Looking For Caregiver

Elderly Care or Disable Care Questionnair


This questionnaire is intended to cover a wide range of situations. Please fill the fields that are relevant to your needs. Your detailed responses will help us promptly move forward on your request, and match you with suitable applicants.

Contact Details
First Name:
Last Name:
What is your relationship to the person(s) that require care?
Are you collaborating with others to find appropriate care? Please explain:
Who will be the official employer?

Phone Number(s):
Home Phone:
Work Phone:
Mobile Phone:
Other Phone:
Which is your primary phone? Home Work Mobile Other

Email address(es):
Home Email Address:
Work Email Address:
Other Email Address:
Which is your primary email? Home Work Other

Your Address:
Street Address:
City:
Province:
Postal Code:
Other Address:

Fax number(s), if you have any:
Home Fax Number:
Work Fax Number:
Other Fax Number:
What is the best time and method of contact, ideally?
Additional Comments:
 

Care Related Questions
Dependants full name(s)
Age
Birth date
Gender Male Female
Comments
Dependants full name(s)
Age
Birth date
Gender Male Female
Comments
Dependants full name(s)
Age
Birth date
Gender Male Female
Comments
Dependants full name(s)
Age
Birth date
Gender Male Female
Comments
 
Is the position mainly for companionship?
Does he/she have any mental health problems, such as depression or loss of memory?
Does he/she have an ongoing medical condition?
Is he/she on medication? Please describe:
Can he/she walk?
Does he/she have any dietary needs?
Does the dependant need therapy:
Will the caregiver be required to give injections, work with feeding tubes, and/or perform other medical procedures?
Will personal care be required?
Will the dependant require assistance bathing?
Does the dependant speak English?
Languages spoken at home:
Will the caregiver accompany dependant to appointments and activities?
Favourite activities or hobbies?
How do you think the dependant will react to the new caregiver?
Additional Comments:
 

Lifestyle Related Questions
Your occupation (if applicable):
Your spouses occupation (if applicable):
Who in addition will be living in the home?
Will the caregiver need to travel/vacation (how often)?
How would you describe yourself/your family to a potential candidate?
 

Schedule Related Questions
Caregiver Start Date:

What kind of help are you looking for?
Full-time Part-time
Live-in Live-out
Total hours per week:
How long do you foresee the need for the caregiver?

Please indicate the average schedule of days/hours (i.e. what time she would start and end her days).
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Days off:
Will you need evening care? Please explain:
Do you require a caregiver to do shift-work, overtime, or have an irregular schedule?
Please explain:
Additional Comments:
 

Domestic Related Questions
Will you retain housekeeping services (if so explain frequency)?
Household Help:

Check the following duties that the caregiver will be expected to perform and how often:

Check Applicable:
Mop floors:
Family laundry
Change linens
Clean Bathrooms
Water plants:
Straighten bedrooms
Trash removal:
Grocery shopping:
Ironing
Vacuum
Dust furniture
Clean refrigerator:
Clean stove/oven:
Other occasional housekeeping:
Caregiver's Housekeeping Responsibilities:
Plan meals Yes No
Prepare meals Yes No
Will meal preparation duties be shared? Yes No
If so, which meals? Please explain:
Will the caregiver be solely responsible for cleaning up after family meals?
  Yes No
Additional Comments:
Do you have any pets? Please describe:
Will pet care be required? Please describe:

Check Applicable:
feeding
grooming
walking
 

Driving Related Questions
Do you require a driver?
If yes, will the caregiver have personal use of a vehicle?
Car Reimbursements
Vehicle availability and limitations:
 

Residence Type Related Questions
Will the care be provided in the dependant�s home?
Description of home (i.e. bungalow, ranch):
Sq. Footage:
Stories:
Number of rooms:
Number of bedrooms:
Number of bathrooms:
Do you have a permanent pool?
Do you have an alarm system?
Do you have lifting/transfer equipment?
What other types of equipment do you have?

Please describe your location?
District: Urban Suburban Rural
What major city is nearest to you?
How far are you from that major city?
What kind of transportation will be available (i.e. bus, trains, employer):
 
Distance to Transport:
Distance to public transportation:
Distance to Town/Shops:
Distance to School:
Distance to Movie Theatre:
Additional Comments:
 

Caregiver Accommodations Related Questions (if applicable):
Furnished Private room (required for live-in)
Locked Room (required for live-in)
Suite
Private entrance
Shared bathroom
Private bathroom
Phone in the caregiver's room
Private line
TV in the caregiver's room
DVD in the caregiver's room
Shared computer
Own computer
Internet access
If shared bathroom, who will the caregiver share with?
Caregiver's room location in the home:
Will the caregiver be allowed vistors?
Will the caregiver have a curfew?
Caregiver's accommodations:
 

Wage Related Questions
Proposed Weekly Wages:
The caregiver will be paid: Weekly Bi-weekly Monthly
Proposed overtime rate/compensation:
Evaluation for a raise will be made after how many months?
 
How many paid vacation days are you offering, if more than standard?
 
How many paid sick days, if any, are you offering?
Although optional, will additional medical be provided?
 
Are you willing to cover the cost of a first-aid course/refresher?
 
What type of bonus(es)/benefits are you willing to offer?
 
Additional Comments:
 
Ideal Caregiver Qualities:
Required Experience:
Do you see the employee as a member of the family, or as an employee?
Will this be your first time hiring an employee of any kind?
What would/does make you a "good" employer?
Do you currently employ a caregiver? Yes No
Number of past caregivers (either live-in or live-out):
 
How long did each one stay? Where were they from? Why did they leave?:
Have you ever employed a foreign live-in caregiver? Yes No
Describe your current care arrangements:
Are you familiar with payroll procedures? Yes No
Should any proposed details stated above not be in accordance to standard, do you agree to abide by all Canadian taxation, and labour laws?
  Yes No
Who can we thank for referring you to International Nannies & Homecare Ltd.?
How did you hear about us?
Final Comments: