Form

Sevens Home Care Application
Contact Information
Full Name*
First Name Last Name

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone 1*
- Area Code Phone Number
Phone 2
- Area Code Phone Number
E-mail*
Position Desired*

Shift Preference*

	Part Time	Full Time	Overnight	Weekends
Please Select

Employment Information
What minimum salary do you require?*
Are you over the age of 18?*

Yes No
Are you a U.S. Citizen?*

Yes No
If no, do you have the legal right and necessary documents to work in the U.S.?

Yes No
Are you willing to travel as needed for the job?*

Yes No
Do you have your own Transportation?*

Yes No
Do you have a valid Driver's License?*

Yes No
Have you applied with us before?*

Yes No
How were you referred to us?*
Education

Level of Education - Please check yes or no to signify if you graduated from each of the following education institutions.*

	Yes, I graduated	No, I did not
High School
College
Technical School
Nursing School

Nursing License #/ CNA Certificate #
Do you have a current CPR certification?*

Yes No
If Yes, What is the expiration Date?
Month Day Year
Please List any Languages you speak in addition to English
Skill Assessment
Can you perform all of the job-related functions of the position for which you are applying?*

Yes No
If no, please explain
Please Check All Areas that You Have Experience:

Homemaker:*

	Housekeeping	Medication Reminders	Meal Preperation	Companionship	Transportation
Please Select

Intermediate:*

	Alzheimer's/Dementia	Restroom Assistance	Bathing/Showering	Live-In Care
Please Select

Advanced:*

	Incontinence Care	Transfers	Fall Prevention/Ambulatory	24 Hour Live In Care
Please Select

Previous Employer
Name of Employer*
Position*
Salary (Numbers Only!)*
Start Date*
Month Day Year
End Date, if applicable
Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*
- Area Code Phone Number
Reason for Leaving
Previous Employer #2
Name of Employer
Position
Salary
Start Date
Month Day Year
End Date, if applicable
Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
Reason for Leaving
Personal Reference
Full Name*
First Name Last Name
Relationship*
Number of Years Known*
Phone Number*
- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Personal Reference 2
Full Name*
First Name Last Name
Relationship*
Number of Years Known*
Phone Number*
- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Criminal Background
Have you ever been convicted of a crime?*

Yes No
If yes, please explain
You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.
Background Authorization
I authorize Sevens Home Care to conduct a complete background investigation in order to assess my eligibility for a position requiring a high level of reliability and trustworthiness. The undersigned authorizes Sevens Home Care to obtain credit information, background information and criminal history information on the undersigned and authorizes the release of such information for the exclusive and confidential use of Sevens Home Care.

I authorize all persons who may have information relevant to this investigation including, without limitation, prior employers, doctors, landlords, creditors and others to disclose it [including photocopies where requested] to Sevens Home Care or their agents. I hereby release and hold harmless from liability all persons on account of such disclosure. I understand that the investigation may include verification of past employment, review of personnel records maintained by any prior employer, education, creditworthiness, and opinions of references.

This authorization shall be valid for a period of time not to exceed one year following the date indicated below or until employment or contract is terminated, whichever occurs first. The release and hold harmless contained herein shall remain in full force and effect with respect to all disclosures provided within this time period.
Gender*

Male Female
Birth Date*
Month Day Year
Submission Date/Time
/ Month / Day Year
at
: Hour Minutes
Digital Signature*
Emergency Contact
Full Name*
First Name Last Name
Relationship*
Phone Number*
- Area Code Phone Number
Phone Number 2
- Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Certification
"I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you."
Submission Date/Time
/ Month / Day Year
at
: Hour Minutes
Digital Singature*
Job Descriptions
Personal Care Provider
Job Responsibilities

1. Provide non-medical in-home and/or community care to the agency’s service recipients
2. Be prompt to scheduled visits and notify the supervisor immediately when unable to do so
3. Be familiar with all rules, policies, and procedures in providing the services
4. Submit all required documentation in a timely manner
5. Follow the service plan of the individual service recipient
6. Keep all records and names of service recipients confidential unless authorized by service recipient’s written consent
7. To immediately report any incident of injury to service recipient or yourself to the supervisor
8. To report any suspicion of abuse or neglect to appropriate authorities and the supervisor
I have Read the Job Responsibilities and agree to perform the above tasks*

Yes
Job Duties

Job duties may include: meal preparation, washing dishes, hygiene, grooming, dressing assistance, laundry, assistance with eating, companionship, shopping, recreational activities, housekeeping, such as dusting, sweeping, vacuuming, mopping, cleaning windows, making the bed, changing linens, emptying trash/garbage, cleaning bathrooms.
I have read and I am qualified to perform the above Job Duties*

Yes
Submission Date/Time
/ Month / Day Year
at
: Hour Minutes
Applicant Digital Singature*
Skill Assessment
Personal Hygiene

Please mark the appropriate box, signifying that you are either trained or experienced. Leave blank if you are neither trained nor experienced. You will be asked to provide copies of certificates to skills that apply.

....*

	None	Trained	Experienced
Bath: Sponge, Shower, Tub
Bed Bath
Shampoo: Sink, Bed, Tub
Nail Care
Skin Care
Oral Hygiene & Denture Care
Shaving
Toiletting & Elimination
Incontinence Care

Ambulation & Exercise

Please mark the appropriate box, signifying that you are either trained or experienced. Leave blank if you are neither trained nor experienced. You will be asked to provide copies of certificates to skills that apply.

....*

	None	Trained	Experienced
Assist with Walker/Cane
Same Ambulation Technique
Positioning of Client

Transfers

Please mark the appropriate box, signifying that you are either trained or experienced. Leave blank if you are neither trained nor experienced. You will be asked to provide copies of certificates to skills that apply.

....*

	None	Trained	Experienced
Bed to Chair
Wheelchair (In and Out)
Bed to Commode

Infection Control

Please mark the appropriate box, signifying that you are either trained or experienced. Leave blank if you are neither trained nor experienced. You will be asked to provide copies of certificates to skills that apply.

....*

	None	Trained	Experienced
Using Gloves, Gowns, Mask, Aprons
Proper Waste Disposal
Hand Washing

Other

Please mark the appropriate box, signifying that you are either trained or experienced. Leave blank if you are neither trained nor experienced. You will be asked to provide copies of certificates to skills that apply.

....*

	None	Trained	Experienced
Making an Occupied Bed
Dressing Patient
Use of a Gait Belt

Homemaker

Please mark the appropriate box, signifying that you are either trained or experienced. Leave blank if you are neither trained nor experienced. You will be asked to provide copies of certificates to skills that apply.

Click to edit*

	None	Trained	Experienced
Planning & Preparing Meals
Changing Linens
Dusting
Vacuuming
Cleaning Bathroom, Kitchen, and Bed
Laundry
Maintain and Safe, Clean & Healthy Environment
Providing Companionship
Transportation Assistance

....
Click to edit
Click to edit
Comments
Please sign to signified that you have recorded your answers to the best of your knowledge.
Submission Time/Date
/ Month / Day Year
at
: Hour Minutes
Applicant Digital Signature*
Affidavit of Good Moral Character
This is a legal affidavit that certifies you, the applicant, is of good moral character for contract services.
Affidavit
As an applicant for contract service with Leland & Michael, LLC doing business as Sevens Home Care, I hereby attest that I am of good moral character and that I have not been found guilty, of any of the following offenses:

1. A felony
2. A violation relating to theft, robbery, and related crimes
3. A violation relating to fraudulent practices
4. A felony violation relating to drug abuse prevention and control
5. A violation relating to lewdness or indecent exposure
6. A violation relating to assault, battery, and culpable negligence
7. A violation relating to child abuse

I further attest

I have not been judicially determined to have committed abuse or neglect against a child, nor do I have confirmed report of adult abuse, neglect, or exploitation; or child abuse or neglect; nor have I committed an act which constitutes domestic violence as defined.

