PimaCare At Home

Assisted living in-home care service in Tucson | A subsidiary of Pima Council on Aging

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Direct Care Worker Application

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Direct Care Worker Application

Phone *

Email *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip 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 minimum state-required liability auto insurance? *

Yes
No

Referred By *

PimaCare at Home/PCOA Website
PimaCare at Home/PCOA Employee
Newspaper
Other

Which employee? *

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 *

Do you have a current Fingerprint Clearance Card? *

Yes
No

Expiration Date *

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

Employer Name #2

Employer Name #3

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

Years Known

Phone

Relationship

Pre-Employment Questionnaire

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.

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