Employment Application — AAA Shepherd's Care Home LLC

Personal information

Full name

Email

Phone

Street address

City

State

ZIP code

Are you a citizen of the United States?

YesNo

If no:

Are you authorized to work in the United States?

YesNo

Do you have documentation?

YesNo

Documentation required.

Position & availability

Select all positions that interest you.

Day ShiftEvening ShiftNight Shift24-Hour Shift/Substitute CaregiverLive in Residential Manager

Weekend availability

Earliest start date

Days / hours available

Credentials & certifications

Check all that apply.

Current CPR/First Aid CertificationPre Service Dementia Care Training for Direct Care Staff — CertificateProviding Inclusive Care: Training for Oregon Long Term-Care Facility Staff — CertificateHome and Community-Based Services and Settings (HCBS) and Individually-Based Limitations (IBL) — CertificateAdult Foster Home — Completed Caregiver Preparatory-Training WorkbookEnsuring Quality Care (EQC) — Certificate or TranscriptAdult Foster Home NWSD Orientation — CertificateSix Rights of Safe Medication Administration for ODHS APD Adult Foster Home Staff — CertificateFire and Life Safety-AFH — CertificateCNA (Oregon)CNA 2 / Medication Aide

Other credentials, licenses, or training

Work experience

List your employment during the past 3–5 years, starting with the most recent. Complete as many of the five sections as apply to you.

Employer 1

Name of business

Contact person

Phone

Mailing address

City

State

ZIP code

Job title

Start month/year

End month/year (or present)

Hours per week

Job duties

Caregiving work experience?

YesNo

If yes, check all that apply.

Provided care to persons dependent in three or more ADLsProvided medication managementJob duties included cleaning and cookingFamiliar with electronic medication administration records (eMARs)Comfortable using electronic systems for documenting, communications, and care coordination

Employer 2

Name of business

Contact person

Phone

Mailing address

City

State

ZIP code

Job title

Start month/year

End month/year (or present)

Hours per week

Job duties

Caregiving work experience?

YesNo

If yes, check all that apply.

Provided care to persons dependent in three or more ADLsProvided medication managementJob duties included cleaning and cookingFamiliar with electronic medication administration records (eMARs)Comfortable using electronic systems for documenting, communications, and care coordination

Employer 3

Name of business

Contact person

Phone

Mailing address

City

State

ZIP code

Job title

Start month/year

End month/year (or present)

Hours per week

Job duties

Caregiving work experience?

YesNo

If yes, check all that apply.

Provided care to persons dependent in three or more ADLsProvided medication managementJob duties included cleaning and cookingFamiliar with electronic medication administration records (eMARs)Comfortable using electronic systems for documenting, communications, and care coordination

Employer 4

Name of business

Contact person

Phone

Mailing address

City

State

ZIP code

Job title

Start month/year

End month/year (or present)

Hours per week

Job duties

Caregiving work experience?

YesNo

If yes, check all that apply.

Provided care to persons dependent in three or more ADLsProvided medication managementJob duties included cleaning and cookingFamiliar with electronic medication administration records (eMARs)Comfortable using electronic systems for documenting, communications, and care coordination

Employer 5

Name of business

Contact person

Phone

Mailing address

City

State

ZIP code

Job title

Start month/year

End month/year (or present)

Hours per week

Job duties

Caregiving work experience?

YesNo

If yes, check all that apply.

Provided care to persons dependent in three or more ADLsProvided medication managementJob duties included cleaning and cookingFamiliar with electronic medication administration records (eMARs)Comfortable using electronic systems for documenting, communications, and care coordination

References

Provide three general references who are not related to you.

Reference 1

Name

Relationship

Phone

Reference 2

Name

Relationship

Phone

Reference 3

Name

Relationship

Phone

Disclosure

Do you have an existing cleared background check through Orchards / Background Check Unit?

YesNo

Enter all previous addresses if you have lived out of state during the past 5 years for more than 60 days.

List any prior names and aliases, including maiden names, married names, name changes, or aliases, if applicable.

Have you ever been accused or substantiated for abuse or neglect?

YesNo

If yes, please explain and include dates.

Attach a copy of your Driver’s License or Identification Card.

Certification & signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or material omission may result in the rejection of this application or, if hired, termination of employment. I authorize AAA Shepherd's Care Home LLC to verify the information provided and to conduct background checks as required by Oregon law for adult foster home employment.

Signature

Date