Apply for CNA - Part Time - Home Instead

Apply for CNA - Part Time

Hello and thank you for your interest in Home Instead. Please fill out the application below and click the Submit button when finished. Fields with an asterisk (*) are required.

Please note that this is the job board for the franchise office located at 353 N 121st Street, Wauwatosa, WI 53226. Each Home Instead franchise is independently owned and operated. To find a franchise near you, please visit the Careers page.

For job related questions please call the franchise office at 414-259-0209.

Summary
Title:	CNA - Part Time
ID:	2024-4-3
Salary Range:	$17.00 - $26.00 per Hour based on Exp.
Location:	Brown Deer, WI
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Primary Phone (Cell Phone):
Secondary Phone:	Secondary Phone
* Email:
Opt-In Confirmation
	I authorize recruiters from Home Instead - Milwaukee to send text messages from 8332288065 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
Resume:	Supported formats: Word, PDF, RTF, Text, and HTML.

	- or Upload from:


Cover Letter:	You can type in a Cover Letter or Copy/Paste from an existing document.

Additional Information

* How did you hear about Home Instead?

If applicable, please specify:

2022_CAREGiver Employment Application

APPLICANT NOTE

If you are considered for a position, we may contact your references and would ask that you notify them in advance. Please do not list relatives or family/relations.

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

Please read "Applicant Note" below.
Complete all parts of this application.
Application will be valid for 60 days.

Applicant Note: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body is required prior to employment.

PERSONAL INFORMATION

Other Names Previously Used:

	Last Name	First Name	Middle Name
1.
2.

Emergency Contacts
Please provide two emergency contacts.

Full Name	Phone Number	Email	Relationship
*	*	*	*

* Have you ever submitted an application here before?

Yes No

If yes, when?

* Have you ever been employed here before?

Yes No

If yes, when?

* Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes No

* Date of Birth:

AVAILABILITY

Due to the nature of this industry, no guarantee can be made as to the schedule or the amount of hours worked. Also please note, we rely upon the availability you state below when making our hiring decision. If your availability changes from what is stated below during the hiring process or at any time during your employment, you must contact our office immediately with the change. Depending upon the change, Home Instead reserves the right to not further consider you for employment. Completion of a more detailed availability form (to which you will be held in compliance with) will be required later in the application process - for now choose the options that best describe your availability generally.

* What date are you available to begin work?:

* Total hours preferred to work per week:

EDUCATION

Please check the highest grade level completed:

	Name	City, State	# Yrs Attended	Graduate?
High School	*	*	*	* Yes No
Vocational/Technical				Yes No
College/University				Yes No

WORK HISTORY

MOST RECENT EMPLOYER

* Are you currently working for this employer?

Yes No

* If yes, may we contact?

Yes No

* Company Name:

* City:

* State:

* Company Phone:

* Dates Employed - From:

* Dates Employed - To:

* Job Title:

* Supervisor's Name (1):

* Supervisor's (or HR) email (1):

* Duties:

Salary:

Per Hour/Week/Month:

Reason for Leaving:

SECOND MOST RECENT EMPLOYER

Are you currently working for this employer?

Yes No

If yes, may we contact?

Yes No

Company Name:

City:

State:

Company Phone:

Dates Employed - From:

Dates Employed - To:

Job Title:

Supervisor's Name (2):

Supervisor's (or HR) email (2):

Duties:

Salary:

Per Hour/Week/Month:

Reason for Leaving:

THIRD MOST RECENT EMPLOYER

Are you currently working for this employer?

Yes No

If yes, may we contact?

Yes No

Company Name:

City:

State:

Company Phone:

Dates Employed - From:

Dates Employed - To:

Job Title:

Supervisor's Name (3):

Supervisor's (or HR) email (3):

Duties:

Salary:

Per Hour/Week/Month:

Reason for Leaving:

CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT FOR EMPLOYMENT

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date:

2020_CAREGiver Employment Application Part II BID + Auto + Skills

Follow-up questionnaire – caregiving experience

Please indicate those tasks in which you have experience. For the areas that you do not have experience, please note if you are willing to learn.

