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THE WHITEHEADS EMPLOYEE APPLICATION

Company Name:

Location:

Date of Application:

1) Applicant Information

Full Legal Name:

Preferred Name (if different):

Address:

City

State

Zip

Phone:

Choose one:

Cell
Home

Email:

Date of Birth:

Position Applying For:

Caregiver / Direct Support Professional (DSP)
Home Health Aide (Non-Medical)
Companion / Homemaker
Other:

Other:

How did you hear about us?

2) Work Eligibility

Are you legally authorized to work in the United States?

Will you be able to provide proof of eligibility if hired?

3) Availability & Scheduling

Date available to start:

Available shifts (check all):

Days
Evenings
Overnights
Weekends
Holidays

Days available (check all):

Duties: we a

Preferred hours per week:

Are you willing to work overtime if needed?

4) Transportation & Driver Requirements

Do you have reliable transportation?

Do you have a valid driver’s license?

Do you carry current auto insurance?

Are you willing to transport clients if assigned?

If yes, what vehicle do you drive (make/model/year)?

5) Education & Certifications

Highest level of education completed:

GED
High School Diploma
Some College
Associate
Bachelor
Other

Other:

School Name:

Year Completed:

Do you have any of the following? (check all):

CPR (current)
First Aid (current)
CNA
HHA training
DSP training/experience
Alzheimer’s/Dementia training
None

Upload/Provide copies at interview:

6) Employment History (Most Recent First)

Employer #1

Company:

Job Title:

Supervisor:

Phone:

Dates Employed:

From:

To:

Reason for leaving:

Duties:

May we contact this employer?

Employer #2

Company:

Job Title:

Supervisor:

Phone:

Dates Employed:

From:

To:

Reason for leaving:

Duties:

May we contact this employer?

Employer #3 (Optional)

Company:

Job Title:

Supervisor:

Phone:

Dates Employed:

From:

To:

Reason for leaving:

Duties:

May we contact this employer?

7) Home Care Experience & Skills

Check skills you are comfortable performing (non-medical):

Bathing assistance
Dressing
Toileting/incontinence care
Transfers/gait belt
Mobility assistance/ambulation
Meal prep
Light housekeeping
Laundry
Companionship/supervision
Dementia/Alzheimer’s care
Medication reminders only
Documentation/shift notes
Client transportation (if approved)

Comfort level working with:

Elderly
Dementia
Developmental disabilities
Behavioral clients
Hospice support (non-medical)

8) Background Disclosure (Required)

Have you ever been convicted of a felony or misdemeanor?

If yes, explain:

Have you ever had allegations of abuse, neglect, exploitation, or misconduct in healthcare?

If yes, explain:

9) References (Non-Relative Preferred)

Reference #1:

Name:

Relationship:

Phone:

Email:

Reference #2:

Name:

Relationship:

Phone:

Email:

Reference #3:

Name:

Relationship:

Phone:

Email:

10) Emergency Contact (For Employee File)

Name:

Relationship:

Phone:

Alternate

11) Applicant Acknowledgements (Initial Each)

Checkbox

I understand this application does not guarantee employment.
I understand I may be required to complete a criminal background check and registry checks, as permitted by Indiana law and agency policy.
I understand I may be required to complete a drug screen, TB test, and/or physical prior to hire or assignment.
I agree to maintain client confidentiality and follow HIPAA guidelines.
I understand abuse/neglect/exploitation must be reported immediately per company policy and state requirements.
I understand caregivers must follow the care plan, document services, and maintain professional boundaries.
I understand timekeeping must be accurate and truthful and may include EVV use if applicable.
I understand falsification of records may result in termination.

12) Applicant Certification & Signature

I certify the information in this application is true and complete to the best of my knowledge. I
understand that false or misleading information may result in disqualification or termination if hired.

Applicant Signature

Clear Signature

Printed Name

Date:

CAREGIVER ORIENTATION & NEW HIRE CHECKLIST (INDIANA)

Company Name:

Employee Name:

Position:

Caregiver
DSP
Homemaker/Companion
Other:

Other:

Start Date:

Date

Time

Supervisor/Trainer:

1) Hiring Packet & Identity Verification

Checkboxes

Employment Application completed & signed
Government-issued photo ID collected (for I-9)
I-9 completed (work authorization verified)
W-4 completed
Direct Deposit form completed (or pay card option)
Emergency Contact form completed
Employee handbook issued and acknowledged (signature)

2) Background & Screening Requirements

Checkboxes

Criminal background check completed/cleared
Registry checks completed (as required by company policy)
Reference checks completed (minimum: ____ references)
Drug screen completed (if applicable)
TB test completed (or chest x-ray on file)
Physical/fit-for-duty statement (if required)

3) Required Training & Competency (Non-Medical Care)

Checkboxes

Client confidentiality / HIPAA expectations
Client rights and dignity/respect
Abuse, neglect, and exploitation prevention & reporting
Professional boundaries & ethics
Infection control / universal precautions
Proper handwashing & PPE use
Fall prevention & home safety
Fire safety / emergency procedures
Documentation requirements (shift notes, task logs)
EVV training (if applicable)
Care plan overview & following authorized tasks only
Communication expectations (call-offs, scheduling, updates)

Skills Competency Check (Supervisor Initial)

Checkboxes

Proper transfer techniques (as allowed)
Mobility assistance / ambulation safety
Toileting assistance & peri-care basics
Bathing safety and dignity
Safe meal prep and dietary awareness
Medication reminders only (no administration)
Light housekeeping and infection prevention standards

4) Certifications (Attach Copies if Applicable)

Checkboxes

CPR certification current
First Aid certification current
CNA license (if applicable)
Other certification:

Exp:

5) Transportation / Driving Verification (If transporting clients)

Driver’s license verified
Auto insurance verified
Vehicle information recorded
Driving expectations reviewed (no texting, seatbelt use, client safety)
Approved for client transport:

Driver’s license verified (Exp: ____ /____ /____)

Auto insurance verified (Exp: ____ /____ /____)

Vehicle information recorded (Make/Model/Year): _______________________

Approved for client transport:

Yes
No
Not Applicable

6) Client Assignment Readiness

Uniform/dress code reviewed
Schedule availability confirmed
First client assigned
Care plan reviewed and understood
Start time confirmed and caregiver contact verified
Supervisor on-call procedure reviewed
Supplies needed issued (gloves, forms, PPE if applicable)

(Name/Case #):

7) Final Acknowledgement (Signatures)

Employee Signature:

Clear Signature

Date:

Trainer/Supervisor Signature:

Clear Signature

Date:

CAREGIVER / DSP JOB DESCRIPTION (NON-MEDICAL)

Company Name:

Job Title:

Caregiver
DSP
Homemaker/Companion

Reports To:

FLSA Status:

Hourly
Non-Exempt

Work Location:

POSITION SUMMARY

The Caregiver/DSP provides non-medical personal care, companionship, and supportive services to
clients in their homes to help maintain safety, dignity, and independence. Caregivers follow the client’s
care plan, document services provided, and communicate changes or concerns to the supervisor
promptly.

ESSENTIAL DUTIES & RESPONSIBILITIES

Personal Care Assistance (Non-Medical): bathing, grooming, dressing, toileting/incontinence care,
transfers/mobility assistance, and standby supervision (as trained/assigned).
Companion & Homemaker Services: companionship, meal preparation, light housekeeping (client
areas only), laundry/linens, errands/shopping (client funds), transportation (if approved).
Documentation & Communication: complete shift notes, use EVV if required, report changes or
incidents promptly.
Professional Conduct: arrive on time, follow the care plan, maintain respectful communication, follow
policies.

NON-MEDICAL LIMITATIONS (IMPORTANT)

Caregivers may not perform skilled nursing tasks such as administering medications/injections, wound
care, sterile dressing changes, diagnoses, or physical therapy services unless otherwise credentialed
and assigned within policy and state requirements. Medication support is limited to reminders only, per
policy.

MINIMUM QUALIFICATIONS

At least 18 years old; pass background screening; reliable attendance; ability to follow instructions and
document care; physically able to perform assigned duties.

ACKNOWLEDGEMENT

Employee Signature:

Clear Signature

Printed Name

Date:

CONFIDENTIALITY / HIPAA + EVV TIMEKEEPING AGREEMENT

Company Name:

Employee Name:

Position:

Date:

1) Confidentiality & Privacy Requirements

I understand that in the course of my employment I may learn confidential information about clients. I
agree to keep all client information confidential, discuss it only with authorized staff, protect
written/electronic records, and never share client photos or information on social media.

2) Professional Boundaries

I will maintain professional boundaries with clients and families. I will not borrow/lend money, accept
large gifts, use client funds without approval/receipts, bring unauthorized visitors, or engage in any form
of exploitation or misconduct.

3) EVV / Timekeeping & Documentation Standards

I agree to clock in/out accurately using EVV or approved methods, record times truthfully, never allow
another person to clock for me, never clock while not present (unless approved), and document
services honestly. Falsification may lead to termination and reporting when required.

4) Abuse, Neglect, and Exploitation Reporting

I understand I must report suspected abuse, neglect, or exploitation immediately to the agency and
follow reporting procedures.

5) Acknowledgement

Employee Signature:

Clear Signature

Printed Name

Date:

Supervisor/Witness Signature:

Clear Signature

Date:

Indiana State of Department of Health Contract # 21-015321-1

THE WHITEHEADS EMPLOYEE APPLICATION

1) Applicant Information

2) Work Eligibility

3) Availability & Scheduling

4) Transportation & Driver Requirements

5) Education & Certifications

6) Employment History (Most Recent First)

Employer #1

Employer #2

Employer #3 (Optional)

7) Home Care Experience & Skills

8) Background Disclosure (Required)

9) References (Non-Relative Preferred)

10) Emergency Contact (For Employee File)

11) Applicant Acknowledgements (Initial Each)

12) Applicant Certification & Signature

CAREGIVER ORIENTATION & NEW HIRE CHECKLIST (INDIANA)

1) Hiring Packet & Identity Verification

2) Background & Screening Requirements

3) Required Training & Competency (Non-Medical Care)

Skills Competency Check (Supervisor Initial)

4) Certifications (Attach Copies if Applicable)

5) Transportation / Driving Verification (If transporting clients)

6) Client Assignment Readiness

7) Final Acknowledgement (Signatures)

CAREGIVER / DSP JOB DESCRIPTION (NON-MEDICAL)

POSITION SUMMARY

ESSENTIAL DUTIES & RESPONSIBILITIES

NON-MEDICAL LIMITATIONS (IMPORTANT)

MINIMUM QUALIFICATIONS

ACKNOWLEDGEMENT

CONFIDENTIALITY / HIPAA + EVV TIMEKEEPING AGREEMENT

1) Confidentiality & Privacy Requirements

2) Professional Boundaries

3) EVV / Timekeeping & Documentation Standards

4) Abuse, Neglect, and Exploitation Reporting

5) Acknowledgement