Cd Pass Form PDF Details

The ADvantage Program Consumer-Directed Personal Services and Supports (CD-PASS) Personal Services Assistant Application for Employment serves as a critical document for individuals seeking employment in this supportive role. It carefully gathers comprehensive information about the applicant, spanning from basic personal and contact data to detailed employment history and qualifications. Prospective employees must disclose their name, address, contact numbers, and if applicable, an email address alongside their desired position, expected pay, and social security number to assure accurate identification and compensation alignment. The form rigorously inquires about the applicant's current employment status, legal eligibility to work within the United States, as well as relationship to the potential employer, which could affect the employment dynamics. Moreover, it probes into the candidate’s ability to perform specific tasks, such as transporting the employer if needed, their criminal background, and specialized training or skills including certifications in CPR, First Aid, and Universal Precautions, ensuring the applicant meets the essential requirements for the role. Additionally, the form requires a detailed employment history to assess the applicant’s previous professional experiences and competencies, alongside references to validate the candidate's work ethic and performance. Ultimately, the document emphasizes the importance of honesty and integrity by highlighting that any falsification or willful omission on the application may lead to dismissal or refusal of employment, underscoring the form's role not only in the application process but in setting the tone for accountability and reliability in potential employees.

QuestionAnswer
Form NameCd Pass Form
Form Length2 pages
Fillable?Yes
Fillable fields93
Avg. time to fill out19 min 10 sec
Other namescdpass, what is the cdpass program through dhs in ok, cd pass form, cd pass application

Form Preview Example

ADvantage Program

Consumer-Directed Personal Services and Supports (CD-PASS)

Personal Services Assistant

Application for Employment

Employer:

Applicant Information for Personal Services Assistant

Last Name

 

 

First

 

 

 

 

Middle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

Telephone

 

 

Other Telephone

 

 

 

 

 

 

 

(

)

-

 

(

 

)

-

 

City

State

Zip

 

E-mail address (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position Desired

 

Pay Expected

 

Social Security #

 

 

 

 

 

 

 

 

$

 

/ Hour

 

 

 

-

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever been employed under any other names? If yes, please list:

In an emergency, please notify:

Name

 

Relationship

 

 

 

 

 

Address

 

Telephone (

 

 

)

 

-

 

Applicant Availability

Are you currently employed?

Yes

No

Are you over age 18?

Yes

No

When will you be available to begin work?

 

 

 

Are you legally eligible for employment in the United States?

Yes

No

Are you related to the Employer?

Yes

No

If yes, what is your relationship? ________________________

Can you transport the Employer if requested?

Yes

No

Have you ever been convicted of a felony?

Yes

No

Conviction will not necessarily disqualify an applicant from employment.

Applicant Personal History

Special Training/Skills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certifications

 

 

 

 

expiration date

 

 

 

 

 

 

 

Licenses

 

 

 

 

 

expiration date

 

 

 

 

 

 

 

CPR

 

 

 

 

 

expiration date

 

 

 

 

 

 

 

First Aid

 

 

 

 

 

expiration date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you had Universal Precautions training?

Yes

No

If yes, when?

 

 

/

 

 

/

 

 

 

 

 

 

 

 

Are there any tasks as a Personal Services Assistant that you w ould not want to do? (examples: driving, bowel/bladder care, lifting)

Yes

No

If Yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADvantage Program CD-PASS 07.03.07

Page 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant Employment History

 

 

Please give accurate, complete employment history,

 

 

 

including full-time and part-time employment, starting with

 

 

 

 

 

 

 

 

 

 

 

 

your present or most recent employer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

Company Name

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

Employed – (State month and year)

 

 

 

 

 

 

 

 

 

 

 

 

 

From

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Supervisor

 

 

 

 

 

 

 

 

Hourly Wage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Job Title and Describe Your Work

 

 

 

 

 

 

 

 

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

Company Name

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

Employed – (State month and year)

 

 

 

 

 

 

 

 

 

 

 

 

 

From

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Supervisor

 

 

 

 

 

 

 

 

Hourly Wage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Job Title and Describe Your Work

 

 

 

 

 

 

 

 

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

Company Name

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

Employed – (State month and year)

 

 

 

 

 

 

 

 

 

 

 

 

 

From

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Supervisor

 

 

 

 

 

 

 

 

Hourly Wage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Job Title and Describe Your Work

 

 

 

 

 

 

 

 

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant References

 

 

Give name, address and telephone number of three references who were your

 

 

 

supervisor, a co-worker, or someone you supervised and who agrees to answer

 

 

 

 

 

 

work reference questions regarding your previous employment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

Name

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

City/State Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

Name

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

City/State Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

Name

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

City/State Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer may contact the employers listed

 

 

 

 

 

 

 

Do Not Contact

 

 

 

 

 

Employer

 

 

 

 

 

 

above unless you indicate those you do not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

want us to contact.

 

 

Reason

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant Statement

 

I understand this application is not an employment contract. I certify that all the statements made in this application are true and that any

falsification of willful omission shall be sufficient cause for dismissal or refusal of employment. I authorize the employer or delegate to investigate

my work and personal history and verify all data given on this application, on related papers and interviews, including, but not limited to OSBI,

nurse aide registries, criminal background, driving record, and licensure. I authorize all individuals, schools, and employers named to provide any

information requested about me, and I release them from all liability for damage in providing this information.

Signature:

Date:

ADvantage Program CD-PASS 07.03.07

Page 2

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