Apply for Community Support Worker

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Summary
Title:Community Support Worker
ID:1001
Location:Wichita, KS
Department:Client Services
Salary Range:$14-18
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Application Information
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Application for Employment
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
Yes   No
Less than 10   10-20   20-30   30-40   40 or more
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

Yes   No

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

Reference 2

Reference 3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

Job Eligibility and Experience
* Have you ever been convicted of a felony?
Yes
No
* Have you ever been convicted of a crime against another person, even a misdemeanor?
Yes
No
We run various background checks:
- Motor Vehicle Record  (MVR)  
- KS Child Abuse/Neglect Registry
- KS Adult Abuse/Neglect Registry  
- KBI Criminal Background  
- National Sex Offender Registry
- Excluded Parties Screen (EPLS)
- Local WPD Report

*You must successfully pass each one of these background checks to work for Pyxis.  

If you have anything to disclose about any of these background checks, please explain below.
* Do you have reliable transportation?
Yes
No
* Do you have a current/valid driver’s license?
Yes
No
* Are you willing to transport participants in your own vehicle? (mileage reimbursement included in pay)
Yes
No
* How many properly operating seatbelts do you have in your vehicle?
* Do you have current car insurance in/with your name?
Yes
No
* Do you have a working cell phone? Are you comfortable with texting? (cell phone reimbursement included in pay)
* Timesheets & documentation are submitted electronically on a time sensitive basis, do you have regular access to internet at your home?
Yes
No

On a scale of 1-5, 5 being highest, please rate your:

* Computer expertise
1
2
3
4
5
* Ability to learn new technology/software
1
2
3
4
5
* Ability/experience in submitting time sensitive documentation
1
2
3
4
5
* Are you CPR certified?
Yes
No
* Do you have any training in de-escalating behaviors?  If so, please explain.

Please explain in detail how you would handle each of the following situations to the best of your ability.

* You are providing individual service (AC/PRI) to a participant in the school setting, the participant becomes angry and disruptive in the classroom by yelling, hitting his/her head on the desk.  What steps do you take to de-escalate the situation and calm the participant down?
* You are out in the community providing group service to clients.  While you are eating with your group at a restaurant, one of your participants becomes upset with another peer and starts to scream and throws food across the room.  What steps do you take to calm the participant down and maintain the behaviors of the other participants in your group?
* You get a call from a parent who is really upset about a situation that occurred earlier in the week and the parent is just finding out about this.  What steps do you take to work with the parent to ensure the working relationship is not damaged, and open lines of communication remain?  How would you prevent this from happening in the future?
* You are unable to see your client; because your client has been out sick all week; what steps would you take to ensure all the client’s missed sessions are made up?
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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