I, = $nurse->fname." ".$nurse->mid_name." ".$nurse->lname ?>, do understand that I am under contractual obligation to
provide the administrative office of Complete Home Care Services Inc with the renewed
documents which are required for continued employment, upon or before the date of expiration.
The documents are as follows:
In addition, I am required to fulfill Complete Home Care Services Inc.’s In-service Education
Program annually in a timely manner.
Employee Name :fname." ".$nurse->mid_name." ".$nurse->lname; ?> Date :__________________________
Witness Name :__________________________ Date :__________________________
Name: =$nurse->fname." ".$nurse->mid_name." ".$nurse->lname ?> | Title #: =$nurse->patient_id?> |
APPEARANCE | .. | Indifferent to attire and grooming, sloppy, unkempt |
.. | Careless in attire | |
.. | Functional attire, neatly groomed | |
.. | Well groomed | |
.. | Immaculate attire and grooming |
BEARING | .. | No bearing, lacks confidence, slovenly posture |
.. | Often appears uncertain, poor posture | |
.. | Holds self well, self confident | |
.. | Sure of self, does reflect confidence | |
.. | Highly confident, inspire others, asserts presence |
EXPRESSION | .. | Uncommunicative, confused thoughts, poor vocabulary |
.. | Poor speaker, hazy thoughts, ideas | |
.. | Speaks well, expresses ideas adequately | |
.. | Speaks, thinks clearly with confidence | |
.. | Exceptional, speaks clearly, concisely with confidence, ideas well thought out |
JOB KNOWLEDGE | .. | None as pertains to this position |
.. | Will need considerable training | |
.. | Basic but will learn the job | |
.. | Well versed in position, little training needed | |
.. | Extremely well versed, able to work without training |
MOTIVATION | .. | None, apathetic, indifferent, disinterested |
.. | Doubtful interest in position | |
.. | Sincere desire to work | |
.. | Strong interest in position, asks question | |
.. | Highly motivated, eager to work, asks many questions |
PERSONALITY | .. | Unpleasant |
.. | Slightly objectionable | |
.. | Likeable | |
.. | Pleasing | |
.. | Extremely pleasing, charming individual |
_____________________________ | _____________________________ | ||
Interviewer Signature | Date |
Name: =$nurse->fname." ".$nurse->mid_name." ".$nurse->lname?> | Title #: qualification_type == 4){ echo "RN"; } elseif($nurse->qualification_type == 5){ echo "LPN"; } elseif($nurse->qualification_type == 6){ echo "PCA"; } elseif($nurse->qualification_type == 7){ echo "HHA"; } ?> | ||||||||||
Side One: Credentials | |||||||||||
Requirements : | I-9 : | ||||||||||
License / Cert.#: = $nurse->lic_no; ?> | Verified: = $nurse->lic_state; ?> | License Exp: = $nurse->lic_exp_date; ?> | |||||||||
NPI#: = $nurse->NPI_Number; ?> | Verified: | E-Verify: | |||||||||
Malpractice:= $nurse->NPI_Number; ?> | |||||||||||
CPR Exp: |
|
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CHRC: | |||||||||||
Side Two: Application | |||||||||||
2 Page Applications: | |||||||||||
Interview: | |||||||||||
References: | |||||||||||
Test: | |||||||||||
Pre-Employment: | |||||||||||
Skills Check List: | |||||||||||
Side Three: Orientation | |||||||||||
Verification of Orientation: | |||||||||||
Do’s and Don’ts: | |||||||||||
Agreement Form: | |||||||||||
Addendum: | |||||||||||
Employee Handbook: | |||||||||||
HIPPA: | |||||||||||
Confidentiality: | |||||||||||
Infection & Safety: | |||||||||||
Payment Auth w/ W4: | |||||||||||
Side Four: Annual | |||||||||||
In-service Cert : | I-9 : | ||||||||||
Competency Grid : | CLIA : | ||||||||||
Supervision : | Performance Evaluation : | ||||||||||
Date Audited : | DOH : |
Last Name: =$nurse->lname?> | First Name #: =$nurse->fname?> | Middle Name #: =$nurse->mid_name?> | |||||
Home Address : =$nurse->address1?> | City : =$nurse->city1?> | State : =$nurse->state1?> | Zip : =$nurse->zipcode1?> | ||||
Telephone : =$nurse->phone ?> | Alternate #: =$nurse->phone ?> | Social Security #: =$nurse->soc_sec ?> | Sex #: =$nurse->gender ?> | ||||
Date of Birth : =$nurse->dob ?> | Maiden Name : =$nurse->maiden_name?> | Email Address : =$nurse->email?> |
Are you a citizen of the United States? | citizen ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
