Online Job Application

Online Application for Employment with Kokua Care
All fields marked with red asterisk • are required
Job Name *
NOTE If you don't know the job name click here to see all current jobs.
First Name *
Middle Initial
Last Name *
Present Mailing Address *
City *
State *
Zip Code *
Home Phone *
Cell Phone
E-mail Address

Work Availability

Specify how many hours; for example 8 hours on Monday (just input the number only); you are available on each day. The amount of work we can assign depends on your flexibility...
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What areas would you prefer to work in? (Please check all areas you would consider. The amount of work we can assign depends on your flexibility.)
Preferences
No PreferenceWEST: WaianaeWEST: MakakiloWEST: KapoleiWEST: Ewa BeachCENTRAL: WahiawaCENTRAL: MililaniCENTRAL: WaipahuCENTRAL: Pearl CityCENTRAL: AieaNORTH: WailuaNORTH: HaleiwaNORTH: WaimeaWINDWARD: LaieWINDWARD: HauulaWINDWARD: KaneoheWINDWARD: KailuaWINDWARD: WaimanaloEAST: Hawaii KaiEAST: Niu ValleyEAST: Aina HainaTOWN: KalihiTOWN: HonoluluTOWN: ManoaTOWN: WaikikiTOWN: Kahala
Date available for work:
Month
Day
Year
Other Skills:
Professional Licenses:

Educational Background

High School:
School;City;State
Degree/Certificate
Graduated?
YesNo
College
School;City;State
Degree/Certificate
Graduated?
YesNo
Nursing School:
School;City;State
Degree/Certificate
Graduated
YesNo
Technical Training:
School;City;State
Degree/Certificate
Graduated?
YesNo

Employment History

Instructions Include information pertaining to patient care, starting with the most recent.
Employer 1
Job Title
Work City
Work State
Telephone
Date Started:
Date Ended:
Reason For Leaving
Employer 2
Job Title
Work City
Work State
Telephone
Date Started:
Date Ended:
Reason For Leaving
Employer 3
Job Title
Work City
Work State
Telephone
Date Started:
Date Ended:
Reason For Leaving
May we call your employers?:
YesNo
If no please explain:
Please describe your most recent hospital, home care, or medical related experience:

Questionnaire:

All questions in this questionaire are required to be answered.
Have you ever been convicted…, *
YesNo
if yes, please explain:
Have you been fired in the last ten years? *
YesNo
if yes, please explain:
Have you been employed or attended school using any other name? *
YesNo
if yes, please explain:
Do you have the legal right to be employed in the United States? *
(If hired, you will be required to provide identification to prove eligibility for employment):YesNo
Have you ever been convicted, pled guilty or no contest, or forfeited bond on bail for any crime other than traffic violations? :
YesNo
if yes, please explain:
As a caregiver, you may be required to manually lift or transfer a patient. The average weight may be 70 lbs. Will you be able to do that? If no, please explain *
YesNo
if yes, please explain:
Do you have any employment restrictions resulting from a non-compete or confidentiality agreement? *
YesNo
if yes, please explain:
Are you willing and able to drive for our clients using their car? *
YesNo
Are you willing and able to drive for our clients using our car? *
YesNo
if yes, please please provide insurance information:
How did you hear about us?

What Would Do? Professional Response Section

Please answer the following questions to the best of your knowledge.
Question #1 *
You are with a client who has mild dementia and their care-plan states that they should not be left alone. The client tells you to leave 15 minutes before her spouse plans to be home. She insists that she will be fine, and becomes agitated when you tell her that you need to stay until her husband returns. What would you do?
Question # 2 *
Your client has high blood pressure medication that is only to be taken if his diastolic pressure is over 100. His blood pressure is 146/82. Do you give him his medication?
Question #3 *
Your client asks you to work outside of your normally scheduled hours, and wants to pay you in cash. What would you do?
Question #4 *
Your client, Mrs. Kauhane has some old jewelry that she wants to give to you. She insists that her children do not want the jewelry, and because you have been so kind to her, she wants you to have it. What do you do?
Question #5 *
A client that you only visit once a week has some redness around the tailbone area. This client is not very mobile,and usually spends his day sitting in a recliner, watching TV all day. What would you do?
Question #6 *
Your client is bed bound, and has had a BM. You have changed his Depends, and now are preparing to give him a bed bath. As per Universal Precaution Guidelines, what should you do before giving him his bath, or performing any other personal care or ADL’s?
Question #7 *
Your client has a cold, but refuses to take his cough syrup. What do you do?
Question #8 *
Your client slipped and fell while you were on shift. What do you do?
Question #9 *
Your client has diabetes and is on insulin. You have been trained to take his blood sugar, and when you test his BS, it is unusually low. What do you do?
Agreement Agreement: Please read the following statements carefully and indicate you have done so by entering your name and today's date in the fields below:

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release providers of reference information, as well as Kokua Care LLC ufrom all liability for any damage that may result from utilization of such information."
Name: First and Last *
Date Today: *

Instructions

All documents below must be provided before being interviewed with our company.

Current CPR card Current First Aid card Current TB clearance Professional License (if applicable) (RN, LPN, CNA certificate)

If you are offered a position with Kokua Care proof of work eligibility must be presented.

Identifying Document (i.e. driver's license or ID card) Employment Eligibility (i.e. US Social Security card

You will be placed on conditional employment with our company until the following background checks have been completed.

Original Criminal Abstract Original Driving Abstract (only if you drive) Adult Protective Services (APS) Central Registry Check Child Welfare Services (CWS) Central Registry Check

Thank you for your interest in Kokua Care

Verification

Please enter any two digits with no spaces (Example: 12) *
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Online Application for Employment with Kokua Care

Work Availability

Educational Background

Employment History

Questionnaire:

What Would Do? Professional Response Section

Verification

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