Online Assessment Form

Form Version
Form:
Section 1: Personal Infomation
Last Name:
First Name:
Date Of Birth(YY/MM/DD):
Marital Status:
Number of Children
Language(s) Spoken
Country of Birth:
Nationality(s):
Section 1 (b):
Height:
Weight:
Car Ownership Yes No Rental
Allergies Yes No
If yes, please clarify
Medical Concerns (confidential)
Do you Smoke? Yes No
Do you Drink? Often Rarely Never
Do you Swim? Yes No
Driver's license? Yes No
Play a musical instrument?
Hobbies:
Section 1 (c): Contact Infomation

Current Residential Address (With Zip/Postal Code)

Telephone # (Work):
Telephone # (Home):
Cellphone #:
E-mail:
Section 1 (d):
When are You Available for Work?

Section 2: Education and Training
What's the highest level of education you achieved?
University College High School Others
If others, please specify.

What subject did you major in?

Study period (Dates)

Did you take any type of health/nursing/medical related courses/training?
Yes No

If yes, please specify.(include study period)

Have you ever taken any First Aid or CPR lessons? Yes No

Have you ever received any certificate or diploma for these specialty trainings? Yes No

Addition notes on your education?
Section 2 (b): Languages
Knowledge in English
Speak: Fluently Well Fair No Knowlege

Write: Fluently Well Fair No Knowlege

Read: Fluently Well Fair No Knowlege

Other Language(s) you speak?

Section 3: Employment History
Start with most recent employer

1: Employer Name & Address

Position:
Date Of Employment:
Time Completed:
Duties:
Reason For Leaving:

2: Employer Name & Address

Position:
Date Of Employment:
Time Completed:
Duties:
Reason For Leaving:

3: Employer Name & Address

Position:
Date Of Employment:
Time Completed:
Duties:
Reason For Leaving:

Section 4: Child/Senior Care

Max Number of children you can take care of

Willing to work for Single Parent?
Yes No

Willing to take full charge in the employer's absence? Yes No

What of the following are you comfortable doing as a nanny?

Care for infant
Care for children
Care for elders
General Cleaning
Cook
Petcare
laundry
Shopping

Section 5: Summary Paragraph
Please summarize in a paragraph why you are a good care giver.