Independent Resource Services
11768 Atwood Rd. #29
Auburn, CA 95603

Voice: (530) 885-6100 TTY: (530) 885-0326 FAX (530) 885-3032

**PERSONAL ASSISTANT APPLICATION**

Date::

Name::

Address:

    [apt. #]:

City:

State:

    Zip Code:

Phone Number:

()-     Message Number: ()-

 

 

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?

Are you willing to work in a smoking environment?

Have you ever been convicted of a felony?

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?

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:


Employer's Name


Address

()-
Phone


Job Position

Date Started: Date Left:

Name of Supervisor: Title:

Reason for Leaving

May we contact:

Description of duties:


Previous Employer Name


Address

()-
Phone

Date Started: Date Left:

Name of Supervisor: Title:

Reason for Leaving

May we contact:

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: (530) 885-6100 TTY: (530) 885-0326 FAX (530) 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' CONSUMERS. 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 EMPLOYER WITH A DISABILITY 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.

 

____________________________________
APPLICANT SIGNATURE

___________________
DATE


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

 

 

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Updated: June 30th, 2015