Application for Employment Form

Directions:

Please complete ALL aspects/sections of the application. All information given will be held in strict confidence. Incomplete applications will not be considered.

purpose of the position:

The primary purpose of the Direct Support Professional (DSP) position is to provide training and/or assistance for individuals we support in hygiene, nutrition, housekeeping, behavioral management, safety, healthcare, and other daily activities both within the home and the community; also to maintain the home/property in a safe and sanitary manner.

essential position functions:

Hygiene: bathing, tooth brushing, shaving, hair care, nail care, etc
Toileting, dressing, nutritional management, physical management/including prosthetic devices, behavioral management, safety, housekeeping, money management, recreation, health care, and community integration.
Administer medications, maintain medication records-including MAR form, TAR form, med count sheets, and all the aspects of medication administration systems.
Perform assigned Register Nurse delegated/trained medical tasks which may include but are not limited to: medication administration via G-tube, diabetic procedure and other medical duties as assigned. Complete the appropriate documentation as necessary.
Provide support for individuals by maintaining the observation skills necessary to identify behavioral/health changes or needs and immediately report to Program manager, administrative director, clinical director or RN.
Document information relevant to the individuals health and welfare. Aiding health professionals and the program in understanding the individuals history, as well as, providing for current and future needs.
Perform general interior and exterior housekeeping and basic repairs including but not limited to: laundry, vacuuming, grounds upkeep, meal preparation, food handling, and storage, maintenance of prosthetic and positioning equipment, cleaning bathrooms, light painting, doorknob replacement, etc.
Participate in meetings and attend mandatory trainings as required/assigned.
Maintain a safe environment. Report any concerns to the Program Manager. Participate in emergency evacuation/safety checks. Follow proper nutrition management, physical management, and behavioral intervention techniques and principals as trained.
Follow established policies, procedures, and guidelines.
Perform other duties as assigned.

working conditions:

Works in a home environment staffed seven days a week/24 hours per day. Schedules can vary on start times and length of shift. The shifts break down in the following way: Day shift 0700-1500, Swing shift 1500-2300, Awake Noc Shift 2300-0700. We also have a flex shift that start at different times depending on the house and client needs (example 1200-2000).

Authority:

Decides and reports any special problems that occur to supervisors and brings any medical/behavioral concerns to supervisor. Decisions are generally situational and could not only impact the health and safety of individuals supported, but could also impact housemates, employees, and/or people within the community.

Basic health decisions may involve: identifying and taking action in the event of illness and/or injury, PRN medication administration, etc.

Basic safety decisions may involve: evaluating the need for assistance, behavior intervention, change in environment, evacuation, activating safety locks and/or alarms, defensive driving techniques, increased supervision, etc.

Contacts:

Will have contact with Physicians, Consultants, Parents/Guardians, Public Persons, Program Manager, Service Coordinators, Administrative Director, Clinical Director for the purpose of exchanging medical and/or other client related information on a daily or as needed basis.

position requirements:

Must be at least 18 years of age
High school Diploma or equivalent
Be able to pass a background check
Must maintain a valid driver’s license and an acceptable driving record
Must be able to read and write proficiently and legibly in English
Oregon Intervention System Certification (provided if hired)
CPR/First Aid ceriftication (provided if hired)
Medication Administration (provided if hired)
Frequent daily lifting up to 75lbs
Must be able to engage and maintain (OIS) approved PPI’s for up to 1 hour (training provided if hired)
Frequent daily squatting, bending, and stooping
Daily contact with individuals who are potentially argumentative, aggressive, destructive, harmful, offensive, and display dangerous behaviors to self or others
Daily exposure to household and sometimes industrial strength cleaning agents
Exposure to a variety of work settings both within the homes and community
Occasional exposure to inclement weather
Occasionally participate in water activities with the individuals as assigned
Must be able to work overtime as needed/required to provide necessary staffing and support for individuals- 7 days a week/24 hours a day
Frequent daily transportation of individuals utilizing wheelchair accessible vehicles, passenger vans, mini vans and/or standard size cars. You must have the ability to drive a car or van
Frequent contact with the public and other agency personnel

Applicant Information * Affirmative Action/Equal Opportunity Employer/Drug-Free Workplace
* If offered employment and accepted, you are required by law to show proof of eligibility to work in the United States.

