Paraprofessional Personnel Application at Health Force of Georgia

Thank you for completing the caregiver career application at Health Force of Georgia. There are 10 sections to the Paraprofessional Personnel Application form. Be sure to complete ALL sections before clicking submit. The form will prompt you if there is required information missing in any section. Fields marked with a red * are required.

Paraprofessional Personnel Application

"*" indicates required fields

1. General Info

Date of Application*

Name*

First Middle Initial Last

Physical Address*

Street Address Address Line 2 Apt # City State Zip Code

Email Address*

Enter Email Confirm Email

Phone*

Skills

End General

2. Emergency Contact

Next of Kin/Emergency Contact*

First Last

Emergency Contact Phone*

End Emergency Contact

3. Requested Information

Are you at least 18 years old?*

Yes

Will you work in a home with a pet?*

Yes

Do you have access to public transportation?*

Yes

Do you have access to a car?*

Yes

Do you have a driver’s license?*

Yes

Driver License Number*

Driver's License State

Driver License Expiration Date*

I am fluent in the following languages

List languages.

What are your work preferences?

List when you are available for work.

What days/hours are you NOT available to work?

List when you are NOT available for work.

Are you available for live-in assignments?*

Yes

Have you ever been bonded?*

Yes

How did you learn of job opportunities at Health Force of Georgia?

Online Search

Professional Colleague

Friend

Other

End Requested Information

4. Criminal Background

Have you been convicted of a crime other than a traffic violation within the last 7 years?*

Yes

If Yes, please explain.

Note: Conviction will not necessarily disqualify an applicant from employment.

End Criminal Background

5. Training Certificate

Training Certificate Number

Issued By

Expiration Date

End Training Certificate

6. Skills Inventory & Education

Tell us about your expeience. Check areas in which you are proficient.

Skills Inventory Checklist A

Check areas in which you have experience or training.

Hospital

Experience

Training

Nursing Home

Experience

Training

Private Home

Experience

Training

Meal Preparation

Experience

Training

Special Diets

Experience

Training

Spinal Cord Injury

Experience

Training

CVA

Experience

Training

Geriatric Care

Experience

Training

Pediatric Care

Experience

Training

Psychiatric Care

Experience

Training

AIDS Care

Experience

Training

Mother/Child Care

Experience

Training

Mental/Retardation Care

Experience

Training

Oncology/Dying Patient Care (Hospice)

Experience

Training

Other. Please explain.

Skills Inventory Checklist B

Check only areas in which you are knowledgeable.

Transfer ROM

Yes

Bathing

Yes

TPR

Yes

Blood Pressure

Yes

Dressing Change Unsterile

Yes

Warm/Cold Compresses

Yes

Ostomy Care

Yes

Foley Care

Yes

Supervise Meds

Yes

Intake and Output

Yes

Test Diabetic Urine

Yes

Specimen Collection

Yes

Other. Please explain.

End Skills Inventory

7. Education

High School Name

High School City & State

Graduated?

Yes

College Name

College City & State

Degree or Major

Graduated?

Yes

Other School or Institution Name

Other School or Institution City & State

Degree or Major

Graduated?

Yes

End Education

8. Employment History

List your last three employers starting with your most recent position. (Please list both permanent and temporary jobs.)

Employer One Info

Name of Employer One

Start Date - Employer One

End Date - Employer One

Employer One Address

Street Address Address Line 2 City State ZIP Code

Employer One Phone

Supervisor Name at Employer One

Position at Employer One

Salary at Employer One

Reason for Leaving Employer One

Type a brief description of why you are not longer working for this employer.

Employer Two Info

Name of Employer Two

Start Date - Employer Two

End Date - Employer Two

Employer Two Address

Street Address Address Line 2 City State ZIP Code

Employer Two Phone

Supervisor Name at Employer Two

Position at Employer Two

Salary at Employer Two

Reason for Leaving Employer Two

Type a brief description of why you are no longer working for this employer.

Employer Three Info

Name of Employer Three

Start Date - Employer Two

End Date - Employer Three

Employer Three Address

Street Address Address Line 2 City State ZIP Code

Employer Three Phone

Supervisor Name at Employer Three

Position at Employer Three

Salary at Employer Three

Reason for Leaving Employer Three

Type a brief description of why you are no longer working for this employer.

End Employer Info

9. References

List three references (Please no family members.)

Reference One

Name Reference One

First Last

Address Reference One

Street Address Address Line 2 City State ZIP Code

Phone Reference One

Occupation of Reference One

Number of Years Known

Reference Two

Name Reference Two

First Last

Address Reference Two

Street Address Address Line 2 City State ZIP Code

Phone Reference Two

Occupation of Reference Two

Number of Years Known

Reference Three

Name Reference Three

First Last

Address Reference Three

Street Address Address Line 2 City State ZIP Code

Phone Reference Three

Occupation of Reference Three

Number of Years Known

End References

10. Oath of Honor

Capability Statement*

Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job is attached. Do not answer this question unless you have been informed about the requirement of the job for which you are applying.

Yes

Oath*

I certify that answers given herein are true and complete to the best of my knowledge. I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge. I authorize investigation of all references and statements contained in the application for employment as may be necessary in arriving at an employment decision. I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contingent upon the satisfactory outcome of a medical examination. I understand that if I am offered employment, I will be working for Health Force of Georgia, on its payroll, at its client’s premises. I understand that my employment may be terminated by Health Force of Georgia at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination. Information provided in my electronic employment application is true and accurate. Clicking submit serves as my electronic signature.

Yes

I consent to my submitted data being collected and stored*

Yes

End Oath of Honor

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