Employment Kansas Personal Care Attendant Employment Questionnaire Interested in working as a Personal Care Attendant for individuals with disabilities? Services provided by a Personal Care Attendant typically includes activities such as: grooming and hygiene tasks, transfers/mobility, meal preparation, exercise, education, health maintenance activities, recreational or social activities, and other activities that promote independence for the individual in their home and in the community. If you are interested in providing care to an individual with a disability, please complete the questionnaire below. We will keep your information on file for 6 months and may contact you about potential work opportunities. Please note: Another Day Inc provides human resources support to individuals with disabilities enrolled in Kansas Medicaid. The Medicaid recipient is a domestic employer who employs care attendants to support them. If a Medicaid recipient requests information about potential care attendants, we will provide them your name and contact information. All Personal Care Attendants must complete State required background screenings. Please complete ALL fields below. Basic Information First Name Last Name Address City State ---KSMO Zip Code Home Phone Cell Phone Email Availability Minimum hours per week you are willing to work ---5 hours10 hours20 hours30 hours40 hours Maximum hours per week you are willing to work ---10 hours20 hours30 hours40 hours Days you are willing to work SunMonTueWedThurFriSat Times of day you are willing to work MorningsAfternoonsEveningsOvernights Maximum Distance you are willing to travel ---5 Miles10 Miles20 Miles30 Miles Education/Certificates High School Diploma/GED YesNo Do you have experience as a Caregiver? YesNo If so, how much? ---Less than 1 year1-2 yearsMore than 2 years Certificates CPRFirst AidL1MACNALPNMANDT/NCI Review & Submit How did you hear about us? ---Online AdFriend/Current EmployerFlyer/Paper Ad Please note: This is not an employment application. This is an online questionnaire that provides basic information about you and indicates your interest in a possible position, if one should become available in the future. 1 Above Homecare will keep your information on file for 6 months and may contact you during this time, if a position meeting your preferences becomes available. At that time, you may be asked to complete an employment application and undergo background checks.