Euro-American Connections & Homecare
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Electronic Daily Health Check-In
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by
Euro-American Connections & Homecare
Friday, June 19, 2020
0
Please leave your contact information and one of our staff will
call you back
Are you a caregiver?
No
Yes
We truly appreciate when our clients share their experiences with us. Please leave your message
in the form below
For contact with
, please, leave your contact information
Get a list of all questions you have to ask a homecare provider before hiring
Employment application
Please fill the application and we will contact you within 48 hours for a follow up
Personal information
Experience & Preferences
Reference check
Please, fill your personal information
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Are you authorized to work in the U.S.?
Yes
No
Do you currently hold a valid drivers license?
Yes
No
Do you have a Car?
Yes
No
Do you speak a second language?
Yes
No
Next step
Please share more information about your work experience and preferences
Why did you decide to become a caregiver?
Current Certifications
(Multiple choices allowed)
HHA
LPN
PCA
Other
CNA
None
Assignment Preference
(Multiple choices allowed)
Live-In
Hourly Part-Time
Hourly Full-Time
Have you worked in Home Care before?
(If yes, how long?)
Less than a year
1-3 Years
4-7 Years
7+ Years
I Have Never Worked in Home Care Before.
Have you previously worked with patients affected by:
(Multiple choices allowed)
Alzheimer's
Kidney Dialysis
Dementia
MRDD
AIDS/HIV
Respiratory
Diabetes
Arthritis
Stroke
Cancer
Parkinson's
Hospice
Decubitus Ulcer (Bedsore)
Osteoporosis
Congestive Heart Failure Depression
Chronic Obstructive
Pulmonary Disease (COPD) Paralyzed
Have you ever had experience with the following tasks
(Multiple choices allowed)
Client Repositioning
Catheter Care
Patient Transferring
Exercises
Colostomy Care
Ostomy Care
Bed Bath (Sponge Bath)
Feeding Tube Assistance
Incontinence Care
Skin Care
Activities of Daily Living (ADL's)
Tracheostomy Site Care
None
Have you ever had experience with the following equipments
(Multiple choices allowed)
Walker
Wheelchair
Gait Belt
Hoyer Lift
Oxygen Tank
Blood Pressure Kit
Hospital Bed
Glucose Monitor
Bed Pan
Bedside Commode
Pulse Oximeter
Sliding Board
None
Are you willing to cook for clients?
Yes
No
Do you have any allergies?
Yes
No
Are you comfortable working with
(Multiple choices allowed)
Taking Care of Couples
Pets in the House
Smoking Clients
Male Clients
None
Back
Next step
Personal and professional reference check
Please list your past 3 employers starting from the most recent one.
Are you currently employed?
Yes
No
Have you ever applied with us before?
Yes
No
Can we send you text messages?
Yes
No
How did you hear about us?
(Multiple choices allowed)
Google
Referred by Current Employee
Social Media (Facebook, Instagram, Linked In)
Newspaper
Family or Friend
Is there anything you would like to add or any reason you are unable to perform all of the tasks of the position you are applying for?
I understanding the
legal work status
Back
Get a quote
Get a quote
Get a quote
Contact the caregiver
Thank you!
Our staff will call you back.
