Date *

Applicant Name *

Position *

Interview Location *

Pre-Screening Questions

Do you have experience lifting/transporting patients? *

Yes

If so, how comfortable are you with this requirement and what technique do you utilize?

Are you able to complete basic housekeeping duties such as cleaning, washing dishes, doing laundry such as bed linens and soiled clothes are clean before the end of your shift, and maintaining a clean living and dining area? *

Yes

If not, which areas are you not comfortable with completing?

Are you able to cook and meal prep for clients? *

Yes

Are you comfortable with documenting necessary information such as care notes when completing a shift? Examples include times prescription medications are administered as well as BP levels and any changes in behaviors? *

Yes

Do you have experience working in a nursing home or assisted living facility? *

Yes

If so, please list the facilities and give a brief description of your responsibilities while employed there?

If extended a job opportunity how soon would you be ready to start work with having proper uniform scrubs, closed toe shoes, reliable transportation, working cellphone? *

Are your currently responsible for transportation for anyone besides yourself such as helping someone else get to work, school, or daycare *

Yes

If so, please explain:

Please list any attributes that you possess that have not already been listed that are beneficial to the position you are applying for: *

Some cases may cause for a caregiver to work 4-12 hour shifts. Are you able to work within these hours without interruption? *

Yes

Can you comply with the 3 hour minimum advance notice before calling in for a scheduled shift? *

Yes

Do you possess a phone and are able to use it for clocking in and out for scheduled shifts and documenting care notes? *

Yes

If not, please provide details:

Scenario Questions

You have been working with a client for several months and developed a great rapport with them. Things have been tough on you and your family financially and the client offers to assist you by offering you money. If you were assured by the client that no one would find out, what would you do? *

You find your client sitting in their chair/bed with a spoiled brief. Personal care is a responsibility while assisting and you will have to help clean and dress the client. Describe how you would begin the process and what tasks you would need to do to complete it. *

You have completed all your assigned tasks in a client's home. Your client can not think of anything for you to do; however, you have an hour left of your assignment. What would you do to make the last hour of service beneficial to your client? *

What do you need to learn to become a great caregiver? *

Are there any areas that you would like to specialize and receive training in? *

Caregiver/CNA Attributes

Are you currently a CNA? *

Yes

Are you able to work with cats? *

Yes

Are you able to work with dogs? *

Yes

Are you able to check vitals for BP, Pulse, O2? *

Yes

Are you able to assist with Diabetes (Check sugar/provide insulin)? *

Yes

Can you assist with a client who is bed bound (changes and bed pan)? *

Yes

Can you make an occupied bed? *

Yes

Can you perform a bed bath for both Male and Female clients? *

Yes

Are you able to transfer/lift manually? *

Yes

Are you able to transfer using a gait belt? *

Yes

Are you a tobacco user? *

Yes

Able to work with a client who is a tobacco user? *

Yes

Can assist with memory care needs (Alzheimer's, dementia, sundowners) *

Yes

Do you have a valid drivers license and vehicle insurance? *

Yes

Are you willing to travel outside of Mobile for assignments? (Daphne, Foley, Summerdale, etc.) *

Yes

Are you able to operate an oxygen machine? *

Yes

Are you willing to work in a facility? *

Yes

Are you willing to follow dress code set form by Gracepoint Home Care? *

Yes

Can you comply with the guidelines in the Team Member Handbook? *

Yes

Are you able to remain professional under stressful conditions? *

Yes

Caregiver Experience Checklist

Please check all that apply:

Licensed CNA

Can provide Companionship

Can engage in conversation with client

Able to prepare meals

Able to clean-up after meal preparation

Able to remind client to take medications

Able to vacuum

Able to make a bed

Able to follow a care plan

Able to complete care notes and activity notes

Able to assist with dressing

Able to clean and change client if incontinent of bladder

Able to clean and change client if incontinent of bowels

Able to assist with fall risk clients with walking and lifting

Able to turn client when bedridden

Able to preform bed bath

Able to check temperature orally

Able to check temperature rectally if needed

Able to check and record pulse

Able to check and record blood sugar

Able to perform nail care on client

Able to perform mouth care on client

Able to perform hair care on client

Able to make an occupied bed

Able to log roll client

Able to insert and care for condom catheter and attach to a urinary collection bag

Able to wash and change linens

Able to clean bathrooms

Able to clean kitchen

Able to do laundry

Able to run errands

Able to accompany clients to appointments

Able to grocery shop for clients when requested

Able to carry and put away groceries

Able to assist client to sitting positions

Able to manually transfer client from bed to chair

Able to manually transfer client from chair to bed

Able to transfer client using hoyer lift

Able to transfer client using gait belt

Able to feed client

Able to assist client with urinal

Able to assist client with bed pan

Able to apply a condom-catheter

Able to empty urinary collection bag

Able to perform ostomy care

Able to perform peineal care

Able to assist client with fedding/peg tube

Able to use suctioning device

Able to perform catheter care

Able to operate a powered wheelchair

Able to operate an oxygen machine

Able to lift clients when needed

How many years of experience do you have? *

Any special circumstances/job limitations that Gracepoint Home Care needs to be aware of that will hinder you from carrying out job responsibilities?