Online Screening Questionnaire

Please complete the form below and hit the submit button.

Name:*
Address:*
E-mail:
Phone:
-
Do you have a cell phone where you can be reached 24 hours?*
Cell phone number if you have one:
-
Driving Info
Do you have reliable transportation?*
Do you have a current driver license?*
Do you have current car insurance?

How far are you willing to drive?

Miles:
Minutes:
Availability
Employment Status Preference:
What county will you drive to?

What days are you available to work?

Weekdays:
Weekends:
What shifts preferred?
Shift duration preferred:
Are you currently a student?*
If a student, where?:
Are you currently working another job?
If yes, where?:
Were you previously employed by Medical Professional, Inc. (MPI Home Care)?
Skills

Please state the months or years of experience in the following work environments.

Indep. Living
Hospital
Hospice
Home Care
Assist. Living
Group Home
Nursing Home:
How many total years do you have in direct patient care?

Do you have any of the following specific skills?

Straight Catheter Insertion
Select:
´╗┐Certificates

Do you have the following certification/ training?

CNA
HHA
Companion/Homemaker
MORC
PCT
Comments
Comments:
Area(s) of Interest: