EMPLOYEE QUESTIONNAIRE

DATE AVAILABLE *

APPLICANT NAME *

NEW

NEW UPDATE

CONTACT # *

Language

E B/L S/E

% Other Language:

TYPE OF WORK *

PAY RATE $ *

SHIFTS AVAILABLE *

OVER TIME *

WEEKENDS *

Select Options

Long-term Short-term School Second Job

Hours:

REFERRED BY

Will you submit to a drug test? *

The essential functions for most positions include working 8-12 hour shifts 5 or more days a week. Can you perform tasks that involve repeatedly transporting heavy objects, squatting, bending, stacking, twisting, reaching, and shrink-wrapping pallets? *

In the course of an 8-hour day, one can expect to repeatedly transport boxes weighing up to 40 pounds. Are you able to repeatedly transport such items? *

How many pounds? *

5-10 11-20 21-39 40+ Lbs

Can you work in a facility where the work environment that is hot or refrigerated? *

Can you work in a fast-paced environment where the temperature is hot, and you are required to perform task that involve folding heated items such as bedding or towels? *

In the course of an 8-hour day, one can expect to repeatedly scan or ticket items. Are you able to repeatedly use an RF scanner gun or ticketing gun? *

How do you prefer to work? *

you able to work in a fast-paced environment? *

While on assignment are you able to perform tasks that involve using repetitive movements? *

While on assignment can you perform tasks that require you to stand for long periods of time? *

Are you sensitive to chemical fumes or air particles? *

Have you been terminated for any cause? *

Why did you leave your last job? *

When was your last day worked? *

Do you have the following equipment? *

Steel Toe Work Boots Safety Back Belt Non-Slip Boots

Work exp. / Notes *

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