Tasks	Experience Yes/No	Willing to Learn
Companionship/Conversation	* Yes No	Willing to Learn
Meal Preparation (meals/snacks)	* Yes No	Willing to Learn
Housekeeping (dust, vacuum, laundry)	* Yes No	Willing to Learn
Bathing/showering Assistance	* Yes No	Willing to Learn
Dressing Assistance	* Yes No	Willing to Learn
Showering Assistance	* Yes No	Willing to Learn
Medication Reminders	* Yes No	Willing to Learn
Hospice Care	* Yes No	Willing to Learn
Stroke Care	* Yes No	Willing to Learn
Dementia Care	* Yes No	Willing to Learn
Incidental Transportation & Errands	* Yes No	Willing to Learn
Incontinence Care	* Yes No	Willing to Learn
Personal Care Assistance (Female)	* Yes No	Willing to Learn
Personal Care Assistance (Male)	* Yes No	Willing to Learn
Diabetes Care Assostance	* Yes No	Willing to Learn
Transferring Assistance (Example: helping a person from chair to standing position)	* Yes No	Willing to Learn
Ambulation Assistance (Example: Ensure a person’s stability and safety when moving)	* Yes No	Willing to learn
Mechanical Lift (Hoyer Lift)	* Yes No	Willing to Learn

* How Many Years of experience do you have as a caregiver?

DRIVERS LICENSE AND VEHICLE INFORMATION

* Drivers License Number

* State of Issuance

* Do you have current auto insurance which meets WI state minimum requirements?

Yes No

* Vehicle: Make

* Model

* Year

* Color

* Plate #

BACKGROUND INFORMATION DISCLOSURE (BID)

INSTRUCTIONS

The Background Information Disclosure form (F-82064) gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make employment, contract, residency, and regulatory decisions. Complete and return the entire form and attach explanations as specified by employer or governmental regulatory agency. NOTE: If you are an owner, operator, board member, or non client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions.

CAREGIVER BACKGROUND CHECK LAW
In accordance with the provisions of Chapters 48.685 and 50.065, Wis. Stats., for persons who have been convicted of certain acts, crimes, or offenses:

The Department of Health Services (DHS) may not license, certify, or register the person or entity (Note: Employers and Care Providers are referred to as "entities");
A county agency may not certify a child care or license a foster or treatment foster home;
A child placing agency may not license a foster or treatment foster home or contract with an adoptive parent applicant for a child adoption;
A school board may not contract with a licensed child care provider; and
An entity may not employ, contract with or, permit persons to reside at the entity.

The list of offenses affecting caregiver eligibility that require rehabilitation review is available from the regulatory agencies or through the Internet at http://DHS.wisconsin.gov/caregiver/StatutesINDEX.HTM.

THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS / CARE PROVIDERS (Referred to as “Entities”):

Programs Regulated under Chapter 48, Wis. Stats.	Treatment Foster Care, Family Child Care Centers, Group Child Care Centers, Residential Care Centers for Children and Youth, Child Placing Agencies, Day Camps for Children, Family Foster Homes for Children, Group Homes for Children, Shelter Care Facilities for Children, and Certified Family Child Care.
Programs Regulated under Chapters 50, 51, and 146, Wis. Stats.	Emergency Mental Health Service Programs, Mental Health Day Treatment Services for Children, Community Mental Health, Developmental Disabilities, AODA Services, Community Support Programs, Community Based Residential Facilities, 3-4 Bed Adult Family Homes, Residential Care Apartment Complexes, Ambulance Service Providers, Hospitals, Rural Medical Centers, Hospices, Nursing Homes, Facilities for the Developmentally Disabled, and Home Health Agencies – including those that provide personal care services.
Others	Child Care Providers contracted through Local School Boards

THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS:

Anyone employed by or contracting with a covered entity who has access to the clients served, except if the access is infrequent or sporadic and service is not directly related to care of the client.
Anyone who is a Child Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14).
Anyone who lives on the premises of a covered entity and is 10 years old or over, but is not a client (“nonclient resident”).
Anyone who is licensed by DHS.
Anyone who has a foster home licensed by DHS.
Anyone certified by DHS.
Anyone who is a Child Care Provider certified by a county department.
Anyone registered by DHS.
Anyone who is a board member or corporate officer who has access to the clients served.

