CenterCare Home Care AgencyAide Registry & Matching Dashboard

Aide Registration

Use this on the iPad when a prospective aide comes in. Submitting saves the record into the searchable dashboard on this device/browser.

Applicant Information

Name, contact, language, culture, address.

Screening only: gender, country/culture, and language are for communication, privacy, and patient-comfort matching. Do not use them for discriminatory hiring decisions.

Application Date

First Name

Last Name

Status

Mobile Phone

Gender / Privacy Match

Years of Aide Experience

Primary Language

Other Languages / Dialects

Country / Cultural Background

Start typing country or cultural background. You may type your own answer if it is not listed.

Position

Best Contact Method

Emergency Contact

Person to contact in case of emergency.

Emergency Contact Name

Relationship

Emergency Phone

Alternate Phone

Address Autocomplete

Start typing the applicant address, then select a free OpenStreetMap suggestion. Street, city, ZIP, borough/county, and neighborhood will fill automatically when available.

Address assist: type a ZIP code or neighborhood/area, then click Fill Area. This fills borough/county, neighborhood, city, and ZIP. Street address is entered manually for accuracy.

ZIP / Neighborhood Quick Fill

Enter ZIP or area, then click Fill Area.

Street Address

Apt

Borough / County

Neighborhood / Area

ZIP

City

State

Address Notes

Availability & Area

Multiple shifts/days/areas can be selected.

Hours Per Week

Maximum Travel

Transportation

Preferred Shifts

Days Available

Service Areas

Case Matching

Preferences, restrictions, and care skills.

Can Care For

Cases Preferred

Cases Avoid

Cooking Ability

Pet Restrictions

Smoking Household

Stairs / No Elevator

Restrictions / Notes

Applicant Screening Questionnaire

Short job-related questions for safety, reliability, and compliance.

Note: Do not include personal medical details. Medical/health clearance is handled separately after conditional offer as required.

1. Legally authorized to work in the United States?

2. Can perform essential HHA/PCA duties, as outlined in the job description, with or without reasonable accommodation?

3. Understand and agree that EVV, time tracking, and care documentation must be 100% accurate, and falsification is grounds for immediate termination?

4. Have you ever left an accepted patient/client assignment without proper notice or authorization?

5. Have you ever been terminated, asked to resign, or separated from a healthcare or home care position due to misconduct, safety violations, or policy issues?

6. Have you ever had a healthcare certificate, license, or registry status suspended, revoked, restricted, or placed under active investigation?

7. Have you ever been the subject of a substantiated finding, pending official investigation, or final agency/employer determination involving patient abuse, neglect, theft, fraud, or documentation falsification?

If any answer above requires explanation, please briefly explain below. Do not include personal medical details.

I certify that all answers provided above are true, accurate, and complete to the best of my knowledge. I understand that false or omitted information may result in rejection of my application or termination of employment.

Answering “Yes” or “Prefer to discuss” does not automatically disqualify you; the agency may review the information as part of hiring/onboarding.

Applicant Certification & Signature

Applicant signs before registration is saved into the searchable registry.

Applicant: ________________________

I certify that the information I provided is true and complete. I understand this is a screening application and does not guarantee employment or patient assignment.

I understand I may not provide patient care until required onboarding, personnel, health, registry, background/CHRC workflow, orientation, and policy requirements are complete.
I authorize the agency to verify my application information, certificate/training information, work history, references, and registry status as permitted by law.

Printed Name

Signature Date

Coordinator Received By

Draw Applicant Signature on iPad

Use finger or stylus to sign inside the box.

Typed Applicant Name

Signature Method

User Setting

Administrator can add users, delete users, reset passwords, and control export access.

Add User

New users can log in to Search / Match and All Records. Only Administrator can export CSV and manage users.

Username

Email for password reset

Role

Temporary Password

Password reset email: enter each user's email address so Forgot Password can send a reset link. Default test users are created with no email until you add one.

Aide Registration

Applicant Information

Emergency Contact

Availability & Area

Case Matching

Work History + Reference

Applicant Screening Questionnaire

Applicant Certification & Signature

Search / Match Aides

Filters

All Records

User Setting

Add User