Application Form

Personal Information

First Name *

Last Name *

Social Security Number

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Social Security Number

Applied for POSITION: Companion, Homemaker, CHHA

How did you learn about Synergy HomeCare?

Have you ever before applied for employment with a Synergy HomeCare agency?

Yes No

Are you now or have you ever been a licensed/certified care provider?

Yes No

Has your professional license ever been investigated or suspended?

Yes No

Type of License

Issuing Authority -State

All License #'s - List State- Exp Date:

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Please check off your COVID-19 vaccination status (required)

Section 2 - Caregiver Background Information

Have you ever been named a defendant in a professional liability action?

Yes No

(if yes, please provide a detailed explanation.)

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Have you ever been released form a job due to discipline or being fired?

Yes No

(if yes, please provide a detailed explanation.)

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Would you consent to a drug test at the agency or client's request?

Yes No

Do you have a current drivers license? (if yes, please include DL# and State)

Do you have a reliable means of transportation?

Yes No

Are you covered by auto liability insurance?

Yes No

Can you submit verification of your legal right to work in the U.S.?

Yes No

If you will be employed on a visa, please specify type of work visa:

Will you consent to a National Criminal Background check and Motor Vehicle Records check?

Yes No

If applicable ( you are an RN or Physician), list the carrier name, address and policy number of any private malpractice insurance you carry in the box below.

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Section 3 - Education

Name of High School:

Location of High School:

Did you graduate?

Yes No

What Year did you graduate?

(Numeric Answer Only)

GED

Yes No

List any additonal educational training:

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CPR Certified?

Yes No

Effective Date

Expiration Date

First Aid Certified?

Yes No

Effective Date

Expiration Date

Section 4 - Skills Questionaire

Briefly explain any additional care giving experience you may have, personal or professional, family, friends etc.

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Please List the Times you are Available to Work

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Previous Facility Types Worked: Check All That Apply

Hospice

Yes No

Nursing Home

Yes No

Private Duty

Yes No

Assisted Living

Yes No

Section 5 - Medical History Questions:

Please List Any Allergies:

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Please list any limitations you may have in relationship to the duties of a Caregiver

Have you had a PPD test in the last 12 months

Yes No

Can you provide a copy of your PPD results?

Yes No

Person to notify in case of an emergency:(please include name, address, telephone number. relationship,)

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Section 6 - PERSONAL REFERENCES:

List (3) Personal References below: Include Name, Relationship, Telephone Number (Non- family members)

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Section 7 - Employment History

Are you currently employed?

Yes No

May we contact your present employer for a reference?

Yes No

Beginning with your most recent employer. Please include Name, Address, Telephone Number, Job description, Duration of employment, Supervisor's Name, Ending Wage, Reason for Leaving.

EMPLOYER # 1 Please include Name, Address, Telephone Number, Job description, Duration of employment, Supervisor's Name, Ending Wage, Reason for Leaving.

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EMPLOYER # 2 Please include Name, Address, Telephone Number, Job description, Duration of employment, Supervisor's Name, Ending Wage, Reason for Leaving.

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EMPLOYER # 3 Please include Name, Address, Telephone Number, Job description, Duration of employment, Supervisor's Name, Ending Wage, Reason for Leaving.

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Section 8 - CAREGIVER PROFILE:

Please read and answer all of the following questions to the best of your ability. There are no wrong answers. The profile is designed to assist the agency in finding the best client match for our caregivers.

SKILLS PREFERENCE: Rank each of the following services with a number between (1&5) or (Not Appplicable) (NA) (5) being most skilled (1)being least skilled.

Companionship

(Numeric Answer Only)

Dressing Assistance

(Numeric Answer Only)

Errands / Shopping/ Appointments

(Numeric Answer Only)

a. Incontinence Mgt.

(Numeric Answer Only)

Incont. Cont. Bladder

Yes No

Incont. Cont. Bowel Incont.

Yes No

Meal Preparation / Cooking

(Numeric Answer Only)

Light Housekeeping / Laundry

(Numeric Answer Only)

Transportation

(Numeric Answer Only)

Ambulation Assistance / Walking / Standing

(Numeric Answer Only)

Showering / Bathing

(Numeric Answer Only)

Routine Transfer Assistance

(Numeric Answer Only)

Bedbound Care

Yes No

Hoyer Lift

(Numeric Answer Only)

Toileting Assistance

(Numeric Answer Only)

Client Gender Preference or Restriction

Would you provide services to a client with pets?

Yes No

If so, please list any restrictions.

Would you provide services to a client who smokes?

Yes No

Are you a Smoker?

Yes No

What do you like most about being a caregiver?

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What do you find the most difficult about being a caregiver?

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Many clients enjoy basic home cooked meals; what are some of you favorite dishes to prepare?

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The use of electronic devices such as cell phones or tablet devices are limited to emergencies or communication with the caregivers supervisior. Any violation of this policy could result in disciplinary action and extension of a caregivers probationary period. Have you read and do you understand the above policy?

Yes No

Assuming the client is mentally competent, who would be in charge, you or the client?

Please list any hobbies or interests you have and any organizations you belong to.

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Would you consider overnight or 12 hr shift work?

Would you consider any of the following types of Live-In assignments?

Synergy HomeCare offers a cash bonus program for Client and Caregiver referrals. Please list any potential customers or employees who may call due to your referral.

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In addition to English, please list any other languages in which you are fluent.

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By submitting this application I hearby authorize Synergy HomeCare to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination (required)

Yes No

Signature

Synergy HomeCare of South Jersey Application Form

Personal Information

Section 1 - General Information

Section 2 - Caregiver Background Information

Section 3 - Education

Section 4 - Skills Questionaire

Section 5 - Medical History Questions:

Section 6 - PERSONAL REFERENCES:

Section 7 - Employment History

Section 8 - CAREGIVER PROFILE: