Availability Form 1

Each franchise location independently owned and operated

1. What position are you applying for? (check one) O 12 hour shifts O Full time O Part-time

2. If you checked live-in, do you have experience doing live-in? O Yes O No How many years?______

3 Do hold an updated HHA or PCA certificate? O Yes O No O HHA O PCA

4. When are you available to start work?______

5. Will you need time off within the next 3 months, vacation, doctor’s appointment, etc? O No O Yes

If Yes, explain______

6. Circle which days you available for work? M T W TH F S Sun am pm overnight

7. Do you have allegories/fears of dogs, cats, other? O No Yes, explain______

8. Are you available to work anytime during the weekend? O Yes O No

9. Are you able to cook and provide healthy meals to seniors? O No O Yes,

10. Which types of foods can you cook well? O American O African O Italian O Asian O other______

11. The job will entail maintaining the home and caring for the senior.

Rate yourself by putting: VG (for very good) A (for adequate) NT (for need training)

___ light housekeeping ____ preparing meals ___ companionship ____ laundry ____ listening skills ___ communication skills ____ flexibility ___ following directions ____ patience

12. If you arrive at the client’s home and no one answers the door, what would you do? ______

13. Would you feel comfortable working with the following? Assisting a female senior in & out of the shower O No O Yes Assisting a male senior in & out of the shower O No O Yes Caring for someone with Alzheimer’s O No O Yes Assisting a senior who is incontinent and needs a diaper changed O No O Yes Caring for someone with Dementia O No O Yes

14. Are you comfortable around a smoker? O Yes O No explain______

15. What areas would you be available to work in? Circle all that apply: O Queens only O Western Nassau County

16. What would you do if a client or their family yells at you or says something unkind?

______

17. In the past, who have you worked with? O Agency O Privately

18. If you had to go to an event but it was scheduled on your work time, how much time do you think is appropriate to give the agency?______

19. If you are a live-in worker, which days are best for you? O Monday morning to Friday morning O Friday morning to Monday morning O Either one