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CARE@SUMALAHEALTH.COM
AGENCY
STATEMENT
EMPLOYMENT
PRIVATE SITTER
PRIVATE CAREGIVER
CERTIFIED NURSE ASSISTANT
LICENSED VOCATIONAL NURSE
CARE
SERVICE OVERVIEW
SERVICE APPLICATION
CONNECT
COMMUNICATIONS
RESOURCES
PRE-EMPLOYMENT
LIVE SCAN
SCREENINGS
TRAININGS
MANDATED REPORTER
CDPH
FILE A COMPLAINT
DISCRIMINATION
FILE A REPORT
EEOC & DFEH
COUNTY RESOURCES
AGENCY
STATEMENT
EMPLOYMENT
PRIVATE SITTER
PRIVATE CAREGIVER
CERTIFIED NURSE ASSISTANT
LICENSED VOCATIONAL NURSE
CARE
SERVICE OVERVIEW
SERVICE APPLICATION
CONNECT
COMMUNICATIONS
RESOURCES
PRE-EMPLOYMENT
LIVE SCAN
SCREENINGS
TRAININGS
MANDATED REPORTER
CDPH
FILE A COMPLAINT
DISCRIMINATION
FILE A REPORT
EEOC & DFEH
COUNTY RESOURCES
PRIVATE CAREGIVER
Leave this field blank
YEARS OF PROFESSIONAL EXPERIENCE
SELECT
0-1
2-3
3-4
5+
PREFERRED LOCATION
SELECT
LOS GATOS, CA – AL
LOS GATOS, CA – LONG-TERM CENTER
SAN JOSÉ, CA
FIRST NAME
LAST NAME
BIRTH DATE
SSN
MOBILE PHONE
EMAIL
ADDRESS
CITY, STATE ZIP CODE
APT/STE
(optional)
DRIVER'S LICENSE
POLICY NAME
POLICY NUMBER
DESIRED WEEKLY HOURS
SELECT
8 – 16
16 – 24
24 – 32
32 – 40
DESIRED HOURS PER SHIFT
MULTI-SELECTION
4
6
8
10
12
PREFERRED SHIFT(S) PER WEEK
MULTI-SELECTION
AM
PM
NOC
WEEKLY AVAILABILITY
MULTI-SELECTION
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
HAVE YOU BEEN GRANTED CLEARANCE BY THE CA DEPARTMENT OF SOCIAL SERVICES?
N/A
YES
NO
IF YOU HAVE BEEN GRANTED CLEARANCE, WHAT IS YOUR PER ID?
TRAINING PROGRAMS
SELECT
N/A
ACCREDITED CNA PROGRAM
CERTIFICATIONS
SELECT
N/A
HOME CARE AIDE
CNA
CPR
SELECT
N/A
BLS
CITIZENSHIP
SELECT
CITIZEN
RESIDENT
NON-IMMIGRANT
UNDOCUMENTED
ARE YOU AUTHORIZED TO WORK IN THE U.S.?
YES
NO
DO YOU HAVE ANY PHYSICAL LIMITATION(S)?
YES
NO
IF "YES," PLEASE EXPLAIN YOUR PHYSICAL LIMITATION(S).
(optional)
COVID-19 VACCINATION
SELECT
I CHOOSE NOT TO DISCLOSE
1ST SERIES
2ND SERIES
1ST BOOSTER
2ND BOOSTER
ARE YOU ABLE TO PROVIDE PROOF OF COVID-19 VACCINATION BY CARD OR BY QR CODE?
I CHOOSE NOT TO DISCLOSE.
YES
NO
ARE YOU COMFORTABLE WITH COVID-19 RAPID ANTIGEN TESTING?
I CHOOSE NOT TO DISCLOSE.
YES
NO
TUBERCULOSIS SCREENING
SELECT
I CHOOSE NOT TO DISCLOSE.
N/A
CHEST X-RAY WITHIN THE LAST 5 YEARS
SCREENING WITHIN THE LAST 6 MONTHS
SCREENING WITHIN THE LAST YEAR
PHYSICAL EXAM
SELECT
I CHOOSE NOT TO DISCLOSE.
N/A
EXAM WITHIN THE LAST 6 MONTHS
EXAM WITHIN THE LAST YEAR
PROFESSIONAL REFERENCE I – FULL NAME
PROFESSIONAL REFERENCE I – RELATIONSHIP
PROFESSIONAL REFERENCE I – COMPANY
PROFESSIONAL REFERENCE I – POSITION
PROFESSIONAL REFERENCE I – PHONE
PROFESSIONAL REFERENCE II – FULL NAME
PROFESSIONAL REFERENCE II – RELATIONSHIP
PROFESSIONAL REFERENCE II – POSITION
PROFESSIONAL REFERENCE II – COMPANY
PROFESSIONAL REFERENCE II – PHONE
HAVE YOU BEEN REFERRED TO SUMALÂ HEALTH?
YES
NO
REFERRAL NAME
ACKNOWLEDGEMENT & ATTESTATION
I HEREBY AUTHORIZE SUMALÂ HEALTH TO CONTACT MY FORMER EMPLOYERS AND PROFESSIONAL REFERENCES I HAVE PROVIDED WITH REGARD TO MY JOB PERFORMANCE AND CHARACTER. IF THIS POSITION REQUIRES THAT I EITHER DRIVE MY EMPLOYER’S VEHICLE, OR MY OWN, I AGREE TO SHOW MY EMPLOYER PROOF OF MY CURRENT INSURANCE ON MY VEHICLE AND PROOF OF MY VALID DRIVER’S LICENSE. I ALSO AGREE TO COOPERATE WITH MY EMPLOYER IN OBTAINING A COPY OF MY DRIVING RECORD, WITH THE UNDERSTANDING THAT MY EMPLOYER WILL PAY ANY NECESSARY COSTS. I UNDERSTAND MY EMPLOYER MAY CHECK PUBLIC COURT RECORDS FOR CASES, CIVIL OR CRIMINAL, LISTED UNDER MY NAME.
ACCEPT
SUBMIT
