Wilson Homecare Application Form
Application Form
Wilson Homecare
P.O. Box 2058
Honolulu, HI 96805-2058
Phone: 808-596-4486
Fax: 808-596-4822
Email: jobs@wilsoncare.com
Website: www.wilsoncare.com
Personal Information
First Name
*
Last Name
*
Social Security Number
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Military Personnel - America
Military Personnel - Europe
Military Personnel - Pacific
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Zip
*
Driver's License Number
--
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
AA
AE
AP
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VT
VI
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Section 1 -
Referral Source
How did you hear about us?
(required)
Section 2 -
Applicant Screening
Thank you for considering Wilson Care Group, an equal opportunity employer which does not discriminate based on sex, age, color, religion, national origin, mental or physical ability, marital status, military service, or sexual orientation. No application will be rejected because of a disability that, with reasonable accommodation, does not prevent performance of essential job duties. I have read and understand this statement about the application process.
(required)
Yes
No
Military Affiliation
Yes
No
What position are you applying for?
(required)
-- Select an Option --
Nurse Aide / CNA / Caregiver (Full Time -or- Part Time)
FLOAT / Area Responder (Emergency On-Call)
LPN (License Practical Nurse)
RN (Registered Nurse)
Have you been previously employed or applied with us in the past?
(required)
Yes
No
If yes, please explain.
Have you been employed or attended school using any other name?
(required)
Yes
No
If yes, please indicate name(s) previously used.
Date you are available to start:
(required)
Ideally, I'd like to work...
(required)
-- Select an Option --
Full Time (30+ Hours)
Part Time (15-29 Hours)
On-Call / Fill-In
Desired Pay Rate?
(required)
Do you have the legal right to work in the United States?
(required)
Yes
No
Have you been fired in the last ten years?
(required)
Yes
No
If yes, please explain.
Have you been convicted or pled guilty/no contest for any crime other than traffic violations?
(required)
Yes
No
If yes, please explain.
Have you been investigated/involved with Adult Protective Services (APS) or Child Abuse & Neglect (CAN)?
(required)
Yes
No
If yes, please explain.
Section 3 -
Employment History
Employment history may or may not pertain to patient care. Starting with the most recent employer (regardless if related to home healthcare), please provide your work history in this format: Company Name / City / State / Phone Number / Job Title / Date Started / Date Ended / Reason for Leaving. (Please provide at least 3 employers if possible). I have read and understand this statement about the application process.
(required)
Yes
No
Employer #1
(required)
Show Plain Text
Employer #2
Show Plain Text
Employer #3
Show Plain Text
May we call your former employer(s)?
(required)
Yes
No
Describe your “hands-on” personal caregiving experience, whether with family, private client, volunteer work, hospital, home care, care home/facility, or school/license (medical-related).
(required)
Show Plain Text
Section 4 -
Evaluation: Skills & Availability
This section is used to help us find you the best possible client(s). Answer these questions truthfully, as this information will be used to find your perfect client matches. The answers provided will not negatively affect your application or chances of employment. Select the skills you can perform with no additional training and/or instruction. Yes – “Experienced.” No – “I need training.” I have read and understand this statement about the application process.
(required)
Yes
No
Basic Skill: Bed Bath
(required)
Yes
No
Basic Skill: Shower
(required)
Yes
No
Basic Skill: Dressing (clothing)
(required)
Yes
No
Basic Skill: Making an Occupied Bed
(required)
Yes
No
Basic Skill: Making an Unoccupied Bed
(required)
Yes
No
Basic Skill: Re-positioning in Bed
(required)
Yes
No
Basic Skill: Wheelchair Use
(required)
Yes
No
Basic Skill: Bedpan / Urinal
(required)
Yes
No
Basic Skill: Incontinent Brief Changes
(required)
Yes
No
Basic Skill: Cooking / Meal Prep
(required)
Yes
No
Basic Skill: Feeding
(required)
Yes
No
Basic Skill: Oral / Denture Care
(required)
Yes
No
Basic Skill: Female Perineal Care
(required)
Yes
No
Basic Skill: Male Perineal Care
(required)
Yes
No
Basic Skill: Shaving
(required)
Yes
No
Basic Skill: Light Housekeeping
(required)
Yes
No
Advance Skill: Operating Hoyer Lifts
(required)
Yes
No
Advance Skill: Gait Belt Transfer
(required)
Yes
No
Advance Skill: Slide Board Transfer
(required)
Yes
No
Advance Skill: Maximum Patient Transfer
(required)
Yes
No
Advance Skill: Empty Catheter Bags
(required)
Yes
No
Advance Skill: Blood Sugar Monitoring
(required)
Yes
No
Advance Skill: Range of Motion Exercises
(required)
Yes
No
Advance Skill: Prepared to Provide CPR
(required)
Yes
No
Do you have the capacity/skill to physically assist, lift, and/or transfer a client (average weight of 150 pounds)?
