Home Host Employment Questionnaire – Rocky Mountain Day Service

Name *

First

Last

Address *

Address Line 2

City *

State *

Zip Code *

Home Phone *

Cell Phone

Work Phone

Permission to call work #

Yes
No

Email *

Social Security Number *

Are you lawfully eligible to work in the United States? *

Yes
No

Are you able to provide at least five years of criminal investigation background information with the United States? *

Yes
No

If no, please explain:

List all the States you have lived in for the past 25 years besides Colorado

Is there anything that may be discovered on your background check you would like to disclose now? *

Yes
No

Details

List all persons that will be living in your home including spouse, children, and any others:

Name 1

Relationship

Age

Date of Birth//

Name 2

Relationship

Age

Date of Birth//

Name 3

Relationship

Age

Date of Birth//

Name 4

Relationship

Age

Date of Birth//

Have you or any member of your household been arrested for violations of the law other than minor traffic violations? *

Yes
No

If yes, please explain

Have you or any member of your household been convicted of a felony or misdemeanor? *

Yes
No

If yes, please explain

*A positive response will not necessarily disqualify an applicant. A criminal investigation will be conducted prior to entering into a contract.

Are you or any member of your household currently on parole/probation? *

Yes
No

If yes, please explain

* A background check is required of all adults (18 years and older) living within a Host Home.

What is your primary language? *

What is your secondary language?

If English is your secondary language, do you believe a person placed in your home would be able to understand you easily? *

Yes
No

Will you agree to speak English when the person placed in your home is in your presence? *

Yes
No

Are you proficient in sign language? *

Yes
No

Are you presently a Host Home Provider with another agency? *

Yes
No

If yes, what agency?

Have you ever been a Host Home Provider with another agency? *

Yes
No

If yes, what agency?

What hours are you available to work?*

How many hours do you work outside the home? *

What are your plans for working when a person receiving services is placed in your home? *

Are you able to provide 24 hours of direct care? *

Yes
No

Home Description

Do you own or rent your home? *

Own
Rent

Total # of rooms *

Total # of bedrooms *

Total # of bathrooms *

On what level will the individual’s bedroom be located? *

Will the individual have their own bathroom or will they share a bathroom? *

Own Bathroom
Shared Bathroom

Is your home wheelchair accessible? *

Yes
No
Sort of

To what extent? ( i.e.: entrance of home, no stairs, bathtub, doors to bathroom and bedroom,etc.) (copy)

Do you have pets in your home? *

Yes
No

If yes, please list what type of animals and how many.

INDIVIDUAL PREFERENCE Rocky Mountain Day Service attempts to match the individual’s preferences and needs with your own. Please mark which of the below you will be interested in serving.

Gender *

male
female
no preference

Do young children frequently visit your home? *

Yes
No

Would you like to share any other information to be taken into consideration when placing someone in your home?

Please list other activities

Why are you interested in becoming a Host Home Provider? *

Describe any experience you have relating to the DD field. (Foster Care, Host home, Nursing home): *

How do you see an individual you may serve as changing your life positively? *

What can you do when difficult situations come up in regard to the person you are hosting? *

Explain to us an average day in your home. *

In your opinion, what skills do you possess that would make you a successful Host Home Provider? *

What skills do you feel you need to gain in order to be a successful Host Home Provider? *

Is there any type of individual that you do not feel comfortable working with? *

How do you see this person changing your life? List positive and negative aspects: *

How long do you see yourself being a Host Home Provider? *

List any trainings or certifications that you currently have: *

The position of Host Home Provider requires yearly training and paperwork. Do you understand you will be required to take annual training and turn in required paperwork? *

Yes
No

In addition, a Host Home Provider needs to provide strict documentation for the individuals they serve of medical issues and medications, behaviors, daily contact notes, incident reports (if needed), etc. Do you feel you can accurately report information on a daily and as needed basis in a clear and understandable way? *

Yes
No

Describe your skill level on completing monthly paperwork: *

Are you willing to transport individuals to appointments, Rocky Mountain Day Service’s events & functions, and other functions and events important to the person? *

Yes
No

If no, please explain:

Have you ever been notified by the Office of the General Inspector that you may not participate or be employed by agencies involved with Medicaid or Medicare benefits? *

Yes
No

List Three Personal References (Name, Address and Contact Number) *

By clicking submit, you agree that this application for employment also serves as verification that the information you have listed on the application is true. I certify that the information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment if I am hired. I authorize the verification of any and all information listed above.

List all persons that will be living in your home including spouse, children, and any others:

What hours are you available to work?*

Home Description

INDIVIDUAL PREFERENCE Rocky Mountain Day Service attempts to match the individual’s preferences and needs with your own. Please mark which of the below you will be interested in serving.

Contact

Address

Locations

Areas served by these community centered boards:

Legal