If not, do you have the right to remain permanently and work in the United States? | remain_permanently ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do you have authorization to work? | authorization_to_work ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Are you involved as a defendant in any professional litigation? | involved_as_defendant ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Have you ever been convicted of a crime? If yes please explain | convicted ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Have you ever been convicted for negligence? | convicted_for_negligence ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do you have any criminal convictions? | criminal_convictions ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
= $citizen->criminal_convictions_details ?> | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Valid New York Drivers License | criminal_convictions ==1) { ?>YES | NO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
List your job history, last two employers. Start with your present status and note any periods in which you were not employed. |
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Name of Employer : | = $employementHistory->name_of_employeer;?> | ||||||||
Address of Employer: | = $employementHistory->address_of_employer;?> | ||||||||
Telephone Number of Employer: | = $employementHistory->tel_of_employer; ?> | ||||||||
Type of work performed: | = $employementHistory->work_performance; ?> | ||||||||
Reason for leaving: | = $employementHistory->reasonForLeaving; ?> | ||||||||
. | |||||||||
Name of Employer : | = $employementHistory->name_of_employeer1; ?> | ||||||||
Address of Employer: | = $employementHistory->address_of_employer1; ?> | ||||||||
Telephone Number of Employer: | = $employementHistory->tel_of_employer1; ?> | ||||||||
Type of work performed: | = $employementHistory->work_performance1; ?> | ||||||||
Reason for leaving: | = $employementHistory->reasonForLeaving1; ?> | ||||||||
. | |||||||||
PHYSICAL RECORD : |
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Do you have any physical defects that preclude you from performing any work for which you are being considered? : | physicaldefects == 1){ echo "YES"; }else{ echo "NO"; } ?> | ||||||||
$nurse->physicaldefects_details; ?> | |||||||||
Were you ever injured? | injured == 1){ echo "YES"; }else{ echo "NO"; } ?> | ||||||||
$nurse->injuryDetails; ?> | |||||||||
Have you any defects in hearing? Yes No | In vision inVision == 1){ echo "YES"; }else{ echo "NO"; } ?> | In speech speach == 1){ echo "YES"; }else{ echo "NO"; } ?> | |||||||
In case of emergency notify: | Relationship: = $nurse->Emergency_Contact_Relationship ?> | ||||||||
Name: = $nurse->Emergency_Contact_Name ?> | Address:= $nurse->Emergency_Contact_Address.",".$nurse->Emergency_Contact_Country.",".$nurse->Emergency_Contact_State.",".$nurse->Emergency_Contact_City.",".$nurse->Emergency_Contact_zipcode ?> | Telephone: = $nurse->Emergency_Contact_Telephone ?> | |||||||
2ND emergency contact: | Relationship: = $nurse->Emergency_Contact_Relationship1 ?> | ||||||||
Name: = $nurse->Emergency_Contact_Name1 ?> | Address:= $nurse->Emergency_Contact_Address1.",".$nurse->Emergency_Contact_Country1.",".$nurse->Emergency_Contact_State1.",".$nurse->Emergency_Contact_City1.",".$nurse->Emergency_Contact_zipcode1 ?> | Telephone: = $nurse->Emergency_Contact_Telephone1 ?> | |||||||
I certify that I a 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 addition 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. |
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Applicant’s Signature:__________________________ | Date: ___________________ | ||||||||
|
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Comments by Interviewer :___________________________________________________________________ | |||||||||
____________________________________________________________________________________________ | |||||||||
Approved by HR management :___________________________________________________________________ | |||||||||
____________________________________________________________________________________________ |
To: _____________________________________ ___________________________________________ Attn :______________________________________ ___________________________________________ |
I authorize the release of any information requested on the form. Applicant: ________________________________ Soc. Sec. No: = $nurse->soc_sec; ?> 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 Applied For: __________________________________ | Personnel Coordinator: __________________________________ |
