Mar 25, 2013 0 Share

Caregiver Questionnaire



School Address: _____________________________________________________________              

Home Address:______________________________________________________________              

School Phone: __________Home Phone ____________Cell:_____________Carrier_______          

Email Address:______________________________________________________________               

Preferred way of communicating:_______________________________________________             


What hours are you available during the following times:

_____ Semester

Monday           Tuesday           Wednesday            Thursday          

Friday          Saturday           Sunday                 

Any planned vacations or absences?_____  Dates:_____ 

Range of Hours           Minimum                     Maximum

_____Semester            _______                      ________

_____Semester            _______                      ________ 

When could you start working?_____

Are you willing to do overnights? _____

Are you willing to do weekends? _____

How long would you commit to a family? ___________________________________________       


What job situation(s) do you feel most comfortable with?

Infant/Toddlers:____School age: _____Teens: ____Adults needing assistance:_____

What is your preference?        _____________________________________________________      

Have you worked with children with special needs?___ Autism?____ Please describe your experience.                                                                                                                

Have you had experience with disabled adults or the elderly? ___


What are your educational interests and plans? ________________________________________  


What are your interests outside of school and work?___________________________________   


­On a scale from 1 – 10 (1=low; 10=high) rate your:

Energy level_____

Quick learner_____

Organizational skills_____

Attention to detail_____


Directness/Communication skills_____



Flexibility of schedule_____


Work efficiently_____

Sense of direction_____

Willingness to learn_____

Salary Expectation     

Hourly $_____

24-hour overnight $_____


 Check if you are willing to do or assist with:

_____              Laundry

_____              Meals

_____              Run errands

_____              Change linens

_____              Run dishwasher, put away dishes

_____              Light vacuuming, dusting

_____              Organizational projects (household and administrative)

_____              Tidy living areas

_____              Mop kitchen floor

_____              Ironing

_____             Assist, or drive with assistance, person with autism to school/camp

_____              Drive mini-van for transportation assistance

_____              Walk/feed dog

_____              Scoop out kitty litter

_____              Dog sit: Overnight___ Extended stays_­__ 


Any pet allergies?_____

Like dogs?___ Cats?_____ Owned or cared for either? _______________________________        

Do you swim?_____

Have you watched children in a pool?_____

Own transportation?_____ Year/size _____

Have you transported people in your care in your car?_____

Have you transported pets in your car?_____

Willing to drive others in your car?_____

Food allergies?_____

Enjoy cooking or meal preparation?_____

Favorite meals to prepare?_________________________________________________________      


What do children/those you care for like most about you? 


What do parents/employers like most about you?


What do you feel are your strengths of your caregiving? 


Any improvement areas?


Reason you applied for this job?


References (Please give at least two)

1) Name:


    Dates of Employment:

    Ages of People Cared For:

2) Name:


    Dates of Employment:

    Ages of People Cared For:

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