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

**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?
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-CallLive-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 prosthesisYes 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:

Description of duties:


Previous Employer


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: (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.