Connecticut Home Care Solutions

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Services
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Employment
Contacts

Employment Application

EMPLOYMENT APPLICATION

Connecticut Home Care Solutions, L.L.C.
Village Commons Unit 102, 137 Norwich Road
Plainfield, CT 06354

"*" indicates required fields

Step 1 of 7 - Personal Information

14%

PERSONAL INFORMATION

Position Title

Your Name*

First Middle Last

Preferred Name

Social Security Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Mobile Phone*

Email*

Are you a United States Citizen?*

Yes

No

Have you ever been certified as a CNA or HHA?*

Yes

No

Have you ever applied for a job with us?*

Yes

No

How did you hear about us?

EDUCATION

Have you graduated from high school?*

Yes

No

High School you attended?*

Address*

Street Address City State ZIP Code

Date of Start*

MM slash DD slash YYYY

Date of End*

MM slash DD slash YYYY

Have you graduated from College?*

Yes

No

College you attended?*

Address*

Street Address City State ZIP Code

Date of Start*

MM slash DD slash YYYY

Date of Graduation*

MM slash DD slash YYYY

Degree

Military Service

Military Service*

Yes

No

Branch Name*

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Rank at Discharge*

Type of Discharge*

If other than honorable, explain.

EMPLOYMENT HISTORY

(Please be sure that ALL names of supervisors and phone numbers are correct)

Previous Jobs

(You can select up to three different previous jobs for three separate jobs)

First Previous Job

Second Previous Job

Third Previous Job

First Previous Job

Company Name*

Company Phone #*

Supervisor*

First Last

Address*

(Company Address) City State ZIP Code

Job Title*

Starting Salary*

Ending Salary*

Explain your responsibilities:*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Reason for leaving?*

May we contact your supervisor?*

Second Previous Job

Company Name*

Company Phone #*

Address*

(Company Address) City State ZIP Code

Supervisor*

First Last

Job Title*

Starting Salary*

Ending Salary

Explain your responsibilities:*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Reason for leaving?*

May we contact your supervisor?*

Third Previous Job

Company Name*

Company Phone #*

Address*

(Company Address) City State ZIP Code

Supervisor*

First Last

Job Title*

Starting Salary*

Ending Salary*

Explain your responsibilities:*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Reason for leaving?*

May we contact your supervisor?*

REFERENCES

(Please list three personal references. Please do not include friends or family members.)

First Reference*

First Last

Mobile Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

What is your relationship with this reference?*

Second Reference*

First Last

Mobile Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

What is your relationship with this reference?*

Third Reference*

First Last

Mobile Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

What is your relationship with this reference?*

DISCLAIMER AND SIGNATURE*

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I agree to following information being true and or correct for this disclaimer.

Signature*

(Please enter your signature)

EMPLOYMENT HISTORY

EMPLOYMENT POSITIONS (Click all that apply)*

Temporary Work

Part-Time Work

Overnight Work

Full-Time Work

Homemaking Work

PCA Work

Companion Work

Transportation Work

Weekdays Only

Weekends Only

Any day

Work with the elderly

Chore Work

Alzheimer’s Clients

Work with women

Work with men

Please Input available hours:*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Summary Questions Sections

Do you have any friends, relatives or acquaintances working for this company?*

Yes

No

If yes, please list name and relationship:*

If hired, would you have transportation to and from work?*

Yes

No

Make and Year of Motor Vehicle owned?*

Do you carry a minimum of at least $20,000/$40,000 on liability for auto insurance?*

Yes

No

How far are you willing to travel?*

Are you able to transport a client with a collapsible wheelchair or walker?*

Yes

No

If hired, are you willing to submit to and pass a controlled substance test?*

Yes

No

Do you currently have a full time job?*

Yes

No

Are you over the age of 21?*

Yes

No

Do you currently have a full time job?*

Yes

No

What date can you begin work?

MM slash DD slash YYYY

Do you smoke?*

Yes

No

Can you work around dogs and cats?*

Yes

No

Do you speak, write or understand any foreign languages?*

Yes

No

List which language(s) / and how fluent you consider yourself to be?*

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? (Please see job description page)*

Yes

No

If no, please list your limitations or restrictions:*

Do you have any other experience, training, qualifications or skills which you feel should be brought to our attention in the case that they make you especially suited for working with us?*

SELF ASSESSMENT SUMMARY

Please rate your level of experience (1=No experience 2=Some experience 3=Experienced 4=Very experienced

Bathing a client in tub*

1

2

3

4

Bathing a client in shower*

1

2

3

4

Sponge bathing client*

1

2

3

4

Washing a clients hair*

1

2

3

4

Applying lotion to client’s skin*

1

2

3

4

Brushing a client’s teeth*

1

2

3

4

Assisting with toileting*

1

2

3

4

Using a bed pan*

1

2

3

4

Changing clients briefs/diaper*

1

2

3

4

Assist client with dressing*

1

2

3

4

Dress client*

1

2

3

4

Assist client with other grooming*

1

2

3

4

Operate a hospital bed*

1

2

3

4

Transferring a client*

1

2

3

4

Positioning/Turning a client*

1

2

3

4

Using a gait belt*

1

2

3

4

Lifting a client*

1

2

3

4

AMBULATION & TRANSFERRING

Please rate your level of experience (1=No experience 2=Some experience 3=Experienced 4=Very experienced

Assist into/out of automobile*

1

2

3

4

Assisting client with walking*

1

2

3

4

Assisting client with cane*

1

2

3

4

Assisting client with walker*

1

2

3

4

Assisting client with wheel chair*

1

2

3

4

Transportation

Please rate your level of experience (1=No experience 2=Some experience 3=Experienced 4=Very experienced

Driving client in their car*

1

2

3

4

Running Errands*

1

2

3

4

Escorting to appointments*

1

2

3

4

Meals

Please rate your level of experience (1=No experience 2=Some experience 3=Experienced 4=Very experienced

Shopping for food*

1

2

3

4

Cooking*

1

2

3

4

Meal preparation*

1

2

3

4

Feeding client*

1

2

3

4

Light Housekeeping

Please rate your level of experience (1=No experience 2=Some experience 3=Experienced 4=Very experienced

Changing bed linens*

1

2

3

4

Vacuuming*

1

2

3

4

Cleaning restrooms/kitchen*

1

2

3

4

Laundry*

1

2

3

4

Specific Conditions

Please rate your level of experience (1=No experience 2=Some experience 3=Experienced 4=Very experienced

Dementia/Alzheimer’s*

1

2

3

4

Parkinson’s*

1

2

3

4

Hospice/End of Life Care*

1

2

3

4

Stroke*

1

2

3

4

Cancer/Chemotherapy*

1

2

3

4

Mental Illness*

1

2

3

4

Paralyzed*

1

2

3

4

Broken hip or replacement*

1

2

3

4

Please take a moment to tell us why you are seeking this type of employment:*

CRIMINAL HISTORY

CRIMINAL RECORD HISTORY RELEASE FORM*

Have you ever had a criminal record?

Yes

No

Name*

First Middle Last

Have you had a previous name?*

Yes

No

Maiden, Alias or Former (provide names and dates changed)*

First Last

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

Gender*

Male

Female

Address*

Please provide your home addresses for the past 7 years, starting with the most current first.

Street Address City State / Province / Region ZIP / Postal Code

Date*

MM slash DD slash YYYY

Address*

Please provide your home addresses for the past 7 years, starting with the most current first.

Street Address City State / Province / Region ZIP / Postal Code

Date*

MM slash DD slash YYYY

Address*

Please provide your home addresses for the past 7 years, starting with the most current first.

Street Address City State / Province / Region ZIP / Postal Code

Date*

MM slash DD slash YYYY

Have you ever been convicted of a crime (felony or misdemeanor)?*

Yes

No

Provide the state, county, and year of conviction:*

Signature*

I authorize Connecticut Home Care Solutions LLC, or its agent, to investigate my criminal background as it pertains to employment as a Connecticut Home Care Solutions employee, or any other employment or volunteer considerations. I release all persons, companies, or corporations furnishing information as part of this background investigation from liability or responsibility. I certify that all information provided is true and complete to the best of my knowledge. I understand that omitting or falsifying information could result in rejection of application or dismissal if hired. The expiration of this authorization shall be for a period of one year from date of signature.

Comments

This field is for validation purposes and should be left unchanged.

Δ

Our Hours

Monday - Friday
8:30-am - 4:30pm

After Hours & Weekends

Emergency Contact

860-564-9191

Connecticut Home Care Solutions

Village Commons, Unit 102
137 Norwich Road
Plainfield, CT 06374

Contact Us

860-564-9191
888-890-6581
info@cthomecaresolutions.com

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