STAR of CA Employment Questionnaire

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Octavia Watson
7 years ago
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1 STAR of CA Employment Questionnaire Please answer the following questions to assist us in determining if you are a good fit with our agency. Name: Date: COMPATIBILITY WITH POSITION: In the role of the Behavioral Therapist you are expected to drive to family homes and school sites to deliver intervention to children with autism spectrum disorders. Intervention consists of a variety of ABA methods which involves playing with children on the floor, following children as they move about, occasional running after a child to redirect them back to the activity, working with children while sitting at a table or desk. Teaching routines may last 5 minutes to 45 minutes and sessions may last 2-3 hours each. The job also requires lifting toy bags and program materials from your car into the home or intervention site. Being able to sustain this level of activity across the day is important to meet the demands of this position. 1. Do you have any physical limitations that would prevent you from being able to perform the essential duties associated with the job? 2. Have you worked with Children please describe? 3. Have you worked with children with Autism? If yes, what were your primary job responsibilities? TECHNICAL SKILLS: (Put X in appropriate box) YES NO Access to Internet Access to Cell Phone Access to Word Access to Excel Do you use a Mac/PC? (circle one) n/a n/a Novice Proficient Expert Comfort Level with Word Comfort Level with Excel INTEREST:

2 1. What has prompted you to send your resume? 2. What type of position are you seeking? 3. Do you currently have other job offers that you are considering? 4. Did somebody refer you? If yes who? WORK HISTORY: 1. Are you currently employed? If so, why are you considering other employment opportunities? 2. Tell me about your current position. What are your key responsibilities? 3. What rate of pay are you looking for? AVAILABILITY: When would you be available to start if you were offered employment? Are you interested in part time or full time employment (PT / FT)? How many hours per week would you be able to work? What days and times can you be available to work? We typically work with clients Monday through Friday, between the hours of 8:00am and 7:00pm. Days: (check all that apply) Monday through Friday Monday through Friday and weekends Times: (check all that apply) 8:00-12:00 12:00-4:00 3:00-7:00 All Times Other schedule considerations: Do you have any standing appointments/commitments that would prevent you from being accessible M-F between the hours of 8:00am-7:00pm? What locations are you most interested in working at this time? Check all that apply: Ventura County: West Ventura (Ventura, Oxnard, Port Hueneme, Camarillo), North-East Ventura (Ojai, Santa Paula, Fillmore) Santa Barbara County: Santa Barbara South (Goleta, Santa Barbara, Carpinteria), Santa Barbara North (Lompoc, Santa Ynez, Buellton, Solvang), Santa Maria

3 San Luis Obispo County (San Luis Obispo, 5 cities {AG, Grover, Shell Beach, Pismo, etc.}, Nipomo/Santa Maria, Coastal {Morro Bay, Los Osos}, Atascadero, Templeton, Paso Robles, Creston, San Miguel) Simi Valley & Conejo Valley (Moorpark, Thousand Oaks, Westlake Village, Oak Park, Newbury Park North Los Angeles Area: San Fernando Valley (Tarzana, Agoura Hills, Van Nuys), Valencia, Palmdale/Lancaster Los Angeles County: South Bay (Palos Verdes, Redondo, Torrance), South LA (Hawthorne, Gardena, Inglewood), West LA (Culver City, Westchester, Marina Del Rey), West LA (Santa Monica, Westwood, Venice), North West LA (Malibu, Palisades) If needed, would you drive to neighboring locations to maintain a full caseload? (Y / N) Check which areas you could drive to: Ventura County: West Ventura (Ventura, Oxnard, Port Hueneme, Camarillo), North-East Ventura (Ojai, Santa Paula, Fillmore) Santa Barbara County: Santa Barbara South (Goleta, Santa Barbara, Carpinteria), Santa Barbara North (Lompoc, Santa Ynez, Buellton, Solvang), Santa Maria San Luis Obispo County (San Luis Obispo, 5 cities {AG, Grover, Shell Beach, Pismo, etc.}, Nipomo/Santa Maria, Coastal {Morro Bay, Los Osos}, Atascadero, Templeton, Paso Robles, Creston, San Miguel) Simi Valley & Conejo Valley (Moorpark, Thousand Oaks, Westlake Village, Oak Park, Newbury Park North Los Angeles Area: San Fernando Valley (Tarzana, Agoura Hills, Van Nuys), Valencia, Palmdale/Lancaster Los Angeles County: South Bay (Palos Verdes, Redondo, Torrance), South LA (Hawthorne, Gardena, Inglewood), West LA (Culver City, Westchester, Marina Del Rey), West LA (Santa Monica, Westwood, Venice), North West LA (Malibu, Palisades) **Please indicate maximum drive time/distance to client home: **Do you have any specific concerns/questions about driving to client homes? EDUCATION: *Please note that, if hired, you will be required to submit your physical, official diploma in order to verify completion of your degree (or high school diploma and transcripts, if degree is in progress). 1. Are you currently in school? If so, what are you studying? 2. What is your class schedule? 3. How long until you complete your current school commitments? 4. Do you plan to return to school in the next 6 months 1 year?

4 5. Have you taken course work in the principles of behavior or Applied Behavior Analysis (ABA)? 6. If so please list/describe: 2 ND LANGUAGE FLUENCY 1. Are you fluent in any languages aside from English (please describe)? TRANSPORTATION: 1. Do you have reliable transportation? 2. Do you have a valid driver s license and auto insurance? JOB REQUIREMENTS: 1. Would you be able to take a TB test? 2. Would you be willing to undergo a Department of Justice review? 3. Would you be willing to undergo a Drug Test/Screening? 4. Would you be willing to submit a copy of your DMV record and/or allow STAR to request such record from the DMV? 5. Have you ever plead guilty or no contest to, or been convicted of any criminal offense? If yes, please describe? 6. Have you ever been arrested for any matters for which you are currently out on bail or on your own recognizance pending trail? If yes, please describe? 7. Have you ever initiated and act of violence in the workplace? If yes, please describe? 8. Have you ever been terminated or asked to resign from any job? If yes, how many times? 9. Has your employment ever been terminated by mutual agreement? If yes, how many times? 10. Have you ever been given the choice to resign rather than be terminated? If yes, how many times? 11. Are you CPR certified? If not, would you be able to attend a recommended CPR training? BENEFITS:

5 1. What benefits are most important to you at this time? Major Medical Insurance Dental Vision Long Term Disability 401K Plan Mileage Compensation

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