I further attest

I have never been investigated by an adult protective services agency or the equivalent. I attest that I do not have any pending criminal charges. Under the penalty of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief.
To the best of my knowledge and belief, my record DOES NOT contain one of the foregoing disqualifying acts of offenses.
Submission Date/Time
/ Month / Day Year
at
: Hour Minutes
Applicant Electronic Signature*
Assessment Test (1 of 20)
1. Mrs. Jones takes her dentures out to be cleaned every night. After brushing them where should they be stored until morning?

A. In a sterilized container

B. On a paper towel on the bathroom counter

C. In clean, clear water
Answer 1*

A B C
Assessment Test (2 of 20)
2. Mr. Smith just had his prescription filled and mentions to you that the pills look different than the pills he usually takes. You...

A. Tell him not to take the medication and contact the Nursing Supervisor immediately

B. Tell him to go ahead and take the pills, they are probably a generic brand of his regular medication

C. Contact Mr. Smith's doctor and tell the doctor the pharmacy made a mistake
Answer 2*

A B C
Assessment Test (3 of 20)
3. Mr. Mitchell has just come home from the hospital after surgery and his neighbor stops you and asks how he is. You...

A. Say he is doing as well as expected
B. Say you are not permitted to discuss his condition, but you will be sure to tell Mr. Mitchell that his neighbor asked about him
C. Tell the neighbor how his surgery went and what his recovery involves
Answer 3*

A B C
Assessment Test (4 of 20)
4. Mrs. Johnston refuses to let you wash her genitals. You should:

A. Let her wash herself
B. Tell her it is your job to wash her and insist that she let you
C. Forget about washing her and use powder to mask the odor
Answer 4*

A B C
Assessment Test (5 of 20)
5. Mr. Morris has just started using a walker to get around. For his own safety you:

A. Pick up all throw rugs in the home; move cords and small furniture out of his way
B. Tell him he can get up and move around, but only in his bedroom
C. Use a wheelchair to take him outside and let him use the walker only outside
Answer 5*

A B C
Assessment Test (6 of 20)
6. Mrs. Kipp has been constipated for the past few days and says that she is uncomfortable. She asks you to please give her an enema. You:

A. Prepare and administer the enema, recording the results on the proper form
B. Contact your Nursing Supervisor and give him/her all information regarding Mrs. Kipp's complaint.
C. Tell Mrs. Kipp you are not allowed to give her an enema and she should just be patient and let nature do its work
Answer 6*

A B C
Assessment Test (7 of 20)
7. Which of the following drinks is highest in protein?

A. Eggnog
B. Orange juice
C. Beef broth
Answer 7*

A B C
Assessment Test (8 of 20)
8. Mr. Frederick wakes and complains of being dizzy. He is sweating and his skin feels clammy. You:

A. Tell him to dangle his feet over the edge of the bed and put his head down
B. Have him lie down and try to get up again in 10 minutes
C. Call your Nursing Supervisor immediately
Answer 8*

A B C
Assessment Test (9 of 20)
9. What is considered the normal temperature of the human body?

A. 97.6
B. 98.6
C. 100.6
Answer 9*

A B C
Assessment Test (10 of 20)
10. Mr. Babs must be transferred from the wheelchair to the commode. You:

A. Hold his hands and pull him out of the wheelchair, then let him walk to the commode and sit down by himself
B. Move the wheelchair as close to the commode as possible; put your forearms under his armpits, then using your legs, lift Mr. Babs and swivel him onto the commode
C. Tell Mr. Babs he must use a bedpan
Answer 10*

A B C
Assessment Test (11 of 20)
11. Mrs. Everest has a headache. She wants to take Tylenol. You:

A. Take the bottle out of the medicine cabinet, take out two pills, and hand them to her
B. Take the bottle out of the medicine cabinet, and give it to her
C. Tell Mrs. Everest that she is not allowed to take Tylenol during your shift
Answer 11*

A B C
Assessment Test (12 of 20)
12. What does TPR stand for?

