Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Anna Myra Dumagpi
Created: 11/06/2019
Other names under which employment may be verified:  
Updated: September 11, 2020

Home Address
Street Address
4715 N Laporte Ave
Unit/Suite Number
City ST/Zip
Chicago, IL 60630
Home Phone
Mobile Phone
7739636516
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us? Friend - Carmen Cortez
Rate of pay desired.   15 per hr
Do you have a valid driver’s license?   Yes
Do you have access to a car? Yes

I am able to work client who has or lives with:
Family
Yes
Hospice
Yes
Cats
No
Dogs
No
Smoker
No
What languages do you speak?   english, tagalog
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Respite Home Care

How many years have you worked as a professional caregiver?  3
What percent of your previous case work has been for an agency?  0
Please explain how you will contribute to strengthen the Water Tower Nursing team.

By providing patient quality care and service.

Please share one or more personal or professional experiences you have had as a caregiver.

Assistance in performing activities of daily living, providing good personal hygiene, preparing healthy meals, medication reminder, doing grocery shopping and other errands. Keeping environment always safe for patient by keeping area clutter free. Encouraging patient to perform exercises as prescribed by PT/MD.

Availability

Days   Yes
Nights   Yes
Weekdays   Yes
Weekends   Yes
Live-in   Yes
Can you travel outside the city of Chicago to work?   No

Education

High School   Perpetual College Rizal
Location:   Manila, Philippines
Did you graduate?   Yes
Subjects Studied   

College   Perpetual College Rizal
Location:   Manila, Philippines
Did you graduate?   Yes
Degree:   BS Nursing

Other:   DeVry University
Location:   Chicago, Illinois
Did you graduate?    Yes
Degree:   BS Information Technology

Special awards you earned or courses you have taken.

Military Service

U.S. Military or Naval Service   No
Military branch and rank at discharge:   

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Good Heart Home Care
Phone
8476350500
Address

2644 E Dempster Suite 209
Park Ridge, IL

Supervisor
Bernadette Pingue- Director of Nursing
Job Title
Quality Assurance
Salary or Rate of Pay
21/ hr
Responsibilities
Review medical records; Follow up orders; Coordinate w/ other disciplines
From
11/04/2019
To
03/27/2020
Reason for Leaving
Pandemic
May we contact this employer?  Yes

Company Name
Astra Home Health Services
Phone
Address

7444 W Wilson Ave Harwood Heights

Supervisor
Ella Rabor (Director of Nursing) 847-219-5438
Job Title
Quality Assurance
Salary or Rate of Pay
22/hr
Responsibilities
Review medical records, follow up laboratory orders and report to MD, Coordinate with outside displines
From
01/08/2018
To
11/05/2018
Reason for Leaving
Advancement
May we contact this employer?  Yes

Company Name
Good Shepherd Home Health Care
Phone
Address

3144 W Montrose Ave
Chicago Illinois

Supervisor
Heidi Nikolich (Administrator) 773-964-0926
Job Title
Quality Assurance
Salary or Rate of Pay
20/hr
Responsibilities
Review medical records; Follow up orders; Coordinate w/ other disciplines
From
04/11/2016
To
11/24/2017
Reason for Leaving
Advancement
May we contact this employer?  Yes

Company Name
Hands & Heart Home Health Care
Phone
7736277591
Address

1159 Wilmette Ave Suite 9
Wilmette, IL 60091

Supervisor
Rock Siapno, RN D.O.N
Job Title
Quality Assurance
Salary or Rate of Pay
23/hr
Responsibilities
Review medical records; Follow up laboratory orders and report to MD; Coordinate with outside displines
From
11/19/2018
To
03/26/2019
Reason for Leaving
Advancement
May we contact this employer?  Yes

 

REFERENCES & ACCEPTANCE

Thank you for entering your employment history in Part Two. Before proceeding, could you please explain any gaps in your work history.
Went for vacation for couple of months
Character References
Please provide the names and contact information for three persons, not related to you, whom you have known for at least one year.
Name
Carmen Cortez
Phone
312-774-6447
Address
Relationship
Friend

Name
Dixie Arroyo
Phone
331-250-6422
Address
Relationship
Nursing Supervisor

Name
Corazon Sasing
Phone
603-781-8615
Address
Relationship
Friend
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

Available to work anytime.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
Went for vacation for couple of months
Additional Certifications
No additional certifications or licenses provided.

Have any of your certifications or licenses been suspended or revoked?  No
If yes, explain.  
Resume Upload (optional)
If hired, would you be able to provide a copy of your Social Security Card?* (IDPH requirement)
Yes

I certify that the information contained in this application is true and correct to the best of my knowledge and I understand that falsification of this information is grounds for refusal to hire, or if hired, termination of my employment.

I agree that my employment is at-will and may be terminated or an offer of employment may be withdrawn by Water Tower Nursing and Home Care, Inc. (WTN) at any time, with or without notice, and for any lawful reason.

I understand that as a condition of employment and for continued employment, WTN may require periodic drug testing. I understand WTN will use the information gathered on this employment application to conduct background checking and will contact my references and agree to such references giving WTN any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise. I hereby release WTN, its shareholders, officers, directors, employees and agents from any an all liability for any damage that may result from the collection or utilization of such information in connection with evaluating my potential employment.

I understand if hired, I will be required to produce documentary evidence proving that I am currently authorized to work in the United States. I understand my continued employment is contingent upon providing proof of continuing work authorization upon expiration of any documents provided at time of hire. I understand I will have to provide a copy of my Social Security card upon hire as required by the Illinois Department of Public Health (IDPH).

I understand and agree that no representative of WTN has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to foregoing, unless it is in writing and signed by WTN’s President.

Accepted by
Anna Myra Dumagpi

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
August 6, 2020
This application has been submitted and can no longer be edited.