License Expiration: CPR Expiration: Liability Insurance Expiration

License Expiration:
CPR Expiration:
Liability Insurance Expiration:
Name:
LVN Requirements
1)
LVN License (check for validity)
2)
At least 1 year experience
3)
Current CPR Card
4)
Individual Professional Liability Insurance
5)
Current Physical Exam with TB test / If TB test is positive, need chest x-rays
6)
At least 2 references from their application
7)
CA ID/DL
8)
Car Insurance
9)
Hep B Waiver
10)
Extra Certificates or Specializations
CNA/CHHA Requirements
1)
CNA/CHHA License (check for validity)
2)
Current CPR Card
3)
Individual Professional Liability Insurance
4)
Current Physical Exam with TB test / If TB test is positive, need chest x-rays
5)
CA ID/DL
6)
Car Insurance
7)
Hepa Waiver
8)
Experience working with facility, home health or hospice
Page 1 of 10
CONFIDENTIAL AMERICAN ALL CARE SERVICES JOB APPLICATION FORM
Please complete the following information and return it to us, incomplete or unsigned applications will not be
considered. This information will remain confidential and nothing will be divulged which is not authorized by you.
PERSONAL DATA
Application Date :
Photo No.
Applicant Name:
First
Last
Middle Initial
Street
City
State
Current Address:
Date of Birth:
Height:
Weight:
Home Phone #:
Cell#:
E-Mail:
SSN#:
Driver's License#:
Previous Address (if less than 5 years at current address):
How many years in this Address:
Zip
California ID#:
Street
City
State
Zip
Please check the following Geographical locations in which you can work:
L.A. County
Orange County
Riverside
San Diego
Ventura
Other areas please specify _______________________________
Have you used any names or Social Security Numbers other than given:
If Yes, Please list Other Names Used :
Sta. Barbara
Yes
San Bernardino
No
Other Social Security # Used:
Have you ever worked for this Company?
Yes
No When:
Do you have any friends or relatives that are working here?
Yes
No
If Yes, Kindly list their names and your relation
Are you a US Citizen?
Yes
No If not are you legally allowed to work here in the US?
Yes
Have you ever been convicted of a crime in the past seven years?
No
If Yes, Kindly explain.
Have you been live-scan fingerprinted?
Yes
No
Are you currently working / employed?
Yes
No May we contact your Employer?
Yes
No
If not kindly explain
Remarks:
Page 2 of 10
JOB RELATED SKILLS
Language(s) (in addition to English)
Are you Driving?
Yes
Sign Languages
No License Plate #
Freeway Driving OK?
If you do not Drive, what will be your primary means of getting from/to work?
Bus
Rides
Car (year/make/model/color)
Smoker?
Non-Smoker
Female Clients
Yes
No
Walk
Bike
2 Door
4 Door
Willing to work in a smoking environment? If not Pls. explain?
Male Clients
Can you do transfers?
Yes
Pet Allergies? Kindly specify:
No
If yes, how much can you support?
No Animals
lbs. If no, pls. state reason
Do you have any physical limitations that would prevent you from performing your duties?
Yes
No
Yes
No
If yes, please explain briefly :
Do you have any allergies that may affect your job performance while in a patient's home?
If yes, please explain briefly :
Do you have any other training, qualifications or skills which you feel make you especially suited to work with us?
Yes
No
If so, please explain:
Do you have a CPR Card?
Yes
No
If Yes, date Issued:
Do you have a First Aid Card?
Yes
No
If Yes, date Issued:
Certified Home Health Aid?
Yes
No
If Yes, C.H.H.A #
Exp.
Certified Nurse Assistant?
Yes
No
If Yes, C.N.A #
Exp.
Other Certifications Kindly Specify:
MEDICAL EQUIPMENT AND EXPERIENCES
NONE
Dementia
G-tube
Nebulizer
Alzheimer
Diabetes
Hip Surgery
Non-Ambulatory Patients
Board & Care
Diaper Changing
Hospice Care
Oxygen Tank
BP Monitoring/Pulse/Temp
Facility/Hospital
Hospital Bed (Elec./Manual)
Parkinson
Catheter
Feeding Tube
Hoyer Lift
Retirement Hotel
Colostomy Care
Gait Belt
Hygiene/Bathing
Residential/one on one
COPD
Glucometer
Massage/ROM Exercises
"Stand-up lift" (ex: SARA lift)
Others please specify:
Stroke Patient
Page 3 of 10
AVAILABILITY
Start Date:
How many hours per week are you available for work?
All
Full time
For which shifts are you available?
Part time
Live-In
Live-Out
Weekends
Holidays
Days
Evenings
Nights
Overnights
Overtime
MON FRM
TO
WED FRM
TO
FRI
FRM
TO
SUN
TUE
TO
THU FRM
TO
SAT
FRM
TO
FLEXIBLE
FRM
For live-in position for how many days are you available?
3 Days
5 Days
FRM
TO
7 Days Others Pls. Specify:
I understand that the basis of my hiring is on the schedule I have provided. Should my schedule change there is no guarantee of
work within my new availability
Applicant’s Signature
EMPLOYMENT HISTORY (FROM MOST RECENT EMPLOYMENT)
Most Recent Employer
Are you currently working for this employer?
Company or Patient's name if private client
From :
DATES EMPLOYED
No
ADDRESS & CITY
to
SUPERVISOR
PHONE NUMBER
May we contact this employer?
Yes
(or family members name and relationship if private)
FAX NUMBER
Yes
No
If no, kindly state reason:
Duties:
Salary per (Hr/Week/Month)
(Circle one please)
Reason for Leaving
A letter of reference has been provided?
Page 4 of 10
EMPLOYMENT HISTORY (FROM MOST RECENT EMPLOYMENT)
Second Most Recent Employer
Are you currently working for this employer?
Yes
No
ADDRESS & CITY
From :
DATES EMPLOYED
to
SUPERVISOR
PHONE NUMBER
(or family members name and relationship if private)
FAX NUMBER
May we contact this employer?
Yes
No
If no, kindly state reason:
Duties:
Salary per (Hr/Week/Month)
(Circle one please)
Reason for Leaving
A letter of reference has been provided?
Third Most Recent Employer
Are you currently working for this employer?
Yes
No
ADDRESS & CITY
From :
DATES EMPLOYED
to
SUPERVISOR
PHONE NUMBER
May we contact this employer?
(or family members name and relationship if private)
FAX NUMBER
Yes
No
If no, kindly state reason:
Duties:
Salary per (Hr/Week/Month)
(Circle one please)
Reason for Leaving
A letter of reference has been provided?
Page 5 of 10
Date:
Name:
Please read through the list of procedures and skills. Check the column that best describes your experience in that area.
NURSING SKILLS INVENTORY
Procedures/Skill
Wound Care: Applying/Removing:
Sterile Dressings
Wet to dry dressing
Wound packing
Wound irrigations
Unna Boot
Home isolation
Suture/Staple Removal
Stump Care
Prosthetic/Orthopedic Devices:
Braces/Splints
Safe lft/transfer techniques, proper body mechanics
Hoyer lift
Range of Motion Exercises
Ambulation with:
Crutches
Walker
Cane/quad cane
Indwelling Foley Catheter:
Male-insertion/change
Female-insertion/change
Irrigation
Obtaining urine specimen
Catheter care
Instructing bladder training program
Suprapubic Catheter:
Insertion/change
Dressing change
Instructing re: care of catheter, etc.
Instruction of Self Cath
Application of External Catheter
Urine Testing:
Sugar and acetone
Clean catch specimen
Instructing patient to perform above
Never or Rarely
Done
Have Done
Please read through the list of procedures and skills. Check the column that best describes your experience in that area.
NURSING SKILLS INVENTORY
Procedures/Skill
Use of Testing Kits:
Ac Hemocult
Chemstrip
Instructing patient to use above
Ostomy Care: ILEO conduit, colostomy
Pouch Application
Irrigation
Instructing patient in care of ostomy
Naso-gastric Tube:
Insertion
Irrigation
Instruction of patient re: care of tube, etc.
