Home Health Caregiver Questionnaire
27 y/o quadriplegic near downtown Denver, Colorado in need of caregivers. CNA license or experience a plus but not required, you will be trained on everything regarding my care.

Please answer the following questions as completely and as accurately as possible. This is to help me gather some information before I interview you

Job responsibilities include:

Bowel care

Bathing and oral care

Dressing

Helping me get in/out of bed

Range of motion/stretching



Preparing meals

Cooking meals

Helping me eat



Housekeeping (Vacuuming, carpet shampooing, cleaning counters and bathroom, washing dishes)

Laundry (washing, folding, and putting away clothes)
Running errands (shopping, ect)
Accompanying (doctors appointments, walks, ect.)
Sign in to Google to save your progress. Learn more
Date filled out *
MM
/
DD
/
YYYY
Name (First and Last) *
Tell me a little about yourself. *
Phone number *
Email *
What is the best way to contact you? *
Required
Do you currently work with Public Partnerships?
Clear selection
Are you able to provide documentation proving your identity and authorization to work? (Needed for I-9 form in the hiring process) *
A free background check through Colorado Bureau of Investigation will be required. This will list ANY arrests, but if charges were dismissed or found not guilty should not affect eligibility. Will anything be on this report? *
If no, what will be on it? (Honesty goes a long way with me) Write Nothing if above is no *
Do you have reliable transportation to get to work? *
Do you have any experience with the job responsibilities? If so, please elaborate. If not put N/A. Experience helpful, but not a requirement. *
Are you vaccinated? (Not required) *
Are you a CNA? (not required) *
Are you allergic to or afraid of large dogs? We have one friendly Cane Corso (Mastiff breed). *
Please list professional references: *
What would you like your starting wage to be? Please keep your experience in mind and that raises are guaranteed for good work! *
What days are you able to work? *
Required
What hours are you able to work? Please list the Day  / Time me example: Monday / 10am - 5pm *
What hours are you NOT able to work? Same format as above! *
When would you be able to start working? *
What kind of work are you looking for? *
Are you willing to travel for up to a week for hospital visits or several days for other reasons? *
What are some qualities about yourself that you believe makes you a better candidate for employment than someone with similar background? *
Do you have any questions for me or any other relevant information you would like to share?
Thank you for your interest!
I will contact you as soon as possible for an interview.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms