Apply for AFL Caregiver

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:AFL Caregiver
ID:1001
Location:Connecticut
Department:Client Services
Resume
Resume:
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* D.O.B :
* SSN:
* Emergency Contact Name:
* Emergency Contact Phone Number:
Application for Employment
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

*
Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

*
*
*
*
*
*
*
*
*
Yes   No
*
*

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

*
*
*
*

Reference 2

*
*
*
*

Reference 3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

PCA Pre-Hire Interview
Please ask the prospective caregiver each question and document their response
* If CNA or HHA, do you have a current license or certificate?
Yes
No
* Do you have a CPR and First Aid certification?
Yes
No
Do you speak spanish?
Yes
No
* Have you previously worked in homecare?
Yes
No
* Are you currently employed?
Yes
No
* Do you have a reliable means of transportation?
* Have you lived in any other state aside from Connecticut in the past 7 years? If so, which states?
* What is your experience with caring for individuals with physical disabilities?
* What is your experience with caring for individuals with cognitive impairements?
* What would you do if you arrive at a client's home and he/she refused to allow you to enter?
* What would you do if your client fell and insisted that you do not call for help and insists that they are all right?
* How would you deal with an office staff who is being what you feel is disrespectful?
Conflict of Interest
* POLICY:
No employee or member of the Board of Directors, Advisory Committee, or other individual, committee, or entity shall derive any profit or gain directly or indirectly by reason of their association with the agency, without the prior knowledge and approval of the Board of Directors. All board members and/or employees, at the discretion and specific request of the board, will be required to submit a disclosure statement annually.
If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Administrator and Board of Directors.
In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the agency and a board member shall not participate in discussions unless requested by the board nor vote on such transactions. The abstention and the reason for it shall be recorded in the minutes.
Field staff in any capacity understands that all clients are clients of the Agency not personal clients of the field staff. Clients may never be serviced privately by an employee of Our Agency for the financial gain of the employee. Should an employee terminate employment with A Caring Heart Nursing Services LLC, the field staff understands that the client may not be encouraged or otherwise moved from our Agency to another agency.

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST.

I have read and am fully familiar with the agency’s policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other matter in which I would profit or gain directly or indirectly as a result of my membership on the agency’s board of Directors or its committees or my employment.
Furthermore, I agree to disclose any such interest which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the agency’s business that might result in any profit or gain directly or indirectly myself.

I also work for another home care agency
Yes
No
If yes, I am disclosing the name of the agency/agencies
Pay Schedule
* PCA: $12 per hour
RN: $35-40 per hour
Caregiver for Level 1 Client: $29.83 per day
Caregiver for Level 2 Client: $ 44.41 per day
Caregiver for Level 3 Client: $ 54.13 per day
Caregiver for Level 4 Client: $75 per day
I have read the above rates and agree that these rates are satisfactory and acceptable to me.
I have read the above rates and I do not accept these rates, therefore, do not desire employment with A Caring Heart Nursing Services LLC at this time.
*
*
ACKNOWLEDGEMENT CONSENT FORM

Sex Offender Registry Investigation Consent

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that a Sex Offender Registry Investigation (SORB) check will be performed with my personal information. I hereby acknowledge and provide permission to A Caring Heart Nursing Services, LLC or its authorized agent to submit a SORB check. This authorization is valid for the entire tenure of my employment with this organization.
Yes
No

Office of the Inspector General (OIG) Investigation Consent

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that A Caring Heart Nursing Services or its authorized agent will conduct an initial and monthly checks of the OIG’s List of Excluded Individuals/Entities (LEIE). I hereby acknowledge and provide permission to A Caring Heart Nursing Services, LLC or its authorized agent to submit such periodic checks with my information. This authorization is valid for the entire tenure of my employment with this organization.
Yes
No

Administrative Actions List

* A Caring Heart Nursing Services, LLC must check all prospective and current employees, subcontractors, volunteers, licensed applicants and current licensee, against the Administrative Actions List. It is a list of vendors that have had a decision against them for not complying with DSS regulations.
Yes
No

Criminal Background Check

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that a Criminal Background Check will be performed with my personal information in the State of Connecticut and any other state that I have resided in the past 7 years. I hereby acknowledge and provide permission to A Caring Heart Nursing Services, LLC or its authorized agent to submit a background check. This authorization is valid for the entire tenure of my employment with this organization.
Yes
No
* By signing below, I provide my consent to all required pre-hiring background checks and subsequent checks for CT regulations and affirm that the information provided on this acknowledgment Form is true and accurate.
Signature
* Date
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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