EMPLOYMENT VERIFICATION TO BE COMPLETED BY THE EMPLOYER |
Applicant’s Name: | Position In Your Employment: |
Employment Dates:(From) ____________________________ (To) _______________________________ | |
Reason for Leaving: ____________________________________________ | |
Would you rehire: YES NO If no, please explain: ____________________________________________ | |
Additional Comments: : ____________________________________________ | |
Signature: : ____________________________________________ | Title: _______________ Date :________________ |
PERSONAL REFERENCE |
Number of Years Acquainted with Applicant ________. 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 :________________ |
HR USE ONLY. DO NOT WRITE BELOW THIS LINE |
Date Mailed: ____________________________________________ | Date Received :________________ |
APPLICANT'S STATEMENTI 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 |
|
Signature: | Date: |
To: _____________________________________ ___________________________________________ Attn :______________________________________ ___________________________________________ |
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 Applied For: __________________________________ | Personnel Coordinator: __________________________________ |
EMPLOYMENT VERIFICATION TO BE COMPLETED BY THE EMPLOYER |
Applicant’s Name: | Position In Your Employment: |
Employment Dates:(From) ____________________________ (To) _______________________________ | |
Reason for Leaving: ____________________________________________ | |
Would you rehire: YES NO If no, please explain: ____________________________________________ | |
Additional Comments: : ____________________________________________ | |
Signature: : ____________________________________________ | Title: _______________ Date :________________ |
PERSONAL REFERENCE |
Number of Years Acquainted with Applicant ________. 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 :________________ |
HR USE ONLY. DO NOT WRITE BELOW THIS LINE |
Date Mailed: ____________________________________________ | Date Received :________________ |
APPLICANT'S STATEMENTI 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 |
|
Signature: | Date: |
Name:fname)) { echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname; } ?> | Date of Birth:dob)) { echo $nurse->dob; } ?> |
General Physical Findings: | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Height: = $height.",".$height_inches; ?> | Blood Pressure: blood_pressure)) { echo $physical_exam_form->blood_pressure; } ?> | Pulse: pulse)) { echo $physical_exam_form->pulse; } ?> | Respiration: respiration)) { echo $physical_exam_form->respiration; } ?> | Weight: weight)) { echo $physical_exam_form->weight; } ?>lbs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Heart: heart)) { echo $physical_exam_form->heart; } ?> | Lungs: lungs)) { echo $physical_exam_form->lungs." ".$nurse->lungs; } ?> | Muscular-Skeletal: muscular_skeleta)) { echo $physical_exam_form->muscular_skeleta; } ?> | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
GU: gu)) { echo $physical_exam_form->gu; } ?> | GI: gi)) { echo $physical_exam_form->gi; } ?> | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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I certify that the above person is free from symptoms indicating the presence of an infectious disease, drug and alcohol abuse and does not have any condition which would interfere with the performance of his/her duties. He/She will be able to transfer patients; provide personal care; light housekeeping; shopping; laundry and skilled nursing functions (if a licensed nurse). |
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Date: | ________ | Physician’s Name: | ________ | Signature : | ________ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Address: | ________ | Phone: | ________ |
Name:/td> | fname)) { echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname; } ?>< | Date of Birth: | dob)) { echo $nurse->dob; } ?> | Sex: | gender)) { echo $nurse->gender; } ?> | ||||||||||||||||||||||||||||||||||||||||
Address: | address1)) { echo $nurse->address1.",".$nurse->country1.",",$nurse->state1.",".$nurse->city1.",".$nurse->zipcode1; } ?> | ||||||||||||||||||||||||||||||||||||||||||||
Emergency Contact: | Emergency_Contact_Name)) { echo $nurse->Emergency_Contact_Name; } ?> | Relationship: | Emergency_Contact_Relationship)) { echo $nurse->Emergency_Contact_Relationship; } ?> | ||||||||||||||||||||||||||||||||||||||||||
Emergency Address/Phone numbe: | Emergency_Contact_Address)) { echo $nurse->Emergency_Contact_Address; } ?> | ||||||||||||||||||||||||||||||||||||||||||||
Indicate if you are suffering from or have a history of the following conditions:
|
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TURBERCULOSIS QUESTIONNAIREIndicate if you have been experiencing the following conditions:
|
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Have you had a positive PPD reading? : positive_ppd==1){ echo "YES"; } else { echo "NO"; }?> | |||||||||||||||||||||||||||||||||||||||||||||
Are you under the care of a physician? : under_care==1){ echo "YES"; } else { echo "NO"; }?> Reason :under_care_explain)) { echo $emp_health_assesment->under_care_explain; } ?> | |||||||||||||||||||||||||||||||||||||||||||||
Do you take depressants, stimulants, narcotic drugs that alter your behavior? : change_behaviour==1){ echo "YES"; } else { echo "NO"; }?> | |||||||||||||||||||||||||||||||||||||||||||||
Do you take prescription medications? prescription_medications==1){ echo "YES"; } else { echo "NO"; }?> If yes, which medications? prescription_medications_explain)) { echo $nurse->prescription_medications_explain; } ?> | |||||||||||||||||||||||||||||||||||||||||||||
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? screening_test==1){ echo "YES"; } else { echo "NO"; }?> | |||||||||||||||||||||||||||||||||||||||||||||
Have you had any operations or hospitalization for illnesses past 5 years?past_illness==1){ echo "YES"; } else { echo "NO"; }?> Reason:past_illness_explain)) { echo $emp_health_assesment->past_illness_explain; } ?> | |||||||||||||||||||||||||||||||||||||||||||||
Name of Physician: : | Telephone: | ||||||||||||||||||||||||||||||||||||||||||||
I have read the above and declare that I have had no injury, illness or ailment other than as specifically identified. I certify that I am not habituated or addicted to any depressants, stimulants, narcotics, drugs, alcohol or other substances that may alter my behavior |
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Employee Signature: | Date: | ||||||||||||||||||||||||||||||||||||||||||||
RN Signature: | Date: |
SECTION III |
HEPATITIS B VACCINE ACEPTANCE / DECLINATION |
Employee Name :_________________________ | |||||
# :_________________________ |
I fname." ".$nurse->mid_name." ".$nurse->lname; ?> , have been informed of the complication / side effects of receiving Hepatitis B vaccine and I choose to have the vaccine administered to me. |
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. | _______________________ | _______________________ | |||||||||||||||||||||||||||||||||
. | Signature/Title | Date | |||||||||||||||||||||||||||||||||
Allergies:Allergies; ?> | Date of Exposure:date_of_exposure; ?> | Location :location; ?> | |||||||||||||||||||||||||||||||||
Type of exposure :type_of_exposure; ?> | |||||||||||||||||||||||||||||||||||
_____________________________________________________ | |||||||||||||||||||||||||||||||||||
Incident Report Completed : incident_report==1) { echo "YES"; } else { echo "No"; } ?> | Worker’s Compensation Report Completed : report_completed==1) { echo "YES"; } else { echo "No"; } ?> | ||||||||||||||||||||||||||||||||||
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Lab Work Performed | |||||||||||||||||||||||||||||||||||
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DECLINATION | |||||||||||||||||||||||||||||||||||
I = $nurse->fname." ".$nurse->mid_name." ".$nurse->lname ?> , understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B Virus (HBV) Infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B Vaccine I can receive the vaccination series at no charge to me. |
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_______________________________ | ________________________________ | ||||||||||||||||||||||||||||||||||
Signature | Date | ||||||||||||||||||||||||||||||||||
_______________________________ | ________________________________ | ||||||||||||||||||||||||||||||||||
Supervisor’s Signature/Title | Date |
Pre- employment Clinical Competency Assessment RN / LPN |
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RN/LPN Reviewer________________________________________ | Date:____________________ | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Comment :________________________________________ |