(required)
Yes
No
If no, please explain.
Please confirm your zip code. This will help us to schedule you with clients within a convenient commute
(required)
(Numeric Answer Only)
Are you willing to travel outside of your zip code to assist clients?
(required)
Yes
No
Are you willing to be a driver for clients using their vehicles -AND- do you have a valid driver's license?
(required)
Yes
No
Wilson Care Group is a 24/7 home healthcare business, providing care to patients/clients in private residences throughout the island of Oahu. To become an active employee, hire-eligible candidates must maintain an on-going schedule of 1 shift (client assignment) a week. I have read and understand this statement about the application process. I can commit to the following:
(required)
Yes
No
Sundays
(required)
Yes
No
Mondays
(required)
Yes
No
Tuesdays
(required)
Yes
No
Wednesdays
(required)
Yes
No
Thursdays
(required)
Yes
No
Fridays
(required)
Yes
No
Saturdays
(required)
Yes
No
Please indicate your shift time/length preferences and availability to work (below). Describe other details about your availability here:
Morning Shifts (before 12 noon)
(required)
Yes
No
Afternoon Shifts (after 12 noon)
(required)
Yes
No
Evening Shifts (after 5 pm)
(required)
Yes
No
Overnight Shifts
(required)
Yes
No
Anytime (no conflicts 24/7)
(required)
Yes
No
Short Shifts (between 3 to 6 hours)
(required)
Yes
No
Long Shifts (between 6 to 12 hours)
(required)
Yes
No
I'm comfortable working with male clients/patients
(required)
Yes
No
I'm comfortable working with female clients/patients
(required)
Yes
No
I'm comfortable working with children/infants
(required)
Yes
No
I'm comfortable working with smokers in the home
(required)
Yes
No
I'm comfortable working with cats or dogs in the home
(required)
Yes
No
Section 5 -
Required Documents & Certifications
Current CPR & First Aid certifications, current Hawaii TB clearance, and COVID vaccination are required for ALL Care Professional positions. If hired, you must provide one document that establishes identity and one that establishes employment eligibility, or one that establishes both. Please see the list of acceptable documents for guidelines. If hired, you will be placed on conditional pre-employment until the following background checks have been completed: Original Criminal Abstract, Original Driving Abstract, Adult Protective Services (APS) Central Registry Check, and Child Abuse & Neglect (CAN) Central Registry Check. This information may be used as part of a background check of employment purposes and to comply with the requirements for various social services programs within Hawaii’s Department of Human Services, which may result in employment suspension or termination. I have read and understand this statement about the application process.
(required)
Yes
No
Do you have a current Hawaii TB Clearance (TST – Tuberculosis Skin Test / CXR – Chest X-ray)?
(required)
Yes
No
Do you have record of a 2-Step TB Clearance (required for Hawaii healthcare workers)?
(required)
Yes
No
Do you have a current Adult CPR certification (BLS meets this requirement)?
(required)
Yes
No
Do you have a current Adult First Aid certification (BLS does NOT meet this requirement)?
(required)
Yes
No
Evidence of COVID-19 vaccination (or a legitament exemption/waiver) is an employment requirement for Hawaii healthcare workers. Have you received -OR- do you plan to receive a COVID-19 vaccination?
(required)
Yes
No
Section 6 -
Authorization & Electronic Signature Disclosure
Authorization: "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed to give you all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release providers of reference information, as well as Wilson Care Group from all liability for any damage that may result from utilization of such information." Electronic Signature Disclosure: The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. By typing your name you are showing clear intent to sign an agreement electronically.
(required)
Yes
No
Electronic Signature (type your first and last name) & Today’s Date:
(required)
Effective Date
*
Signature
Submit Application