Employment Application Which division are you applying for? Home and Community-Based Services Assisted Living & Customized Living (AL/CL) HCBSPersonal InformationStaffing PreferencesPreferred Gender of StaffMaleFemaleNo PreferencePreferred ScheduleMorningAfternoonEveningOvernightFlexibleLanguage PreferredEnglishSomaliSpanishHmongOromoOtherReferral InformationHave you made multiple referrals with different companies?YesNoLiving SituationOwn HomeFamily HomeApartmentFoster CareAssisted LivingOtherFunding InformationPayorMedical Assistance (MA)MedicaUCareBridgeviewHealthPartnersOtherPMI Number (Optional)Waiver TypeCADIBIDDEWOtherIndividual InformationDiagnosesAllergiesSmoker?Behavioral Concerns (Optional)Mobility Concerns (Optional)Support Team InformationRecent Hospitalizations (Last 6 Months)YesNoServices NeededBasic Support Services24-Hour Emergency Assistance (24EA)Adult Companion ServicesHomemakerIndividual Community Living Supports (ICLS)Individualized Home Supports (IHS)Night SupervisionRespite Care (In-Home)Respite Care (Out-of-Home)Employment ServicesEmployment Development ServicesEmployment Exploration ServicesEmployment Support ServicesIn-Home Support ServicesIndividualized Home Supports with Family TrainingIndividualized Home Supports with TrainingSemi-Independent Living Skills (SILS)Service InformationGoals & OutcomesDocument UploadsCSSPChoose File Service AuthorizationChoose File Support PlanChoose File CSSP AddendumChoose File AssessmentChoose File Other Relevant DocumentsChoose File Additional InformationSubmit Referral Assisted Living & Customized LivingPersonal InformationPreferred Contact MethodPhoneTextEmailAddress InformationHow far are you willing to travel for shifts?0–10 Miles10–20 Miles20–30 Miles30–50 Miles50+ MilesDo you currently hold a valid driver's license?YesNoDo you currently have auto insurance?YesNoDo you currently carry auto insurance?YesNoEligibility & Background InformationAre you legally authorized to work in the United States?YesNoHave you ever been convicted of a felony?YesNoHave you ever been disqualified from working in healthcare or assisted living services?YesNoHave you ever been substantiated for abuse, neglect, or maltreatment?YesNoAre you able to pass a Minnesota DHS background study?YesNoAre there any restrictions that would prevent you from safely performing job duties?YesNoPosition InformationWhich position(s) are you applying for?Full-Time DSPPart-Time DSPMorning Shift DSPAfternoon ShiftCommunity Support StaffHomemakerRespite WorkerEmployment SpecialistFloat StaffOn-Call StaffDesired Employment TypeFull-TimePart-TimeMorning ShiftAfternoon ShiftEvening ShiftOvernightCasualWeekends OnlyShift AvailabilityShift TypeYesNoShift TypeMorningsAfternoonsEveningsOvernightWeekendsHolidaysWeekly AvailabilityDayMondayTuesdayWednesdayThursdayFridaySaturdaySundayShift TypeMorningsAfternoonsEveningsOvernightExperience & QualificationsDo you have previous healthcare, assisted living, caregiving, HHA, CNA, DSP, PCA, or nursing support experience?YesNoWhich populations have you supported?Elderly IndividualsDementia / Memory CarePhysical DisabilitiesMental HealthDevelopmental DisabilitiesBehavioral Support NeedsHospice / End-of-Life CareYears of ExperienceLess than 1 Year1–2 Years3–5 Years5+ YearsSkills & CompetenciesDo you have experience with:Medication Administration Yes NoBathing & Grooming Assistance Yes NoTransfers & Mobility Assistance Yes NoDementia Care Yes NoDocumentation / Charting Yes NoVital Signs Monitoring Yes NoPersonal Care Assistance Yes NoMeal Preparation Yes NoMechanical Lift Experience Yes NoBehavioral Support Yes NoInfection Control Procedures Yes NoHousekeeping Yes NoEducation InformationDid you graduate?YesNoDid you graduate?YesNoCertifications & LicensesCPR Certified? Yes NoCPR Certified? Yes NoMedication Administration Training? Yes NoUpload CertificationsChoose File HHA Certified? Yes NoFirst Aid Certified? Yes NoEmployment HistoryMost Recent EmployerWas this role healthcare or assisted living related? Yes NoPrevious EmployerProfessional ReferencesReference #1Reference #2Document UploadsUpload ResumeChoose File Upload Auto InsuranceChoose File Upload CPR / First Aid CertificatesChoose File Upload Driver’s LicenseChoose File Upload CNA / HHA CertificatesChoose File Upload Additional DocumentsChoose File Important QuestionAre you comfortable working independently with residents? Yes NoAre you willing to complete required assisted living training? Yes NoAre you comfortable documenting services electronically? Yes NoAre you comfortable assisting residents with personal cares? Yes NoApplicant AcknowledgementPlease read and acknowledge the following: I understand employment is contingent upon passing all required background studies. I understand this position may require lifting, transfers, personal cares, and direct resident support. I understand accurate documentation and resident confidentiality are required. I understand all staff must follow assisted living policies, resident rights, infection control procedures, and safety standards. I certify the information provided is accurate and complete.Electronic SignatureApplicant SignatureChoose File Submit Form HCBSPersonal InformationStaffing PreferencesPreferred Gender of StaffMaleFemaleNo PreferencePreferred ScheduleMorningAfternoonEveningOvernightFlexibleLanguage PreferredEnglishSomaliSpanishHmongOromoOtherReferral InformationHave you made multiple referrals with different companies?YesNoLiving SituationOwn HomeFamily HomeApartmentFoster CareAssisted LivingOtherFunding InformationPayorMedical Assistance (MA)MedicaUCareBridgeviewHealthPartnersOtherPMI Number (Optional)Waiver TypeCADIBIDDEWOtherIndividual InformationDiagnosesAllergiesSmoker?Behavioral Concerns (Optional)Mobility Concerns (Optional)Support Team InformationRecent Hospitalizations (Last 6 Months)YesNoServices NeededBasic Support Services24-Hour Emergency Assistance (24EA)Adult Companion ServicesHomemakerIndividual Community Living Supports (ICLS)Individualized Home Supports (IHS)Night SupervisionRespite Care (In-Home)Respite Care (Out-of-Home)Employment ServicesEmployment Development ServicesEmployment Exploration ServicesEmployment Support ServicesIn-Home Support ServicesIndividualized Home Supports with Family TrainingIndividualized Home Supports with TrainingSemi-Independent Living Skills (SILS)Service InformationGoals & OutcomesDocument UploadsCSSPChoose File Service AuthorizationChoose File Support PlanChoose File CSSP AddendumChoose File AssessmentChoose File Other Relevant DocumentsChoose File Additional InformationSubmit Referral
