LAST NAME:
Employment Application
Care Positive - A Residential Care
Agency
APPLICANT INFORMATION
Last Name
First
M.I.
Street Address
Date
Apartment/Unit #
City
State
Phone
E-mail Address
Date Available
ZIP
Desired Salary
Social Security No.
Position Applied for
Are you a citizen of the United States? YES
NO
If no, are you authorized to work in the U.S.? YES
Have you ever worked for this company? YES
NO
If so, when?
Have you ever been convicted of a felony? YES
NO
If yes, explain
EDUCATION
NO
High School
From
Address
To
Did you graduate?
To
Did you graduate?
Other
From
Degree
Address
College
From
YES
YES
NO
Degree
NO
Degree
Address
To
Did you graduate?
YES
REFERENCES
Please list three professional references.
Full Name
Relationship
Company
Phone (
)
Address
Full Name
Relationship
Company
Phone (
)
Address
Full Name
Relationship
Company
Phone (
Address
)
NO
PREVIOUS EMPLOYMENT
(
Company
Phone
Address
Supervisor
Job Title
)
Starting Salary $
Ending Salary $
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference? YES
NO
Company
Phone
Address
Supervisor
Job Title
(
)
Starting Salary $
Ending Salary $
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference? YES
NO
Company
Phone
Address
Supervisor
Job Title
(
)
Starting Salary $
Ending Salary $
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference? YES
NO
MILITARY SERVICE
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.
[Electronic] Signature:
Date
I agree that my electronic signature is the legally binding equivalent to my handwritten signature. When I execute
an electronic signature, on all pages of this application, it has the same validity and meaning as my handwritten
signature.
Electronic Signature: *
Please Type your First and Last Name
Date: ___________
Care Positive
Pre-Employment Phone/ Written Reference Request
Applicant Information:
Applicant Name:
Date:
Position Applied For:
Previous Employer Information:
Name of Contact:
Title:
Address:
Company:
City, State, Zip:
Reference Questions:
Hello, applicant ____________________________ has applied for a position with our company and has
listed you as his/her previous employer.
Contact Attempts Notes:
1:
3:
2:
4:
May we ask you to verify the following information?
1) Was the Applicant was an employee of your Company?
_____ Yes
_____ No
2) The period of Employment was from __________ to ____________
If there are different dates indicate here: and from _________ to ________.
3) The applicant’s salary on the hiring date was $______ .
Check one:
___ Hourly
___ Weekly ___ Yearly
4) The applicant’s position on the date of the end of employment was _______________________
5) The applicant’s salary on the date of the end of employment was $______ .
Check one:
___ Hourly
___ Weekly ___ Yearly
6) The applicant’s job description and responsibilities were:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
7) The reason for the ending of employment was:
_______________________________________________________________________
_______________________________________________________________________
Please take a moment to rate the applicant from 1-5 in the following areas:
5 = Excellent
4 = Above Average
3 = Average
1 = Unacceptable
a) Cooperation and reliability
2 = Improvement Needed
0 = Not Applicable
________
b) Job Knowledge and Productivity ________
c) Quality of Work
________
8) Would you rehire this person? ______ Yes
9)
______No
Can you provide commentary on their overall job performance?
________________________________________________________________________________
________________________________________________________________________________
Care Positive
Hepatitis B Declination
Name: ____________________________
Date:______________
Address: _________________________________
City: ____________________ State:______
Zip:_______
Phone: _______________________
_____ I have received the Hepatitis B Vaccine in the past and will provide the
agency with documentation.
_____ I have not receive the Hep B vaccine and choose not to receive it at this time.
Applicant [Electronic] Signature: _______________________ Date:___________
Care Positive
Nursing Assistant Skill Validation Competency – Adult/Geriatric Care
Applicant’s Name:________________________ Date:___________
Initial Date of Certification:___________ Annual (Use of skills):___________
Please complete the following form by initialing next to all skills that you have
experience in and date (ex. MQ/ 2014). After reviewing the policy, a nurse
supervisor will validate all pertinent skills.
Skills
Nurse’s Initials/Date
RN Validator/Date
Temperature ----------- Auxiliary
------ Oral
------ Rectal
------ Ear
Pulse
------ Apical
------ Brachial
------ Carotid
Respiration
Blood Pressure
Feeding
ADL’s --------------Bathing
----- Complete
------------------------
------------------------
----- Partial
----- Shower
Oral Care
Skin Care
Hair Care
Nail Care
Perennial Care
Shaving
Dressing
Toileting
---- Bedpan
---- Urinal
---- Commode
Transferring
----- Bed
----- Chair
----- Commode
----- Wheelchair
----- Hoyer Lift
--- PROM Exercise
--- FROM Exercise
Body Mechanics
Changing Bed
Occupied
Unoccupied
Emptying Foley
Collecting Specimen
Stool Sample
Urine
Sputum
Universal
Precautions
Hand washing
Soiled Laundry
Specimen Collection
Safety
Side Rails
Emergency
Procedures
Disaster Protocol
Fire Safety
Environmental
Communication
Documentation
Dementia Care
Postmortem Care
[Medication Technicians Only, Answer for the skills below]
Skills
Med Tech’s Initials/Date RN Validator/Date
Medication Passing
Documentation
Verification of
Order
Number of Hours of Med. Tech. Training :_____________________
Date when Training was Completed: ________________
Comments:___________________________________________________________
____________________________________________________________________
______________________________________________________________
Additional Training Recommendations:
____________________________________________________________________
________________________________________________________________
CNA
Employee [Electronic] Signature: ____________________ Date:______________
Med Tec
Employee [Electronic] Signature: ____________________ Date:______________
RN Review Signatures:
RN Validator [Electronic] Signature: _____________________ Date:___________
RN Validator [Electronic] Signature: _____________________ Date:___________
RN Validator [Electronic] Signature: _____________________ Date:___________
RN Initials and Name:
1.______________________________
2.______________________________
3.______________________________
Care Positive
Medical Statement
Name:____________________________ Date:__________
Address:__________________________________________
City:________________ State:___________ Zip:__________
Phone:______________ Cell:______________
Medical Information
Physician:_________________________________________
______ I have examined the above patient, and he/she is free from communicable
disease.
______ There are no lifting restrictions and the applicant is able to physically
perform duties.
______ There is no apparent evidence of substance abuse.
Immunizations
Date:_______ TB Test Results_______ mm
Date:_________ Hepatitis B
Date:_______ Chest X-ray Results________
Date:_________ MMR
Date:_________ Tetanus
Drug Screen:_______________________________________________________
Comments:________________________________________________________
Signature:__________________________ Date:____________________
Care Positive
Employee/Character Reference Verification
Name:________________________________________ Date:__________
Address:_____________________________________________________________
____________________________________________________________________
Position Applied:______________________________________________________
I consent to have professional and personal references verified for employment.
____________________________________________________________________
Signature
Date
Name of reference:_________________________________________________
Position:_______________________________________
Eligible for rehire:_____________ Attendance:__________________
Length of Employment:_________________ Work Performance:_________
Comments:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Signature:_______________________________ Date:______________