Employee Availability

ELITE HOME HEALTH CARE

Employee Availability

Employee Full Name:

Hours Available to Work

Please indicate specific times. If not available, enter N/A.

	Mon	Tue	Wed	Thu	Fri	Sat	Sun
AM
PM

1. Are you legally authorized to work in the USA?

Authorization up to date?

2. Do you own a car?

3. Other languages spoken:

4. Allergies affecting work?

5. Circumstances to decline a case?

6. Distances you will not travel?

7. How were you referred?

8. U.S. Armed Forces?

If yes, branch:

9. Do you have a consumer already?

Consumer Name:

Schedule:

Hours per week:

Employee Signature:

Date:

ELITE HOME HEALTH CARE

Employee Availability

Office Hours:

HR Fax:

Telephone:

Email:

Address: