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Pre-Interview Candidate Screening Checklist
Candidate Basic Information
Full Legal Name
*
Preferred Name
Phone Number
*
Email Address
*
Current Complete Address
*
Transportation & Reliability
Reliable Transformation?
*
Reliable Transformation?
A
Yes
B
No
Primary Transportation
*
Primary Transportation
A
Personal Vehicle
B
Public Transportation
C
Ride Share
D
Other
Valid Driver’s License (if driving):
*
Valid Driver’s License (if driving):
A
Yes
B
No
Vehicle insured (if driving):
*
Vehicle insured (if driving):
A
Yes
B
No
Able to travel to client locations as scheduled?
*
Able to travel to client locations as scheduled?
A
Yes
B
No
Availability
Days available:
*
Days available:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred shift:
*
Preferred shift:
Day
Evening
Overnight
Flexible
Minimum hours per week available:
*
Experience & Credentials
Prior caregiving experience?
*
Prior caregiving experience?
A
Yes
B
No
Years of experience
*
Certifications
*
Certifications
CPR
First Aid
HHA
CNA
None
Compliance Readiness
Willing to undergo a background check?
*
Willing to undergo a background check?
A
Yes
B
No
Willing to complete TB/Physical?
*
Willing to complete TB/Physical?
A
Yes
B
No
Authorized to work in the U.S.?
*
Authorized to work in the U.S.?
A
Yes
B
No
Communication
Preferred contact method
*
Preferred contact method
Text
Phone
Email
Able to respond promptly to agency communications?
*
Able to respond promptly to agency communications?
A
Yes
B
No
I confirm all information provided is true.
Signature
*
Date
*
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Office Use Only
Meets basic requirements?
Yes | No
Proceed to full interview?
Yes | No
Notes
Submit
