Requirements for Employment
Expired/Expiring Documents
Complete Home Care Services, Inc. requires the following documents for employment:
In addition, I am required to fulfill the 12 hours of the In-service Education Program.
I will be separated from HCR and CHRC after 60 days of not working with Complete Home Care Services.
I will need to sign the CHRC/102 form to resume employment.
| Employee Name: | Date: |
| Witness Name: | Date: |
APPLICATION FOR EMPLOYMENT
| Last Name: | First Name: | Middle: | ||
| Home Address: | City: | State: Zip: | ||
| Telephone #: | Alternate #: | Social Security #: | ||
| Sex: | Date of Birth: | Maiden Name: | ||
| Email Address: | ||||
| Are you a citizen of the United States? | ||
| If not, do you have the right to remain permanently and work in the United States? | ||
| Do you have authorization to work? | ||
| Are you involved as a defendant in any professional litigation? | ||
| Have you ever been convicted of a crime? If yes please explain: | ||
| Have you ever been convicted for negligence? | ||
| Do you have any criminal convictions? | ||
| Valid New York Drivers License |
| School | Name and Location of school | Years | Major Subject |
|---|---|---|---|
List your job history, last two employers. Start with your present status and note any periods in which you were not employed.
| Name of Employer: | Telephone Number of Employer: |
| Address of Employer: | |
| Type of work performed: | |
| Reason for leaving: | |
| Name of Employer: | Telephone Number of Employer: |
| Address of Employer: | |
| Type of work performed: | |
| Reason for leaving: | |
Do you have any physical defects that preclude you from performing any work for which you are being considered?
Were you ever injured? Give details:
Have you any defects in hearing? In vision: In speech:
| Name: | Relationship: |
| Address: | Telephone: |
| Name: | Relationship: |
| Address: | Telephone: |
I certify that I am free from any health impairment which is of potential risk to the patient or which might interfere with the performance of my duties including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter my behavior.
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary be terminated at any time without any previous notice.
Approved by HR management:
WRITTEN REFERENCE
I authorize the release of any information requested on the form.
Applicant: Soc. Sec. No:
Signature:
The above individual has applied for employment with Complete Home Care Services, Inc. He/she has authorized the release of information requested on the form. We would appreciate your replies to the questions asked. Enclose additional information if you wish. All information is confidential. A return envelope is provided for your convenience. Thank you for your assistance.
Position In Your Employment:
Employment Dates: (From) (To)
Reason for Leaving:
Would you rehire: If no, please explain:
Additional Comments:
Signature: Title: Date:
Relationship to Applicant:
Additional comments with regard to Applicant's character, judgment, reliability, interpersonal relationships and/or any other information which you would like to provide:
Signature: Date Mailed: Date:
I certify that answers given herein are true and complete.
I authorize Investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by the Executive Director of this organization.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
WRITTEN REFERENCE
I authorize the release of any information requested on the form.
Applicant: Soc. Sec. No:
Signature:
The above individual has applied for employment with Complete Home Care Services, Inc. He/she has authorized the release of information requested on the form. We would appreciate your replies to the questions asked. Enclose additional information if you wish. All information is confidential. A return envelope is provided for your convenience. Thank you for your assistance.
Position In Your Employment:
Employment Dates: (From) (To)
Reason for Leaving:
Would you rehire: If no, please explain:
Additional Comments:
Signature: Title: Date:
Relationship to Applicant:
Additional comments with regard to Applicant's character, judgment, reliability, interpersonal relationships and/or any other information which you would like to provide:
Signature: Date Mailed: Date:
I certify that answers given herein are true and complete.
I authorize Investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by the Executive Director of this organization.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
REQUIRED EMPLOYEE HEALTH ASSESSMENT
| Name: | Date of Birth: | Sex: |
| Address: | ||
| Emergency Contact: | Relationship: | |
| Emergency Address/Phone number: | ||
| CONDITION | YES | NO | CONDITION | YES | NO |
|---|---|---|---|---|---|
| DIABETES | BACK PAIN | ||||
| KIDNEY DISEASE | PAIN ON URINATION | ||||
| HEART DISEASE | CHANGE IN BOWEL HABITS | ||||
| HIGH BLOOD PRESSURE | INCREASED THIRST | ||||
| ARTHRITIS | PERSISTENT SORES/LUMPS | ||||
| MENTAL ILLNESS | INFECTIOUS DISEASE | ||||
| EPILEPSY/CONVULSIONS | CANCER | ||||
| SWELLING IN THE EXTREMITIES | ANY OTHER PHYSICAL DISABILITY | ||||
| ALLERGIES: | |||||
Indicate if you have been experiencing the following conditions:
| CONDITION | YES | NO | CONDITION | YES | NO |
|---|---|---|---|---|---|
| PERSISTENT COUGH FOR < 3 WEEKS | UNEXPLAINED WEIGHT LOSS | ||||
| BLOOD IN THE SPUTUM | LOSS OF APPETITE | ||||
| SHORTNESS OF BREATH | HOARSENESS | ||||
| NIGHT SWEATS | FATIGUE | ||||
| CHEST PAIN | FEVER |
Are you under the care of a physician? Reason:
Do you take depressants, stimulants, narcotic drugs that alter your behavior?
Do you take prescription medications? If yes, which medications?
If required in your position, would you be willing to have screening test for drugs/alcohol done on your blood/urine as a condition for employment?
Have you had any operations or hospitalization for illnesses past 5 years? Reason:
Name of Physician: Telephone:
I have read the above and declare that I have had no injury, illness or ailment other than as specifically identified. I certify that I am not habituated or addicted to any depressants, stimulants, narcotics, drugs, alcohol or other substances that may alter my behavior.
| Employee Signature:
[ Click to Sign ]
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Date: |
| RN Signature: | Date: |
SKILLS COMPETENCY CHECKLIST
This check list will help us when making assignments based on your level of competence to meet the patient's needs.
| Name: | Title: |
| Special Training/Experience: | |
Check the skills you can perform independently.
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Nutrition (understand elements of): |
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I need in-services in the following areas:
| Signature:
[ Click to Sign ]
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Date: |
| CHC staff: | |
Pre-Employment Clinical Competency Assessment RN / LPN
| Name: | Status: |
| Signature:
[ Click to Sign ]
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Date: |
| Physical assessments | |
| Venipuncture | |
| Foley insertion/care | |
| IV Therapy | |
| IV med administration | |
| Pumps: Cadd, Gemstar, Kangaroo | |
| Central line and dressing change | |
| IV flush /care of central line | |
| Port Access and Deaccess | |
| IM/SC med administration | |
| Wound care/dressing changes | |
| S/P tube insertion/care | |
| Care /maintenance of ostomy | |
| Blood glucose monitoring/testing/teaching/cleaning/calibration | |
| Collection and transport of lab specimens | |
| Collection of urine specimens | |
| Use of assistive devices /patient teaching | |
| Insertion/maintenance of NG tubes | |
| Maintenance of G tubes/ J Tube | |
| Insertion/maintenance of enema/suppository | |
| Chest PT | |
| Special consideration | |
| Pulse Oximetry | |
| Vent dependent | |
| Pediatric Nursing | |
| HHA orientation/supervision |
PROFESSIONAL CERTIFICATION / LICENSE
Please upload or capture a clear photo of the FRONT of your Certificate or Nursing License below.
IDENTIFICATION: SOCIAL SECURITY CARD
Please upload or capture clear photos of the FRONT and BACK of your Social Security Card below.
IDENTIFICATION: PHOTO ID CARD
Please upload or capture clear photos of the FRONT and BACK of your Driver's License or State ID.