Caregiver Preference Checklist

Important: Please read the article "What you should know when hiring an in-home caregiver" prior to completing this form. Please select all that you are willing to work with: Home Health Agency Domestic Employment Agency "Word of Mouth" Caregivers For Home Health Agency: Date To Begin:__________________________ Live-in (24 hours) Mon-Fri Weekends only Split Shifts (i.e. 12/12) Come and go (4 hours minimum. Indicate times) Mon:______ Tues:_____ Wed:______ Thur:______ Fri:______ Sat:______ Sun:______ For Domestic Employment Agency/Word of Mouth Caregivers: Date to Begin:___________ Current immigration status is important Current immigration status is not important Live-in (24 hours) Mon-Fri Weekends only Split Shifts (i.e. 12/12) 24 hr. Live-in daily pay:______ Number of days off per week: ______ Live-in Weekend only pay: ______ Hourly pay for shifts:______ 24 hr. Live-in holiday pay:______ Hourly holiday pay:______ Come and go (6 hours minimum. Indicate times) Mon:______ Tues:_____ Wed:______ Thurs:______ Fri:______ Sat:______ Sun:______ Relief Caregiver Information ***A relief caregiver should be available for all live-in/hourly positions. If going through an employment agency it is customary that you pay an additional finder's fee for a regularly scheduled relief caregiver. There is no additional fee paid when going through a Home Health Agency. General Caregiver Preferences: (Please check all acceptable items) Male Female Smoker okay Non-smoker White Black Filipino Asian Hispanic Other Quiet/non-talkative Soft-spoken voice Outgoing Talkative Energetic Low-key Spiritual/Religious Likes dogs/cats Speaks good English Fair English Not important Valid Drivers License with own car Valid Drivers license (will use client's car) Drivers License not required Skilled nursing care required (RN, LPN) Companion Certified Nursing Assistant Homemaker Caregiver Tasks: Purchase Groceries Prepare Meals Type of Cooking______ Light Housekeeping Heavy Housekeeping (windows, floors) Assist with bathing and personal grooming Run Local Errands Handle day-to-day routine tasks (putting out garbage) Accompany to social/recreational activities Medication reminder Medication dispensing