Full Name (First, Middle, Last):

First Name

Middle Name

Last Name

Address Information:

Address

Apt #

City

State

Zip

Contact Information:

Phone Number

Alternate Phone

Date Available to start:	Date
Are you at least 18 years of age?		Yes	No
Have you ever applied to this company before?		Yes	No	If yes, when?	Date mm/dd/yyyy
Have you ever worked for this company before?		Yes	No	If yes, when?	Date mm/dd/yyyy
Are you legally allowed to work in the United States?		Yes	No

scheduling information:

I am seeking a permanent position?

Yes

Type of employment desired:
Full	Part	Temporary	On-Call	No Preference

Available:
Mon	Tues	Wed	Thurs	Fri	Sat	Sun

Shift Availability:
Any	Day (7am-3pm)	Evening (3pm-11pm)	Night (11pm-7am)

Are you willing and available to work overtime?
Yes	No

Do you have friends or relatives employed at this company?
Yes	No	Name

Do you have access to reliable transporation?
Yes	No

Is there any reason you would not be able to be at work, on time, every day?
Yes	No

If you answered yes, please explain what might prevent you from being dependable and steadily performing all of the work applied for in this application:

If employed, what needs do you have for time off from work?

Physical information: you are not required to disclose information about a physical or mental limitations that you believe will not interfere with your capability to perform the essential functions of the work for which you are applying. If you want us to consider special arrangements to accommodate a physical or mental impairment, you may identify that impairment in the space provided below and suggest the kind of accommodation that you believe would be appropriate:

Have you ever had any founded reports of child abuse or substantiated adult abuse?
Yes	No

Education Information:

High School:

High School
Did you graduate?
Yes	No
Did you receive a diploma?
Yes	No
Did you receive a GED?
Yes	No

College:

College
Years Completed:
1	2	3	4

Did you graduate?
Yes	No

Degree or Certificate

Major/Courses

Graduate School:

Graduate School
Years Completed:
1	2	3	4

Did you graduate?
Yes	No

Degree or Certificate

Military Infoarmation:

Are you a veteran?
Yes	No

Duty/Specialized Training

Skills and Qualifications:

How proficient are you at navigating a computer and using the internet on a scale of 1 to 5 (5 being the best):
1	2	3	4	5

How many words per minute do you type?

Have you ever been or are currently CPR trained?
Current	In the Past	Never
Have you ever been or are currently First Aid trained?
Current	In the Past	Never
Other qualifications such as special skills, abilities, or honors that should be considered (including other languages or things related to this field you wish to bring to our attention such as past work with people with developmental disabilities and in emergency procedures):

References:
References will be checked. Please provide only verifiable references. You must include 1 personal reference who is a member of your family. Additionally, please list 2 professional references who are not related to you (professor, supervisor, co-worker, etc). We do not collect social security numbers. If any of your references require a social security number to confirm information, please call us with that information.

Personal Reference:

First Name	Last Name	Phone Number	Occupation
How long have you known them?

Professional Reference:

First Name	Last Name	Phone Number	Company
Work Relationship (co-worker, supervisor, etc.)

2nd Professional Reference:

First Name	Last Name	Phone Number	Company
Work Relationship (co-worker, supervisor, etc.)

Employment History:
Please list the names of your present & previous employers in chronological order (with present or most recent employer listed first). You may also include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment.

1. Current/Most Recent Employer:

Employer

Address

Type of business

Phone Number

Dates employed from:

Start Date mm/dd/yyyy

End Date mm/dd/yyyy

Job Title

Duties

Supervisor Name

Supervisor Title

Starting Wage

Final Wage

Reason for Leaving

What will this employer say was the reason your employment ended?

