Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without

prior written permission.

Private Caregiver or Attendant Interview Questions This form structures your interview with each caregiver, giving you examples of the most important information to obtain. This form also gives you a place to take notes from each interview so you can easily review the content of each interview, avoiding any confusion later.

1. What is the level of staff training? _____ nurse’s aide/support worker/home health aide _____ Registered nurse’s assistant _____ Registered nurse

2. Do you have a license or certification? _____ yes _____ no __________________ regulating agency

3. What has been your training?

_________________________________________________________________________________________________________________________________________________________________________________

4. What caregiving services have you given in the past?

_____ housekeeping _____ medication management _____ bathing _____ meal preparation _____ shopping _____ escort to appointments _____ companionship _____ post-operative care _____ palliative/hospice care _____ driving _____ toileting _____ grooming Other: _________________________________________________________________________________________________________________________________________________________________________________

5. What were the medical problems of your previous clients?

Alzheimer’s _____ Dementia ______ Parkinson’s _____ Cancer _________ Heart problems _____ COPD ______ End of life care _______

Other: _____________________________________________________

THIS

IS A

DEMO

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without

prior written permission.

6. What is the minimum number of hours for a shift?

________________________________________________________

7. How much notice will I get if you are going on vacation? Do you have a person that you can recommend if you are sick or going on vacation? ______________________________________________________________________________________________________________________

8. Hourly rate? Weekly rate?

________________________________________________________

9. What types of emergencies have you dealt with in the past? _________________________________________________________________________________________________________________________________________________________________________________

10. If my loved one becomes verbally aggressive (yelling, arguing), what would you do: _________________________________________________________________________________________________________________________________________________________________________________

11. If my loved one becomes physically aggressive (throwing an object,

hitting), what would you do? _________________________________________________________________________________________________________________________________________________________________________________

12. Describe the most challenging situation you have been in when providing

care? _________________________________________________________________________________________________________________________________________________________________________________

13. Are there any types of patients that you are uncomfortable caring for? _________________________________________________________________________________________________________________________________________________________________________________

14. How do you feel about caring for someone in my loved one’s condition?

______________________________________________________________________________________________________________________

THIS

IS A

DEMO

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without

prior written permission.

15. Are you comfortable providing end of life care? (if applicable) ______________________________________________________________________________________________________________________

16. Do you provide a receipt for tax purposes? ___________________________________________________________

17. Reference names and phone numbers: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

18. Share your expectations with the caregiver or attendant you are interviewing:

a. Vacation notice: ________________________________________ b. Resignation notice: _____________________________________ c. What you expect regarding the care and employment (arrive on

time, document patient’s activities, personal care, etc.) d. Other:

_______________________________________________________________________________________________________________________________________________________________ _____________________________________________________

19. Share the following information with the caregiver regarding your loved

one’s needs: a. Health status and medical diagnoses b. Medication type and dosing c. Behavioral problems or concerns, mood problems or concerns,

personality characteristics (social, quiet, private, etc.), d. Interests (cards, reading, television) e. Personality type of caregiver you’re requesting (talkative, patient,

firm, etc.) f. Family support g. Services required h. Other:

_______________________________________________________________________________________________________________________________________________________________

THIS

IS A

DEMO