CNA / LPN / RN Application — Kaff Homecare Inc

Personal Information

Position Desired *

Date Available *

Type of Employment Desired

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc.

City *

State *

ZIP Code *

Phone Number *

Alternative Phone Number

Email Address *

Do you have a valid driver's license?

Yes No

Class

CDL?

Yes No

Have you ever served in the military?

Yes No

Do you speak any other language(s)? Specify

Do you have the legal right to obtain employment in the United States?

Yes No

Can you perform the essential functions and responsibilities of the position for which you are applying?

Yes No

Do you require any special accommodation to perform required duties?

Yes No

Have you ever worked for Kaff Homecare, Inc.?

Yes No

Do any of your relatives work for Kaff Homecare, Inc.?

Yes No

List any current licenses, certifications, or registrations required for the position for which you are applying. Include date received.

License or Certification Number

Date of License

Expiration Date

Mandatory: All applicants with an Illinois license or CNA certification must provide the license or certification number and the date of such license or certification.

CPR or First Aid Certification — Training Date

Mantoux Test Date

Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation?

Yes No

You must provide at least three current reference letters and/or the names of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications in the field.

Reference 1 *

Reference 2 *

Reference 3 *

Education and Skills

Level of Education Completed

High School GED College 0-3 Years Degree: Associate Bachelor Masters

Specify Major

Software Applications

Typing Words Per Minute

Experience

List your last 5 years of work experience.

01 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

02 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

03 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

04 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

05 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

Applicant Certification

I agree to carry out the designated responsibilities to the best of my ability. I have read the position description. I am aware there is a conditional period of 3 months prior to permanent employment. *I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. I authorize the investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed. *

Name *

Date *

Certified Nursing Assistant Skills Checklist

Print Name *

Date

Directions: Please select a value for each skill to give us and interested facilities an assessment of your clinical experience. Each skill below requires a rating.

Rating key: 1 = No experience · 2 = Minimal experience / works with supervision · 3 = Independent / works without supervision in most cases · 4 = Senior / works at a supervisory or teaching level

Has knowledge of and can provide care and assist patients with the following tasks:

Ambulation

1234

CRUTCHES

WALKER

CANE

GAIL BELT

Personal Care

1234

A.BED

B.TUB

C.SHOWER

2.SKIN CARE

A.BACK RUB

B.DECUBITUS PREVENTION OR CARE

A.ASSIST AS NEEDED

B.USE OF ASSISTIVE DEVICES

A.CLEAN OR FILE OR TRIM WITH CLIPPERS

A.MOUTH CARE

B.BRUSH TEETH

C.DENTURE CARE

7.SHAVING: SAFETY RAZOR OR ELECTRIC RAZOR

Nutrition or Hydration

1234

1.FEEDING TECHNIQUES

2.ASSIST WITH EATING

3.USE OF FEEDING ASSISTIVE DEVICES

4.MEASURE AND RECORD INTAKE

5.ENCOURAGE FLUIDS

Assisting or Care of Patient with Bowel and Bladder Elimination

1234

1.BEDPAN OR URINAL

2.BEDSIDE COMMODE

3.CARE OF INCONTINENT PATIENT

4.STOMA CARE

5.BOWEL OR BLADDER TRAINING

6.MEASURE AND RECORD OUTPUT

Urinary Catheter Care

1234

1.PERINEAL HYGIENE

2.FOLEY CATHETER

3.SUPRA PUBLIC CATHETER

Transfer Techniques

1234

1.USE OF TRANSFER GAIT BELT

2.WEIGHT BEARING

3.NON-WEIGHT BEARING

4.MECHANICAL LIFT

5.WHEELCHAIR

Turning / Position Patient

1234

1. SUPINE

2. SIDE-LYING

3. IN CHAIR

4. IN BED

5. USE OF LIFT SHEET

Communication

1234

1. VERBAL

2. NON-VERBAL WITH COGNITIVELY IMPAIRED PATIENTS

Range of Motion Excersices

1234

1. ACTIVE

2. PASSIVE

3. COMBINATION

Take & Record Vital Signs

1234

A. ORAL

B. RECTAL

C. EAR CANAL

2. PULSE

A. APICAL

B. RADIAL

C. PEDAL

3. RESPIRATIONS

4. BLOOD PRESSURE

5. HEIGHT

6. WEIGHT

B. BED SCALE

A. STANDING

C. CHAIR SCALE

Safety Devices

1234

1. VEST RESTRAINT

2. (SOFT) WRIST / ANKLE RESTRAINT)

3. PADDED SIDE RAIL

4. SIDE RAILS

Mental Health & Social Services Needs

1234

1. DEMONSTRATES PRINCIPLES OF BEHAVIOR MANAGEMENT

2. PROVIDES EMOTIONAL SUPPORT TO PATIENT

3. ECOURAGES FAMILY SUPPORT

4. ECOURAGES PATIENTS TO MAKE PERSONAL CHOICES

5. REPECTS PATIENT'S RIGHTS AND DIGNITY, INCLUDING PRIVACY & CONFIDENTIALITY

6. ENCOURAGES SELF-CARE AS ABILITY ALLOWS

8. KNOWLEDGE OF DOMESTIC VIOLENCE AND VIOLENT INJURY REPORTING STATUES

7. KNOWLEDGE OF ADULT, CHILD AND ELDER ABUSE REPORTING STATUTES

Safety / Emergencies

1234

1. RECOGNIZES & REPORTS SAFETY HAZARDS

2. RECOGNIZES & REPORTS EMERGENCIES AND RESPONDS APPROPRIATELY

3. HANDLES O2 SAFELY

4. OBSERVES, REPORTS & DOCUMENTS CHANGES IN BODY FUNCTIONS, BEHAVIOR

Care of Prosthetic Devices

1234

1. LIMBS

2. EYE GLASSES

3. HEARING AIDS

Specimen Collection

1234

1. URINE

2. STOOL

3. SPUTUM

Understand and Can Perform

1234

A. ACE BANDAGES

B. SUPPORT STOCKINGS

2. CARE OF THE DECEASED

1. DIABETES

2. CANCER

3. HEART DISEASE

4. O2 THERAPY

5. RESPIRATORY DISEASE

6. TERMINAL

7. INFECTIOUS DISEASE

Certification

To the best of my knowledge, the information I have provided on this skills checklist and application is true and correct. *

Name *

Date

Please complete all required fields and skill ratings (*) before submitting.

Your application is sent securely to Kaff Homecare staff and used only for hiring.