Nannies Canada, Nanny Services Canada, Canada |International Nannies & Homecare Ltd.

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:

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

Gende

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 Question

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 Question

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?

Are you willing to cover the cost of a first-aid course/refresher?

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:

Looking For Caregiver