Independent Resource Services
11768 Atwood Rd. #29
Auburn, CA 95603
Voice: (916) 885-6100 TTY: 885-0326 FAX 885-3032

**PERSONAL ASSISTANT APPLICATION**

Name:
Email Address:
Address:	[apt. #]:
City:
State:	Zip Code:
Phone Number:	()- Message Number: ()-
SSN#:
Auto Insurance: Company Name
Policy Number
Driver's Lic#:
Name, address & phone # of person to call in case of emergency:
Are you willing to work in a smoke free environment?	Yes No
Are you willing to work in a smoking environment?	Yes No
Have you ever been convicted of a felony?	Yes No
If yes, please describe conditions
	**CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM EMPLOYMENT
Salary Preference: $/Hour $/week $/Month

Areas Preferred:

Auburn	South Placer	Colfax
King's Beach	El-Dorado-West Slope	El Dorado-East Slope
S. Lake Tahoe	Alpine	Other

**Check as many as apply**

---

Schedule Preferred:	Full-Time	Part-Time	Split-Shift
	Emergency/On-Call	Live-in	Other

(Please Check all that apply; it may be more than one, e.g., on-call and PT)

Days available (Please check all that apply)

S

M

T

W

Th

F

S

Other comments about schedule, e.g. flexible schedule, min hours, etc.:

Have have any experience in attendant work or nursing? Explain when and what our duties were:

Have you been trained in lifting and transferring? Yes No

If yes, where, and what type of training?

What is the maximum weight you will lift? lbs.

Training certificates and date(s) received:

Home Health Aide

Nurse's Aide

First Aid

CPR

Other

How did you find out about PIRS

---

Willing to work with:

Female	Male	No Preference	Alzheimer's
Quadriplegic	Paraplegic	Elderly	Any

Comments:

---

Services willing to perform (Check all that apply)

Personal Care

1. Respiration	Yes	No	Willing to learn
2. Bowel and bladder care	Yes	No	Willing to learn
3. Feeding	Yes	No	Willing to learn
4. Bathing	Yes	No	Willing to learn
5. Dressing	Yes	No	Willing to learn
6. Menstrual Care	Yes	No	Willing to learn
7. Ambulation	Yes	No	Willing to learn
8. Moving in and out of bed	Yes	No	Willing to learn
9. Oral hygiene and grooming	Yes	No	Willing to learn
10. Skin care	Yes	No	Willing to learn
11. Care and assistance with prosthesis	Yes	No	Willing to learn
12. Range of motion	Yes	No	Willing to learn
13. Assist at night	Yes	No	Willing to learn
14. Companionship	Yes	No	Willing to learn

15. Other

Domestic Services

1. Light cleaning	Yes	No	Willing to learn
2. Heavy cleaning	Yes	No	Willing to learn
3. Laundry	Yes	No	Willing to learn
4. Shopping	Yes	No	Willing to learn
5. Meal preparation	Yes	No	Willing to learn
6. Meal clean-up and menus	Yes	No	Willing to learn
7. Transportation	Yes	No	Willing to learn
8. Watering/Light yard work	Yes	No	Willing to learn
9. Reading (books, bills, letters, etc.)	Yes	No	Willing to learn
10. Feeding pets	Yes	No	Willing to learn

11. Other

---

Employment History:

Most Recent Employer

Address

()-
Phone

Date Started: Date Left:

Name of Supervisor: Title:

Reason for Leaving

May we contact: Yes No

Description of duties:

Previous Employer

Address

()-
Phone

Date Started: Date Left:

Name of Supervisor: Title:

Reason for Leaving

May we contact: Yes No

Description of duties:

---

REFERENCES

Please note: Applications cannot be accepted without complete name, address and phone number of three personal references (no relatives, please). Thank you.

1

Name

Address

City     State     Zip Code

Phone No. (W) ()-     (H) ()-

Relationship

How long have you known this person? year(s) month(s)

2

Name

Address

City     State     Zip Code

Phone No. (W) ()-     (H) ()-

Relationship

How long have you known this person? year(s) month(s)

3

Name

Address

City     State     Zip Code

Phone No. (W) ()-     (H) ()-

Relationship

How long have you known this person? year(s) month(s)

---

Placer Independent Resource Services
11768 Atwood Rd. #29
Auburn, CA 95603
Voice: (916) 885-6100 TTY: 885-0326 FAX 885-3032

ASSISTANT CONTRACT

(PLEASE READ CAREFULLY)

I UNDERSTAND THAT I WILL NOT BE EMPLOYED BY PIRS, BUT WILL BE SCREENED AND HAVE REFERENCES CHECKED TO BE CONSIDERED FOR REFERRAL TO PIRS' CLIENTS. I WILL NOT BE AUTOMATICALLY REFERRED TO DISABLED EMPLOYERS IN THE COMMUNITY. IT IS PIRS' DISCRETION TO REFER ASSISTANTS AS THEY SEE FIT.

I UNDERSTAND I AM EXPECTED TO BE WELL GROOMED, DEPENDABLE, PATIENT, AND AM TO FOLLOW WRITTEN AND VERBAL INSTRUCTIONS, AND GIVE AT LEAST TWO WEEKS NOTICE TO MY EMPLOYER BEFORE LEAVING MY JOB; BREAKING THIS UNDERSTANDING WILL MEAN THAT REFERRALS THROUGH PIRS WILL DISCONTINUE.

I WILL REPORT TO PIRS WHEN I AM HIRED BY A DISABLED EMPLOYER WITHIN TWO WEEKS. IF I HAVE ANY PROBLEMS WITH MY EMPLOYER AFTER WORKING WITH HER/HIM FOR A WHILE, I WILL REPORT TO PIRS. I AUTHORIZE THAT INFORMATION REGARDING PREVIOUS EMPLOYMENT AND PERSONAL CHARACTERISTICS BE PROVIDED TO PIRS BY THE PARTIES LISTED AS REFERENCES IN MY APPLICATION. THE INFORMATION WILL BE USED FOR EMPLOYMENT PURPOSES ONLY.

I GIVE MY FULL PERMISSION FOR RELEASE OF ALL INFORMATION ON THIS APPLICATION TO PIRS AND ASSOCIATED AGENCIES, AS NEEDED.

THE ABOVE INFORMATION IS TRUE AND FACTUAL TO THE BEST OF MY KNOWLEDGE.

PLEASE FILL OUT THIS FORM, PRINT AND MAIL IT TO:

PERSONAL ASSISTANT APPLICATION
C/O Placer Independent Resource Services
11768 Atwood Rd. #29
Auburn, CA 95603

Please email comments or questions about web site to Webmaster
Copyright © 2002, 2003, 2004, 2005, 2006, 2007, 2008 Placer Independent Resource Services
Updated: July 23rd, 2008