FAIR EMPLOYMENT ACT
Wisconsin’s Fair Employment Law, Chapters 111.31 - 111.395, Wis. Stats., prohibits discrimination because of a criminal record or pending charge; however, it is not discrimination to decline to hire or license a person based on the person’s arrest or conviction record if the arrest or conviction is substantially related to the circumstances of the particular job or licensed activity.

PERSONALLY IDENTIFIABLE INFORMATION
This information is used to obtain relevant data as required by the provisions set forth by the Wisconsin Caregiver Background Check Law. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches. For example, the Department of Justice uses social security numbers, names, gender, race, and date of birth to prevent incorrect matches of persons with criminal convictions. The Department of Health Services’ Caregiver Misconduct Registry uses social security numbers as one identifier to prevent incorrect matches of persons with findings of abuse or neglect of a client or misappropriation of a client’s property.

Completion of this form is required under the provisions of Chapters 48.685 and 50.065, Wis. Stats. Failure to comply may result in a denial or revocation of your license, certification, or registration; or denial or termination of your employment or contract. Refer to the instructions (F-82064A) on page 1 for additional information. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches.

Check the box that applies to you.

	Employee / Contractor (including new applicant)
	Applicant for a license or certification or registration (including continuation or renewal)
	Household member / lives on premises - but not a client
	Other

If you selected Other, please specify

NOTE: If you are an owner, operator, board member, or non client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions.

* Name (First and Middle):

* Name (Last):

Position Title (Complete only if you are a prospective employee or contractor, or a current employee or contractor.):

Any Other Names By Which You Have Been Known (Including Maiden Name):

* Birthdate:

* Gender:

Male Female

* Social Security Number:

* Home Address:

* City:

* State:

* Zip Code:

* Business Name and Address - Employer or Care Provider (Entity):

SECTION A - ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION

* Do you have any criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, local, military and tribal courts?

Yes No

If Yes, list each crime, when it occurred or the date of the conviction, and the city and state where the court is located. You may be asked to supply additional information including a certified copy of the judgement of conviction, a copy of the criminal complaint, or any other relevant court or police documents.

* Were you ever found to be (adjudicated) delinquent by a court of law on or after your 10th birthday for a crime or offense? (NOTE: A response to this question is only required for group and family day care centers for children and day camps for children.)

Yes No

If Yes, list each crime, when and where it happened, and the location of the court (city and state). You may be asked to supply additional information including a certified copy of the delinquency petition, the delinquency adjudication, or any other relevant court or police documents.

* Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? A response is required if the box below is checked:

Yes No

Response Required

(Only employers and regulatory agencies entitled to obtain this information per sec. 48.981(7) are authorized to, and should, check this box.)

If Yes, explain, including when and where it happened.

* Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client?

Yes No

If Yes, explain, including when and where it happened.

* Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client?

Yes No

If Yes, explain, including when and where it happened.

* Has any government or regulatory agency (other than the police) ever found that you abused an elderly person?

Yes No

If Yes, explain, including when and where it happened.

* Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?

Yes No

If Yes, explain, including credential name, limitations or restrictions, and time period.

SECTION B – OTHER REQUIRED INFORMATION

* Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services?

Yes No

If Yes, explain, including when and where it happened.

* Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility?

Yes No

If Yes, explain, including when and where it happened and the reason.

* Have you been discharged from a branch of the US Armed Forces, including any reserve component?

Yes No

If Yes, indicate the year of discharge:

* Have you resided outside of Wisconsin in the last 3 years?

Yes No

If Yes, list each state and the dates you lived there.

* Have you had a caregiver background check done within the last 4 years?

Yes No

If Yes, list the date of each check, and the name, address, and phone number of the person, facility, or government agency that conducted each check.

* Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services, a county department, a private child placing agency, school board, or DHS designated tribe?

Yes No

If Yes, list the review date and the review result. You may be asked to provide a copy of the review decision.

A “NO” answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.

I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1,000.00 and other sanctions as provided in DHS 12.05 (4), Wis. Adm. Code.

* Signature (type name):

* Date:

Submit

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