| Senior-Assist Care Provider Database |
| Sample Provider Listing |
Personal Information Name: Street Address: City Day Phone: Cell Phone: Email: Gender: Certification: __Non-Certified Companion/Attendant __PCA __CNA __LPN __NA __RN __First Aid Expires: ___/___ __CPR Expires: ___/___ __Other ________________________ Education (Highest Level): __Less than GED __ GED __ High School Diploma __Associate __Baccalaureate __Masters Services Offered: ______________________________ ______________________________ ______________________________ ______________________________ Special Care Experience __Mental Retardation __Mental Illness __Autism __Spinal Cord __Brain Injury __Dementia __Alzheimer's __Other ________________________ Work Experience: 6mo.-1Yr. 1-2 Yrs. 3-5 Yrs. 6-10 Yrs. Other _______ Identification: Yes No Verifiable References? 10 Yr. DMV Record? Criminal Bkgrnd. Report? Current (annual) TB Skin Test? Availability: Locale/County(s): __________________ Hours: 1AM-6AM 6AM-12AM 12AM-6PM 6PM-12PM All Day Overnight Live-In Travel Other ___________ Days: Mon Tue Wed Thu Fri Sat Sun Driving Skill/Access: Yes No Valid Driver License? Auto Insurance? Have Personal Vehicle? Willing to Transport Client? Willing to Drive Client's vehicle? Language Skills: English Spanish Speak Read Write Work Status: Yes No 1099 Non-Employee* Employee Only Comments: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ * Independent Contractor Agreement (See Below) |
