Direct Care Worker Request for Information DOWNLOAD A PRINTABLE VERSION OF THIS DOCUMENT: Word or PDF Soreo® In Home Support Services, LLC is an administrator of in-home support services whose business is to obtain and/or administer contracts for in-home services for clients who are eligible for Arizona’s Long Term Care System or for eligible services through other public and private entities by subcontracting with professional independent caregivers. Soreo® In Home Support Services, LLC is seeking to hire qualified Direct Care Workers who are professional independent caregivers in the business of providing in-home support services. The material requested in this document is to provide Soreo® In Home Support Services, LLC with information to determine if your qualifications match Soreo® In Home Support Services, LLC’s current needs. Please respond fully to each question. Referred by (optional): Personal Information Your Name (required) Your Email (required) Please leave this field empty. Home Telephone (required) Cell Telephone Other Telephone Address, City, State, Zip (required) Mailing Address (if different from physical address) Have you ever interviewed with Soreo or its affiliates before? YesNo If yes, list date(s), job title(s), & location(s) Have you ever been employed by Soreo or its affiliates before? YesNo If yes, list date(s), job title(s), & location(s) Do you have any relatives employed by Soreo or its affiliates? YesNo If yes, list date(s), job title(s), & location(s) DCW Qualifications There are certain requirements that must be met to provide Direct Care Worker services to Soreo clients. Do you have the following (a "No" answer may not preclude you from obtaining a contract as you will have the opportunity to be compliant with these requirements): Do you have DCW training certification? YesNo Do you have experience using a Hoyer lift? YesNo Do you have experience using a gait belt? YesNo Do you have experience cooking? YesNo Do you have experience ironing? YesNo Will you offer DCW services in the home of a smoker? YesNo Will you offer DCW services in a home with pets? YesNo .............................Large dogs? YesNo .............................Cats? YesNo Do you have Article 9 certification? YesNo Do you have "Prevention and Support" (CIT) training certification? YesNo Are you CPR certified? YesNo Are you First Aid certified? YesNo Can you provide Tuberculosis free test results? YesNo Do you have Level 1 Fingerprint clearance? YesNo DCW's are required to clear certain background checks. Is there anything in your history that may preclude you from obtaining clearance related to: Child Protective Services background check? Level 1 Fingerprint through the Arizona Department of Public Safety? List of Excluded Individuals and Entities (LEIE) through the Federal govt? YesNo Education Highest grade completed: 9 (High School)10 (High School)11 (High School)12 (High School)1 (College)2 (College)3 (College)4 (College)More than 4 years of College School Address Major Studies Degree, Diploma, License, or Certification High School High School Address Major Studies Diploma earned College/University College Address Major Studies Degree or Certificate earned Vocational/Business Vocational/Business School Address Major Studies License/Certificate earned List any Professional Designations Primary Language Spoken (required) Other Languages Spoken Other Special Knowledge, Skills or Qualifications Work History List all work history for the past 10 years, starting with the most recent. All information must be completed. You may attach a resume, but not in place of completing the required information. JOB 1 (REQUIRED) Begin Date (required) End Date (required) Employer/Contractor Name (required) Employer/Contractor Address (required) Supervisor Name (required) Supervisor Phone (required) Starting Salary/Rate (required) Ending Salary/Rate (required) Job Title (required) Reason for Leaving (required) Duties & Responsibilities (required) JOB 2 Begin Date End Date Employer/Contractor Name Employer/Contractor Address Supervisor Name Supervisor Phone Starting Salary/Rate Ending Salary/Rate Job Title Reason for Leaving Duties & Responsibilities JOB 3 Begin Date End Date Employer/Contractor Name Employer/Contractor Address Supervisor Name Supervisor Phone Starting Salary/Rate Ending Salary/Rate Job Title Reason for Leaving Duties & Responsibilities If you have any other positions to list, please do so here: Related Work Information What date are you available to start? Please describe your availability on the following days (required): Work Locations: (check all areas you are interested in offering your services as a DCW) Tucson Central TucsonNorth TucsonSouth TucsonEast TucsonWest TucsonMarana/Avra ValleyGreen Valley/SahuaritaVail/Rita RanchOro ValleyCatalinaSaddlebrookOracleSan Manuel Casa Grande Casa GrandeMaricopaHidden ValleyArizona CityCoolidgeEloyFlorenceStanfield Phoenix Central PhoenixNorth PhoenixSouth PhoenixEast PhoenixWest PhoenixScottsdaleTempeGlendaleParadise ValleyChandlerLitchfield ParkPeoriaWickenburgCave CreekQueen CreekGilbertGoodyearMesaFountain HillsCarefreeBuckeyeAvondaleGuadalupeSurpriseTollesonEl MirageYoungtownApache Junction References (Required) Name Address Telephone Name Address Telephone Name Address Telephone Name Address Telephone Certification & Authorization The information provided herein is true and correct. I understand that, in the event of contracting with Soreo, my contract may be terminated if any information that I have given herein, or if any other information I provide to Soreo, is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize Soreo to inquire into my educational, professional, and past work history and to contact my references as needed to research my qualifications to be a Direct Care Worker. I hereby give my consent to any former employer or contractor to provide work-related information about me to Soreo and will hold Soreo and my former employer/contractor harmless from any claim made on the basis that such information about me was provided or that any contract decision was made on the basis of such information. I understand that nothing in this Request for Information, the granting of an interview or my subsequent contracting with Soreo is intended to guarantee a contract with Soreo. I hereby acknowledge that I have read and agree to the above statements.