Training Beyond High School (College or University, Nursing, Business College, or other schools you have attended.) Under credits earned indicate Q for Quarter Hours and S for Semester Hours.

    Describe any education or training you have had which is not covered above, such as vocational school, correspondence courses, service school schools, in service training, or volunteer work which you feel is relevant to the job or jobs for which you are applying. Also include relevant licenses or certificates. Be specific.

    WORK EXPERIENCE: Provide a complete description. This information will be used to determine your qualifications. BE SPECIFIC. Start with your most recent job. BE CERTAIN TO INCLUDE SERVICE IN THE ARMED FORCES. For part time work, show the average number of hours per month. Indicate any changes in job title under same employer as a separate position.

    PROFESSIONAL REFERENCES: (Please list three business references who have knowledge of your experience and ability.)


    PENALTY: A person who provides false information on this form may be subject to forfeiture and sanctions, as provided in Wis. Stat. § 50.065(6)(c) and Wis. Admin Code § DHS 12.05(4).

    Completion of this form to verify your eligibility for employment/service as a “caregiver” is required by Wis. Stat. § 50.065 and Wis. Admin Code ch. DHS 12. Failure to complete this form may result in denial or termination of your employment, contract or service agreement.

    Answering “NO” to all questions does not guarantee employment, a contract, or service agreement.
    If more space is required, attach additional documentation to this form and indicate “see attached” in your answer.



    Roots Residential AFH, LLC Caregiver Tier Level Descriptions

    Caregiver I
    $8-10 per hour

    CBRF certified and general shift paperwork (shift log, sign in, resident log, MAR, etc). Attends to residents ADL’s, holds a valid driver’s license and is able to take residents on outings and appointments.

    Caregiver II
    $10-12 per hour

    All of the above stated including; able to double on third party interactions including assessments, and meetings. Holds core responsibility.

    Caregiver III
    $13+ per hour

    All the above stated as well as independently completing ISP/BSP, assessments, and House Lead with core responsibilities.


    Up and coming leader in training with special projects.


    Pay Periods run from Saturday to Friday. (Example: 5/20/17-5/26/17)

    0-40 = Hourly Pay

    40-60 = Time and a Half

    60+ in one week’s pay period = Double Time

    ALL NATIONAL HOLIDAYS are recognized as double time 12am-12am.

    Two opportunities for discretionary bonus recognition being Roots Day (JUNE) and Christmas time. This opportunity is for staff exceeding expectations on consistent basis.

    Health Benefits and Group Life Insurance available