AGENCY WORKER FORM

Update
d 2014

Date
___________________________________________________________
Agency
___________________________________________________________
Workers Name
___________________________________________________________
Job Title
___________________________________________________________
______________________________________________________________________________
1. References:
A. Number of references checked? __________________
B. Date reference check was completed?

__________________

C. Was reference sent by mail or phone? ______________

2. Worker date of hire? _________________
3. Was criminal background check completed? ________________
4. Was PPD completed? _________
A. Date PPD was completed? __________
B. Was PPD over the 90 day requirement? ________
5.

Did the worker sign off on personal policies or handbook? ____________

6. Worker credentials:
A. What is the workers license number and expiration date?
______________
B. Did the worker complete 40 hrs. of training from the agency? (20 hrs.
for respite) ___________
C. Did the worker pass the skills test? ___________
D. Prior to servicing COSAs clients, did worker complete training or
skills test passed? _________

AGENCY WORKER FORM

E.

Update
d 2014

If applicable, is worker licensed for current position? ___________

F. Was the worker trained on Universal precautions?

7. Did the worker receive in service trainings on the following topics?
A. Principles of cleanliness and home safety? _______________
B. Communication with older people? _____________________
C. Understanding aging and functionally impaired older people? __________
D. Observing, appraising, and reporting changes in consumers situations?
___________