Gastrostomy Tube:
Insertion/change
Irrigation
Instruction of patient re: care of tube, etc
Manual removal of fecal impaction
Auscultation of:
Heart
Lungs
Abdomen
Repiratory Hygiene:
Oxygen therapy
IPPB treatment, nebulizers, inc. spirometer
Suctioning
Tracheostomy care
Chest tubes
Instruction in use of metered dose inhalers
Medication Administration:
Intradermal
Sub q
IM
Z track
Patient instruction: self injection
Blood Glucose Monitors
Never or Rarely
Done
Have Done
Please read through the list of procedures and skills. Check the column that best describes your experience in that area.
NURSING SKILLS INVENTORY
Procedures/Skill
Special Diets:
ADA Diabetic Diet
Low salt
Low fat
High Fiber
Phlebotomy:
Blood draws
Intervenous Therapy:
Venipunctures
Central lines
IV pumps and controllers
IV maintenance
Sub Q infusion
Pain Assessment & Interventions
Use of VAS scale
Initiation of opioid therapy
Titration of opioids
Knowledge of WHO pain ladder
Knowledge of equinanalgesics
Knowledge of dosing
Never or Rarely
Done
Have Done
EDUCATION AND REFERENCES
EDUCATION AND TRAINING
Name of School
Location
Courses
Year Completed
Diploma, Degree or Certificate Received
(Please furnish names, addresses & telephone numbers of two people to whom you are not related & by whom you are not employed)
REFERENCES
Name
:
Address
:
Occupation
:
Phone No.
:
Name
:
Address
:
Occupation
:
Phone No.
:
Number of years Acquainted:
Number of years Acquainted:
PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for having a
job and that the answers given by me are true and correct to the best of my knowledge. I further understand that any
misstatement or omission of fact on this application or on any other related documents shall be grounds for rejection of
this application or for immediate discharge if given a job, regardless of the time elapsed before discovery
I hereby authorize the company to thoroughly investigate my references, work record, education and other matters
related to my suitability for employment and further, authorize the references I have listed to disclose to the company
and all letters, reports and other information related to my work records, without giving me prior notice of such
disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations,
partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such
investigation or disclosure
I understand that nothing contained in the application, or conveyed during any interview which maybe granted or
during my job tenure, if given opportunity, is intended to create employment contract between me and the company. In
addition, I understand and agree that if I am given a job, this will be for no definite or determinable period and may be
terminated at any time, without notice, at the option of either myself or the company, and that no promises or
representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the
company’s designated representative.
Signature of Applicant
:
Printed Name
:
Date Signed
:
Interview Date
:
Interviewed By
:
Page 9 of 10
REFERENCE CHECK
_________________________________ has applied for a position at AMERICAN ALL CARE SERVICES and has listed you
as a previous employer. We would appreciate if you could verify we were given and evaluating his/her performance. All
information given to us will be kept in the most strictest confidence.
1.) How long was the applicant employed with your company? ___________________________________
2.) What are the applicant’s strong points? ___________________________________________________
3.) What are the applicant’s weak points ? ___________________________________________________
4.) What was the position applicant held? ____________________________________________________
5.) Would you rehire the applicant? _________________________________________________________
6.) Salary per hour? ______________________________________________________________________
Please rate the applicant’s in the following areas:
( Check appropriate box)
CRITERIA
EXCELLENT
GOOD
___________________________________
Signature of Person Verifying Employment
POOR
COMMENTS
Attendance
Cooperation
Initiative
Job Knowledge
Productivity
Punctuality
Quality
Reliability
TO BE COMPLETED BY APPLICANT
__________________________________________________________________________
Applicant name ( print clearly)
Social Security Number
__________________________________________________________________________
Employer Name ( Print Clearly) Street
City
State
zip
__________________________________________________________________________
Employer Phone Number
Title of Position Held
I hereby authorize you to disclose all and any information concerning my employment.
_______________________________________ ____________________
Employee Signature
Date
Page 10 of 10

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