Sub Staff Application

Complete the Sub Staff application by providing accurate information, ensuring that all required documents are attached, and reviewing the details carefully.

Full Name*

Date Of Birth*

Email Address

Phone Number

Address

City

State

Zip Code

Driver's License Number*

Highest Level of Education Completed

Who referred you to our agency? Reference name and phone number

As part of the application process, we require all applicants to submit any files that certify their credentials. This includes but is not limited to certifications such as CPR/First Aid, ESI, Mandt, and any other experience credentials.

Describe your experience in detail, working with individuals with physical or intellectual disabilities (please do not use names or personal information when detailing your experience)

Who is your current or last employer? What is your job title and brief description of your duties?

Have you been convicted of a crime other than speeding?

Yes

If you answered YES, you MUST list the date of conviction, county/state in which the conviction occurred and the type of conviction(s). Please note that a conviction is not necessarily a disqualification for hiring.

Please include a brief description of the conviction including what the conviction was for, what happened and who was involved? Use separate sheet of paper if need additional space for additional convictions.

Are you willing to support a male?

Yes

Are you willing to support a female?

Yes

Are you willing to accept an emergency placement (which has no advance notice, quick or same day)?

Yes

Are you willing to work with an individual who has a vision impairment including blindness?

Yes

Are you willing to work with an individual who has a hearing impairment including deafness?

Yes

Are you willing to work with an individual who does not communicate with words?

Yes

Are you willing to work with someone who requires constant supervision in the community?

Yes

Are you willing to work with someone who requires physical assistance for things such as bathing, toileting, brushing teeth and utilizing adaptive devices?

Yes

Are you willing to work with someone who drinks alcoholic beverages, tobacco or vape use, marijuana, or other street drugs, has alone time with significant other?

Yes

Are you willing to work with someone who yells, name calls, swears, make threats?

Yes

Are you willing to work with someone who hits, kicks, bites, spits?

Yes

Are you willing to work with someone who breaks property, throws things?

Yes

Are you willing to work with someone who elopes?

Yes

Are you willing to work with someone who hurts self (bangs head, cuts self, skin picking, etc.)?

Yes

Are you willing to work with someone who has poor sexual boundaries (masturbation in public areas of the home or community, poor boundaries with others)?

Yes

Are you willing to work with someone who displays sexually inappropriate behaviors (requires constant supervision in the community and with/around children)?

Yes

Are you willing to work with someone who steals/theft of property?

Yes

If you would like to provide additional information or explanation to any of the above questions, please use this area:

What is the names(s) of The Shared Living Provider(s) that you are going to be Direct Support Staff for and who is the participant in TVN services?

Are you open to The Vessel Network putting you in contact with any other Shared Living Providers that may need Direct Support Staff ?

Yes

List any specialist training you have including Mandt, CPR/First Aid, Med Aide, etc. Please provide a photocopy of all certifications.

Are you proficient using Therap software?

Yes