Instrumental Activities of Daily Living (IADLS):*
- Include shopping and using the telephone
- Is the correct name for ADLs
- Are all the tasks that DCWs do
- Are tasks that clients should always do for themselves
For DCWs, it is important to understand that*
- Clients are ill and need as much care as possible
- Some clients are not ill, but they need assistance with some tasks
- When people get older, they cannot care for themselves
- The level of assistance must be the same for all clients
Consent*
I agree
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.
Consent*
I agree
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.
Consent*
I agree
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.

Direct Care Worker Application

Education/Training

Certifications/Skills

Employment History (Please begin with most recent)

Transportation and Availability

Professional References

Pre-Employment Questionairre

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