Your duties and responsibilities:

How much notice did you give when resigning?
If none, please explain:

2. Next Previous Employer:

Employer

Address

Type of business

Phone Number

Dates employed from:

Start Date mm/dd/yyyy

End Date mm/dd/yyyy

Job Title

Duties

Supervisor Name

Supervisor Title

Starting Wage

Final Wage

Reason for Leaving

What will this employer say was the reason your employment ended?

Your duties and responsibilities:

How much notice did you give when resigning?
If none, please explain:

3. Next Previous Employer:

Employer

Address

Type of business

Phone Number

Dates employed from:

Start Date mm/dd/yyyy

End Date mm/dd/yyyy

Job Title

Duties

Supervisor Name

Supervisor Title

Starting Wage

Final Wage

Reason for Leaving

What will this employer say was the reason your employment ended?

Your duties and responsibilities:

How much notice did you give when resigning?
If none, please explain:

4. Next Previous Employer:

Employer

Address

Type of business

Phone Number

Dates employed from:

Start Date mm/dd/yyyy

End Date mm/dd/yyyy

Job Title

Duties

Supervisor Name

Supervisor Title

Starting Wage

Final Wage

Reason for Leaving

What will this employer say was the reason your employment ended?

Your duties and responsibilities:

How much notice did you give when resigning?
If none, please explain:

Have you ever been discharged or asked to resign from any job?
Yes	No	If Yes, how many times?
Has your employment ever been terminated by mutual agreement?
Yes	No	If Yes, how many times?
Have you ever been given the choice to resign rather than be terminated?
Yes	No	If Yes, how many times?
If you answered yes to any of the above 3 questions, please explain the circumstances of each occasion:

Please explain in regards to any gaps in your employment history in excess of one month:

Have you ever been disciplined for attendance or lateness problems?
Yes	No
If yes, please explain:

Driving History:

Authorization for release of motor vehicle records:

I understand that my motor vehicle record will be ordered periodically to determine my eligibility to drive a company vehicle. In accordance with the Fair Credit Reporting Act, I acknowledge the receipt of the above disclosure and authorize Supported Independence Services of Oregon (SISO) or their designated agent to obtain my motor vehicle record. This authorization is valid as long as I am an employee or employee candidate and many only be rescinded in writing.

By checking this box, I agree to the terms listed above

Driver License Information:

State

Class

Number

Expiration

Driving Record (last 3 years):

Number of tickets:
Number of accidents:
Do you have automobile liability insurance?
Yes	No
Company providing policy:

How did you hear about us?

Craigslist Ad
Website
Previous employee
Previous Employee Name
Current employee
Current Employee Name
Other
Please explain

Employment Disclosure:

I understand and agree that driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the company has a drug free work place. I understand that if a pre-employment drug test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. If employed, I understand that the taking of drug test is a condition of continual employment and I agree to undergo drug testing consistent with company policies and applicable federal, state, and local law.

I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or if employed disciplinary action up to and including immediate dismissal. I authorize the company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization form for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above mentioned information. I hereby release, discharge and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the company and its representatives for seeking such information and all other persons corporations or organizations furnishing such information.

If hired by the company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this company. I also understand that the company employs only individuals who are legally eligible to work in the United States.

This application will be considered active for a maximum of sixty (60) days, if you wish to be considered for employment after that time, you must reapply.

I certify that all of the information I have provided on this application is true, accurate, and complete.

This agency has my permission to contact references and previous employers as work references.

Applicants conditionally accepted for employment will be required to complete a criminal history/background check. Being hired by SISO is conditional pending an approved criminal history/background check.

If hired, your name or picture may appear in our company newsletter or on our company website. Information relating to achievements within the company, as well as employee birthdays (not birth year) may also be shared in our newsletter or on our website. If employees wish to refrain from either of these publications, please submit a written request to our administrative office.

AUTHORIZATION FOR RELEASE OF INFORMATION

As part of my employment with SISO, I hereby consent to and authorize the release of any and all information that may be considered in evaluation my qualifications for employment.

I therefore release all parties and persons connected with this request from all claims, liabilities, and/or damages arising out of providing such information.

By checking this box, I agree to the terms listed above

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