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Employee Information Form

The information on this form is collected for the purposes of evaluating your application for employment with our company and should you be offered employment, the application will help us match your skills to appropriate clients. All information collected by Classic Caregivers Ltd. is protected by the Personal Information Protection and Electronic Documents Act and will be kept confidential. All of the questions below are optional and your consent is implied by submitting answers to the questions.


 
Background Information
Last Name
First Name
City
Postal Code
Telephone #
Cell #
Pager #
SIN #
Birth Date
Allergies?
Languages Spoken?

Do you have a valid Drivers Licence?Yes  No 
Drivers licence #
Are you comfortable driving a client’s vehicle?Yes  No 
Are you comfortable driving a client in your vehicle?Yes  No 
What have you done that you are the most proud of?
Are you willing to work in a smoking environment?Yes  No 

 
Availability for work - Please write the hours that you are available for work each day. Also tick whether you can do live in or live out work.
Monanytime or from to live inlive out
Tuesanytime or from to live inlive out
Wedanytime or from to live inlive out
Thuranytime or from to live inlive out
Frianytime or from to live inlive out
Satanytime or from to live inlive out
Sunanytime or from to live inlive out

 
Areas you will work in - The more areas you are available to work in the easier it is to find you work.
Vancouver Surrey Langley
White Rock Richmond Abbotsford
West Vancouver Burnaby Chilliwack
North Vancouver Tri Cities Tswass/Delta

 
Are you working right now? Yes No
If yes how much notice will you give your present employer and when will you be available?

 
Education
Have you taken a care aide program? Yes No
School     Date Graduated
Is your CPR up to date? (Please provide a copy of any certificates and CPR) Yes No
Other health related education?

 
Work History
Name of your most recent employer:
Date started
Date finished
Duties
Contact Name
Phone#

 
Previous Employer
Date started
Date finished
Duties
Contact Name
Phone#

 
Previous Employer
Date started
Date finished
Duties
Contact Name
Phone#

 
Work Experience - Please tick duties you have experience with and are comfortable performing.
Personal Care
Colostomy bag Catheter bag
Suppositories/Enemas Personal hygiene
Peri Care Bowel care
Bathing Manual transfers
Mechanical lifts 
Medical Care
Quad care Trach care
Feeding tubes Suctioning
TED stockings Glucometers
Medications ROM exercises
Blood pressure 
Client Diagnosis
Stroke care Dementia care
Heart disease Alzheimers care
Palliative care Brain injury clients
Diabetic clients Parkinson clients
ALS clients MS clients
Hip replacement clients 

 
Cooking
Have you cooked for an elderly client before? Yes No
What type of food?
Do you have experience with cooking special diets for clients? Yes No
What special diets?
Are you able to cook Chinese dishes? Yes No
How would you rate your cooking on a scale of 1-poor to 10 - excellent?

 
Housekeeping - Please check duties in which you have had experience:
Dusting Washing floors
Vacuuming Washing windows
Laundry Cleaning stove
Cleaning fridge Cleaning cupboards
Ironing Washing/drying clothes
Changing bed linens 
  
How would you rate your housekeeping?
Are you comfortable doing housekeeping for a client?

 
References - List 3 work related references that we may contact as a reference for you.
NamePhone numberPosition/Company
1.
2.
3.

 
Have you had a criminal record search done within the last year? If so, please attach copy. Yes No
Have you ever been arrested? Yes No
Will you consent to having a police record check before being employed with us? Yes No

 
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VANCOUVER: VICTORIA: TOLL FREE:
t. 604.263.3621  
f. 604.263.4139
e. vancouver@classiccaregivers.com		 t. 250.412.0214  
f. 250.412.0215
e. victoria@classiccaregivers.com		 1.888.263.5168
 
CALGARY: EDMONTON: TOLL FREE:
t. 403.242.2750  
f. 403-242-2759
e. calgary@classiccaregivers.com		 t. 780.428.2750  
f. 780.428.2753
e. edmonton@classiccaregivers.com		 1.888.263.5168
 
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