Date: 9/17/2014

Application Form

Visiting Angels of Austin

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.  You must be able to read and write in English; pass a crimminal background screening; a drug screen; provide a clear tb to be eligible for hire.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Preliminary Questionaire

Number Question Effective Date Expiration Date
1 Are You Currently Working? (required)  
     
2 If you are currently working, are you looking for replacement work or supplemental work?  
 
 
3 Do you Have Caregiving Experience? (required)  
 
 
 
 
 
4 How Many Years of Caregiving Experience do you have? (required)  
  (Numeric Answer Only)    
5 Do you Have a Current CNA License? (required)  
 
7 Are You Interested In Live-In Assignments? (required)  
 
 
 
 
8 What is your Expected Hourly Rate? (required)  
     
9 Do You Have Reliable Transportation? (required)  
     
10 Have you Previously Worked for Visiting Angels? (required)  
 
 
 
11 What Date are You Available to Begin with Visiting Angels? (required)  
     

Section 2 - Descriptive Information

Number Question Effective Date Expiration Date
1 Describe your Recent Jobs: (required)  
 
2 What do You Enjoy about Working with Seniors: (required)  
 
3 Describe your Strengths and how These Would Make you a Good Candidate for Visiting Angels: (required)  
 
4 What Did You Like Most About your Last Position(s): (required)  
 
5 What Did You Like Least About Your Last Position(s): (required)  
 
6 Are You Willing to Work with Smokers? (required)  
     
7 Are You Willing to Work with Pets? (required)  
 
 
 
 
 

Section 3 - Availability

Number Question Effective Date Expiration Date
1 Describe Your Availability to Work. Visiting Angels provides 24x7 Services; List days and times and any pertinent availability information. (Be Very Specific): (required)  
 
2 How Many Hours Per Week are you Available to Work? (required)  
     
3 What Areas of Austin and surrounding communities are you willing to travel to for work: Lakeway, Round Rock, North Austin, South Austin, Westlake, etc. (Be Very Specific)? (required)  
 

Section 4 - Skill Level 1 -- COMPANION

Number Question Effective Date Expiration Date
1 Are you able and willing to assist with meal preparation, outings, errands, light housekeeping, laundry, medication reminders/prompting, walks, light exercise, companionship activities that enhance life and general upkeep of a client's areas. (required)  
     
2 Describe your Ability and experiences that would show your ability to provide companionship services. (required)  
 
3 Are you Willing to Participate in Activities Outside the Home such as Shopping and/or Errands (required)  
 
 
 
 
 
4 Are you Willing to Assist with Light Projects, such as Organization, Light Packing, etc. (required)  
     

Section 5 - Skill Level 2 -- COMPANION WITH LIGHT SKILLS

Number Question Effective Date Expiration Date
1 Are you able and willing to assist with COMPANIONSHIP as listed above as well as assisting with light dressing, toileting, grooming and stand-by shower assistance. (required)  
     
2 Describe your Ability and experiences that would show your ability to provide companionship with light skills. (required)  
 

Section 6 - Skill Level 3 -- HIGH SKILLED CAREGIVER / CNA

Number Question Effective Date Expiration Date
1 Full Bathing Assist Regardless of Patient Condition (required)  
     
2 Full Grooming Assist Regardless of Patient Condition (required)  
     
3 Full Toileting Assist Regardless of Patient Condition (required)  
     
4 Full Ambulation Assistance Regardless of Ancillary Aids (required)  
     
5 Full Transfer Assistance Provided Client is Able to Bear Weight (required)  
     
6 Hoyer Lifts (required)  
     
7 Colostomy Bags (required)  
     
8 Clients who are Fully Bedbound (required)  
     
9 Hospice Clients (required)  
     
10 Parkinson's Client (required)  
     
11 Forms Dementia (required)  
 
 
 
 
 

Section 7 - Special Skills:

Number Question Effective Date Expiration Date
1 Describe Any Special Skills You have that Would be Applicable (i.e. Gourmet Cooking, Sewing, etc.) (required)  
 
2 List Any Applicable Interest and/or Hobbies: (required)  
 

Section 8 - Acknowledge the Following:

Number Question Effective Date Expiration Date
1 I am at Least 18 Years of Age: (required)  
     
2 I can Provide 2 Employer References and 1 Personal Reference (required)  
     
3 I am Free from any Criminal Conduct as put forth by DADs (required)  
     
4 I am Able to Pass a Pre-Employment Drug Screen (required)  
     
5 I am Aware the NAR and EMR will be Searched to determine my employment eligibility per DADs and Texas Health and Safety Codes (required)  
     
6 I am Able to Provide or Obtain a Clear TB Screening (required)  
     
7 I am Aware of Convictions Barring Employment in Private-Duty per Texas Health and Safety Code, Section 250.006(a) (required)  
     
8 I am Able to Provide Verification of Citizenship for Employment Purposes (required)  
     

Section 9 - Employment History

Number Question Effective Date Expiration Date
1 Employer 1 (Most Recent): (required)  
     
2 Employer 1: Duties (required)  
 
3 Employer 2 (required)  
     
4 Employer 2: Duties (required)  
 



I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.