VA of Willamette Valley Application Form
Application Form
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.
Personal Information
First Name
*
Last Name
*
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*
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Email
*
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*
Address 2
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Section 1 -
Preliminary Questionnaire
What type of Caregiving experience do you have?
(required)
-- Select an Option --
Yes, with Facilities
Yes, with Private Residence/Homes
Yes, both in Facilities and Private Homes
Yes, with Family members only
How much Caregiving Experience do you have?
(required)
-- Select an Option --
Less than 6 months
6 months
1 year
1-3 years
4+ years
What is your total, in years, Caregiving Experience?
(required)
Have you ever worked for Visiting Angels before?
(required)
Yes
No
If yes, when and what location?
Who referred you to Visiting Angels?
(required)
Are you currently working?
(required)
Yes
No
If you are currently working, are you looking for supplement work or replacement work?
-- Select an Option --
Supplement my current job
Replace my current job
How many hours a week are you available for work?
What is your preferred schedule to work?
Section 2 -
Personal Information
Have you ever lived outside of Oregon in the last 7 years?
(required)
Yes
No
If yes, please specifcy all states going back 7 years
Have you received any traffic violations within the last 7 years?
(required)
Yes
No
If yes, please provide all details
Section 3 -
Availability
Please specify which weekdays you are available to work (Mon, Tue, Wed, etc)
(required)
Please specify if you are available to work Weekends (Sat and/or Sun)
(required)
Please specify if you available to work Mornings, Afternoons or Both Mornings and Afternoons
(required)
Are you available to work Evenings?
(required)
Yes
No
Are you available to work Overnight Shifts?
(required)
Yes
No
If yes, what days of the week can you do Overnights?
(required)
Are you available to work Short Notice/Emergency Coverage?
(required)
Yes
No
Are you willing to work on Holidays?
(required)
Yes
No
Section 4 -
Locations
Are you willing to work in Linn and Benton County?
(required)
Yes
No
Please list ALL cities you are willing to work; Albany, Corvallis, Lebanon, Philomath, Scio, Sweet Home
Are you willing to work in Marion and Polk County?
(required)
Yes
No
Please list ALL cities you are willing to work; Dallas, Independence, Monmouth, Salem, Keizer, Stayton, Sublimity
Section 5 -
COMPANION SKILLS Self Assessment
Are you able and willing to assist with meal preparation, light housekeeping/laundry, medication reminders/prompts, walks and companionship (reading, games, hobbies) in order to enhance the overall well-being and happiness of our clients?
(required)
Yes
No
How much experience do you have with Companion Care (check one)
(required)
-- Select an Option --
Less than 6 months
6-12 months
1-3 years
3+ years
Describe your experience that would demonstrate your abilities to provide Companionship services
(required)
Show Plain Text
Section 6 -
COMPANION AND LIGHT SKILLS Self Assessment
Are you able and willing to assist with Light Personal Care services, such as; assisting with dressing, toileting, grooming and stand-by shower assistance; as well as companionship services as noted above?
(required)
Yes
No
How much experience do you have providing Light Personal Care Assistance?
(required)
-- Select an Option --
None
Less than 6 months
6-12 months
1-3 years
3+ years
Indicate your level of comfort and competence providing stand-by assistance with Showering
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Assisting with Toileting
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Section 7 -
HIGH SKILLED CAREGIVER/CNA SKILLS Self Assessment
Are you able and willing to provide a High skill level of Caregiving/CNA services?
(required)
Yes
No
How much experience do you have providing HIGH SKILLED Caregiving/CNA services?
(required)
-- Select an Option --
None
Clinical Experience only
6-12 months
1-3 years
3+ years
Please describe your level of comfort/competence providing full Shower Assist
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Personal Private Care-Incontinence care, genital care
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Full Dressing Assist
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Full Ambulation Assist-Assist with walking, using a cane, walker etc
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Using a Gait Belt
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Using a Hoyer Lift
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Lifts/Transfers
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Giving a Bedbath
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/completent
Very comfortable/completent
End of Life Care/Hospice Care
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/completent
Very comfortable/completent
Working with Alzheimer's/Dementia
(required)
-- Select an Option --
Not comfortable/competent
Somewhat comfortable/competent
Very comfortable/competent
Section 8 -
Education
Name of High School and Location (City/State)
(required)
Did you receive a High School Diploma?
Yes
No
Name of College and Location (City/State)
Major and Degree Earned
Name of Univeristy and Location (City and State)
Major and Degree Earned
Section 9 -
Certification and Training
Do you have a current CNA license?
(required)
Yes
No
Have you completed training on Medication Administration
(required)
Yes
No
Please indicate your level of training and experience providing care to people with Alzheimers/Dementia
(required)
-- Select an Option --
None
Less than 6 months
6-12 months
1-3 years
3+ years
Please include any additional skills, training and/or education related to Caregiving that you possess
Show Plain Text
Section 10 -
Current/Most Recent Employer
Employer/Company Name AND City and State
(required)
Company (Area code) and Phone Number
(required)
Start Date (Month/Year)
(required)
End Date (Month/Year)
(required)
Please describe your duties
(required)
Reason for leaving (be specific please)
(required)
May we contact this employer to verify your details?
(required)
Yes
No
Section 11 -
Previous Employer
Employer/Company Name AND City and State
Company (Area code) Phone Number
Start Date (Month/Year)
End Date (Month/Year)
Please describe your duties
Reason for leaving (be specific please)
Section 12 -
Prior Employer
Employer/Company Name AND City and State
Company (Area code) Phone Number
Start Date (Month/Year)
End Date (Month/Year)
Please describe your duties
Reason for leaving (be specific please)
Section 13 -
First Personal Character Reference (non relative)
Full Name & Relation (Friend, Neighbor, Co-worker, etc)
(required)
(Area code) Phone Number
(required)
Years known
(required)
(Numeric Answer Only)
Section 14 -
Second Personal Character Reference (non relative)
Full Name & Relation (Friend, Neighbor, Co-worker, etc)
(required)
(Area code) Phone Number
(required)
Years known
(required)
(Numeric Answer Only)
Section 15 -
Third Personal Character Reference (non relative)
Full Name & Relation (Friend, Neighbor, Co-worker, etc)
(required)
(Area code) Phone Number
(required)
Years known
(required)
Section 16 -
Acknowledgment
I certify that I am at least 18 years old
(required)
Yes
No
I am aware that Visiting Angels of Willamette Valley enforces a strict Drug Free Policy
(required)
Yes
No
I certify that I have reliable transporation, proof of insurance and a valid Oregon Drivers License
(required)
Yes
No
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature
Submit Application