A. Temperature, Pulse, Respiration
B. Temperature, Pulse, Responsiveness
C. Time, Place, Responsiveness
Answer 12*

A B C
Assessment Test (13 of 20)
13. During your shift with Mr. Miner, you notice bruises on his arms and legs. He tells you that his son got angry when he wet the bed. You suspect abuse. Do you:

A. Call the son and ask him what happened
B. Tell Mr. Miner he should not put up with that kind of abuse
C. Call your Nursing Supervisor
Answer 13*

A B C
Assessment Test (14 of 20)
14. Mrs. Nesmith wet the bed. You must change her sheets. The first thing you do is:

A. Remove the old sheets
B. Soak up the excess moisture with paper towels
C. Put on gloves
Answer 14*

A B C
Assessment Test (15 of 20)
15. After you put clean sheets on Mrs. Nesmith's bed you:

A. Put the dirty sheets in a plastic bag until wash day, then wash in hot soapy water and dry on high heat
B. Put the dirty sheets in a plastic bag until wash day, then wash them with the rest of the laundry using bleach
C. Wash the dirty sheets separately with bleach
Answer 15*

A B C
Assessment Test (16 of 20)
16. It's lunch time. You fix Mr. Jacob's his favorite soup and a sandwich. There is enough for two people so you:

A. Throw the extra away
B. Store the extra in the refrigerator with the date on it
C. Join him for lunch
Answer 16*

A B C
Assessment Test (17 of 20)
17. You finished your shift for the day and you are running a little late. You:

A. Wait to complete your documentation tomorrow
B. Complete your documentation using at least two sentences for each shift
C. Be sure your documentation is complete and signed or initialed in all the appropriate places
Answer 17*

A B C
Assessment Test (18 of 20)
18. An example of a well-balanced meal is:

A. Chicken, potatoes, peas
B. Chicken, potatoes, rice
C. Chicken, potatoes, Jello
Answer 18*

A B C
Assessment Test (19 of 20)
19. You are walking behind Mrs. Gehman when she suddenly faints. You:

A. Quickly move out of the way so she does not injure you as she falls
B. Support her from behind and using your body, gently slide her to the ground
C. Catch her and carry her back to her bed
Answer 19*

A B C
Assessment Test (20 of 20)
20. Mrs. Jenkins has extremely dry skin. The doctor has prescribed a medicated lotion to be applied two times a day. You:

A. Apply the lotion to Mrs. Jenkins
B. Call the Nursing Supervisor
C. Give the lotion to Mrs. Jenkins to apply herself
Answer 20*

A B C
Assessment Test is Complete!

Please Click the SUBMIT FORM button below to complete your application.
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Contact Information

Employment Information

Education

Skill Assessment

Previous Employer

Previous Employer #2

Personal Reference

Personal Reference 2

Criminal Background

Background Authorization

Emergency Contact

Certification

Job Descriptions

Personal Care Provider

Skill Assessment

Affidavit of Good Moral Character

Affidavit

Assessment Test (1 of 20)

Assessment Test (2 of 20)

Assessment Test (3 of 20)

Assessment Test (4 of 20)

Assessment Test (5 of 20)

Assessment Test (6 of 20)

Assessment Test (7 of 20)

Assessment Test (8 of 20)

Assessment Test (9 of 20)

Assessment Test (10 of 20)

Assessment Test (11 of 20)

Assessment Test (12 of 20)

Assessment Test (13 of 20)

Assessment Test (14 of 20)

Assessment Test (15 of 20)

Assessment Test (16 of 20)

Assessment Test (17 of 20)

Assessment Test (18 of 20)

Assessment Test (19 of 20)

Assessment Test (20 of 20)