I, 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:

  • NYS Nursing Registration Certificate (Every 3 years)
  • Malpractice Insurance Policy (Annual)
  • CPR Card (Every 2 years)
  • Annual Physical Exam including . . .
    • PPD/ Mantoux Skin Test for TB OR
    • Chest X-Ray for TB (if history of + PPD every 3 years)
    • Drug Screen (Annual)
    • Rubeola and Rubella Titre
  • Annual Health Assessment
  • Medical History Questionnaire
  • NPI Number
  • Social Security Card and Picture ID or Passport
  • Resume and 2 References


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 :__________________________

INTERVIEW DOCUMENTATION

Name: fname." ".$nurse->mid_name." ".$nurse->lname ?> Title #: 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

Overall impression: | Unsatisfactory | Marginal | Satisfactory | Very Good | Excellent

_____________________________ _____________________________
Interviewer Signature Date

AUDIT SHEET

physical_exam_form) ?>

APPLICATION FOR EMPLOYMENT

Last Name: lname?> First Name #: fname?> Middle Name #: mid_name?>
Home Address : address1?> City : city1?> State : state1?> Zip : zipcode1?>
Telephone : phone ?> Alternate #: phone ?> Social Security #: soc_sec ?> Sex #: gender ?>
Date of Birth : dob ?> Maiden Name : maiden_name?> Email Address : email?>
citizen); ?> citizen ==1) { ?> remain_permanently ==1) { ?> authorization_to_work ==1) { ?> involved_as_defendant ==1) { ?> convicted ==1) { ?> convicted_for_negligence ==1) { ?> criminal_convictions ==1) { ?> criminal_convictions ==1) { ?>
Are you a citizen of the United States? YES NO
If not, do you have the right to remain permanently and work in the United States? YES NO
Do you have authorization to work? YES NO
Are you involved as a defendant in any professional litigation? YES NO
Have you ever been convicted of a crime? If yes please explain YES NO
Have you ever been convicted for negligence? YES NO
Do you have any criminal convictions? YES NO
criminal_convictions_details ?>
Valid New York Drivers License YES NO
availability); ?> availability_borough); ?> educationBackground); foreach($edu as $educationBackground){ ?>
License No: lic_no; ?> State: lic_state; ?> Expiration Date: lic_exp_date; ?> :
Title: qualification_type == 4){ echo "RN"; } elseif($nurse->qualification_type == 5){ echo "LPN"; } elseif($nurse->qualification_type == 6){ echo "PCA"; } elseif($nurse->qualification_type == 7){ echo "HHA"; } ?>
Position Applied For: position_applied; ?>
Availability:: , , , , , ,
Preferred Shifts: preferred_shifts ?>
Languages spoken: preferred_shifts ?>
Boros: , , , , ,

EDUCATION BACKGROUND

School Name Location of school Years Major Subject
school ?> location_school ?> edu_years ?> major_subject ?>
.
.
.
Employee ID #: _______________

EMPLOYMENT HISTORY

employementHistory); ?>

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 : name_of_employeer;?>
Address of Employer: address_of_employer;?>
Telephone Number of Employer: tel_of_employer; ?>
Type of work performed: work_performance; ?>
Reason for leaving: reasonForLeaving; ?>
.
Name of Employer : name_of_employeer1; ?>
Address of Employer: address_of_employer1; ?>
Telephone Number of Employer: tel_of_employer1; ?>
Type of work performed: work_performance1; ?>
Reason for leaving: reasonForLeaving1; ?>
.

PHYSICAL RECORD :

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"; } ?>
$nurse->injuryDetails; ?>
Have you any defects in hearing? Yes  No In vision inVision == 1){ echo "YES"; }else{ echo "NO"; } ?> In speech speach == 1){ echo "YES"; }else{ echo "NO"; } ?>
In case of emergency notify: Relationship: Emergency_Contact_Relationship ?>
Name: Emergency_Contact_Name ?> Address:Emergency_Contact_Address.",".$nurse->Emergency_Contact_Country.",".$nurse->Emergency_Contact_State.",".$nurse->Emergency_Contact_City.",".$nurse->Emergency_Contact_zipcode ?> Telephone: Emergency_Contact_Telephone ?>
2ND emergency contact: Relationship: Emergency_Contact_Relationship1 ?>
Name: Emergency_Contact_Name1 ?> Address:Emergency_Contact_Address1.",".$nurse->Emergency_Contact_Country1.",".$nurse->Emergency_Contact_State1.",".$nurse->Emergency_Contact_City1.",".$nurse->Emergency_Contact_zipcode1 ?> Telephone: 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.

Applicant’s Signature:__________________________ Date: ___________________
HR USE ONLY. DO NOT WRITE BELOW THIS LINE
Comments by Interviewer :___________________________________________________________________
____________________________________________________________________________________________
Approved by HR management :___________________________________________________________________
____________________________________________________________________________________________

WRITTEN REFERENCE

To: _____________________________________
___________________________________________
Attn :______________________________________
___________________________________________

I authorize the release of any information requested on the form.


Applicant: ________________________________
Soc. Sec. No: 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 STATEMENT

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

Signature: Date:

WRITTEN REFERENCE

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 STATEMENT

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

Signature: Date:

Physical Examination Form

physical_exam_form); ?>
Name:fname)) { echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname; } ?> Date of Birth:dob)) { echo $nurse->dob; } ?>
height_feet)) $height=explode('/', $physical_exam_form->height_feet); else $height=''; if(!empty($physical_exam_form->height_inches)) $height_inches=explode('/', $physical_exam_form->height_inches); else $height_inches=''; ?>
General Physical Findings:
Height: 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; } ?>
Tests Required by Law of ALL Males & Females
Test Date Result in mm Result Date
PPD(Mantoux) ppd1_testDate)) { echo $physical_exam_form->ppd1_testDate; } ?> ppd1_result)) { echo $physical_exam_form->ppd1_result; } ?>mm ppd1_resultDate)) { echo $physical_exam_form->ppd1_resultDate; } ?>
PPD (Mantoux) 2nd ppd2_testDate)) { echo $physical_exam_form->ppd2_testDate; } ?> ppd2_result)) { echo $physical_exam_form->ppd2_result; } ?>mm ppd2_resultDate)) { echo $physical_exam_form->ppd2_resultDate; } ?>
X-Ray if positive PPD xray_testDate)) { echo $physical_exam_form->xray_testDate; } ?> xray_result)) { echo $physical_exam_form->xray_result; } ?> xray_resultDate)) { echo $physical_exam_form->xray_resultDate; } ?>
Rubella Titre rubella_testDate)) { echo $physical_exam_form->rubella_testDate; } ?> rubella_result)) { echo $physical_exam_form->rubella_result; } ?> rubella_resultDate)) { echo $physical_exam_form->rubella_resultDate; } ?>
Rubeola Titre (If born after 11/1/57 Rubeola verified) rubeola_testDate)) { echo $physical_exam_form->rubeola_testDate; } ?> rubeola_result)) { echo $physical_exam_form->rubeola_result; } ?> rubeola_resultDate)) { echo $physical_exam_form->rubeola_resultDate; } ?>
rubeola_details)) { echo $physical_exam_form->rubeola_details; } ?>
Influenza Vaccine Site: influenza_testDate)) { echo $physical_exam_form->influenza_testDate; } ?> influenza_resultDate)) { echo $physical_exam_form->influenza_resultDate; } ?>
Lot Number: lot_num)) { echo $physical_exam_form->lot_num; } ?> Expiration : lot_exp)) { echo $physical_exam_form->lot_exp; } ?>
Specify Disease Immunization or Test (May be requested by state or client)
Dates
Diphtheria Diphtheria)) { echo $physical_exam_form->Diphtheria; } ?>
Tetanus Tetanus)) { echo $physical_exam_form->Tetanus; } ?>
Mumps Mumps)) { echo $physical_exam_form->Mumps; } ?>
Rubella Vaccine RubellaVaccine)) { echo $physical_exam_form->RubellaVaccine; } ?>
Measles Vaccine 1.MeaslesVaccine1)) { echo $physical_exam_form->MeaslesVaccine1; } ?> 2.MeaslesVaccine2)) { echo $physical_exam_form->MeaslesVaccine2; } ?>
HB Vaccine : 1.HB1)) { echo $physical_exam_form->HB1; } ?> 2.HB2)) { echo $physical_exam_form->HB2; } ?> 3.HB3)) { echo $physical_exam_form->HB3; } ?>
Drug Screen : 1.DrugScreen)) { echo $physical_exam_form->DrugScreen; } ?> 2._____________ 3._____________
Specify any follow-up treatment needed for positive test results or delay due to pregnancy:
due_to_pregnancy)) { echo $physical_exam_form->due_to_pregnancy; } ?>
Medications (List all medications prescribed on a continuing basis):
list_of_medications)) { echo $physical_exam_form->list_of_medications; } ?>
Physical Limitations (to the best of your knowledge):
a. Does this person require eyeglasses? eyeglasses==1){ echo "YES"; } else { echo "NO"; }?> hearing aide? hearingAid==1){ echo "YES"; } else { echo "NO"; }?>
b. Has this person been treated for any disease entity or injury which hampered his/her ability to function normally for extended periods? extended_periods==1){ echo "YES"; } else { echo "NO"; }?>
If yes Explain
extended_periods_explain)) { echo $physical_exam_form->extended_periods_explain; } ?>
______________________________________________________________________________________
c. Is this person presently being treated for any disorders of a chronic or recurring nature? (Please include any history of back injury, congenital defect, brain or nervous disorders, etc.): disorders==1){ echo "YES"; } else { echo "NO"; }?>
If yes Explain
extended_periods_explain)) { echo $physical_exam_form->extended_periods_explain; } ?>
______________________________________________________________________________________

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).

Date: ________ Physician’s Name: ________ Signature : ________
Address: ________ Phone: ________

REQUIRED EMPLOYEE HEALTH ASSESSMENT

emp_health_assesment) ?>
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:
CONDITION YES/NO CONDITION YES/NO
DIABETES diabetes==1){ echo "YES"; } else { echo "NO"; }?> BACK PAIN back_pain==1){ echo "YES"; } else { echo "NO" ;}?>
KIDNEY DISEASE kidney_disease==1){ echo "YES"; } else { echo "NO"; }?> PAIN ON URINATION pain_urination==1){ echo "YES" ;} else { echo "NO" ;}?>
HEART DISEASE heart_disease==1){ echo "YES" ;} else { echo "NO" ;}?> CHANGE IN BOWEL HABITS change_bowel_habit==1){ echo "YES" ;} else { echo "NO" ;}?>
HIGH BLOOD PRESSURE high_blood_pressure==1){ echo "YES" ;} else { echo "NO" ;}?> INCREASED THIRST increased_thirst==1){ echo "YES" ;} else { echo "NO" ;}?>
ARTHRITIS arthritis==1){ echo "YES" ;} else { echo "NO" ;}?> PERSISTENT SORES/LUMPS persistent_lumps==1){ echo "YES" ;} else { echo "NO" ;}?>
MENTAL ILLNESS mental_illness==1){ echo "YES" ;} else { echo "NO" ;}?> INFECTIOUS DISEASE infectious_disease==1){ echo "YES" ;} else { echo "NO"; }?>
EPILEPSY/CONVULSIONS epilepsy==1){ echo "YES" ;} else { echo "NO" ;}?> CANCER cancer==1){ echo "YES" ;} else { echo "NO"; }?>
SWELLING IN THE EXTREMITIES swelling_extremities==1){ echo "YES" ;} else { echo "NO" ;}?> ANY OTHER PHYSICAL DISABILITY other_disability==1){ echo "YES" ;} else { echo "NO" ;}?>
ALLERGIES allergies==1){ echo "YES" ;} else { echo "NO" ;}?>

TURBERCULOSIS QUESTIONNAIRE

Indicate if you have been experiencing the following conditions:
CONDITION YES/NO CONDITION YES/NO
PERSISTENT COUGH FOR < 3 WEEKS cough_3_weeks==1){ echo "YES" ;} else { echo "NO" ;}?> UNEXPLAINED WEIGHT LOSS unexplained_weight_loss==1){ echo "YES" ;} else { echo "NO" ;}?>
BLOOD IN THE SPUTUM blood_sputum==1){ echo "YES" ;} else { echo "NO" ;}?> LOSS OF APPETITE appetite_loss==1){ echo "YES" ;} else { echo "NO" ;}?>
SHORTNESS OF BREATH shortness_breath==1){ echo "YES" ;} else { echo "NO" ;}?> HOARSENESS hoarseness==1){ echo "YES" ;} else { echo "NO" ;}?>
NIGHT SWEATS night_sweat==1){ echo "YES"; } else { echo "NO" ;}?> FATIGUE fatigue==1){ echo "YES" ;} else { echo "NO" ;}?>
CHEST PAIN chest_pain==1){ echo "YES" ;} else { echo "NO"; }?> FEVER fever==1){ echo "YES"; } else { echo "NO"; }?>
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

Employee Signature: Date:
RN Signature: Date:

hb_form); ?>
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.



. _______________________ _______________________
. 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"; } ?>

Hepatitis B
Vaccine
TYPE DATE DOSE SITE SIGNATURE OF NURSE
Initial Dose Initial_Dose_Type)) { echo $hbForm->Initial_Dose_Type; } ?> Initial_Dose_Date)) { echo $hbForm->Initial_Dose_Date; } ?> Initial_Dose)) { echo $hbForm->Initial_Dose; } ?> Initial_Dose_Site)) { echo $hbForm->Initial_Dose_Site; } ?>
Second Dose Initial_Dose_Type2)) { echo $hbForm->Initial_Dose_Type2; } ?> Initial_Dose_Type2)) { echo $hbForm->Initial_Dose_Type2; } ?> Initial_Dose2)) { echo $hbForm->Initial_Dose2; } ?> Initial_Dose_Site2)) { echo $hbForm->Initial_Dose_Site2; } ?>
Third Dose Initial_Dose_Type3)) { echo $hbForm->Initial_Dose_Type3; } ?> Initial_Dose_Type3)) { echo $hbForm->Initial_Dose_Type3; } ?> Initial_Dose3)) { echo $hbForm->Initial_Dose3; } ?> Initial_Dose_Site3)) { echo $hbForm->Initial_Dose_Site3; } ?>
Booster Dose Initial_Dose_Type4)) { echo $hbForm->Initial_Dose_Type4; } ?> Initial_Dose_Type4)) { echo $hbForm->Initial_Dose_Type4; } ?> Initial_Dose4)) { echo $hbForm->Initial_Dose4; } ?> Initial_Dose_Site4)) { echo $hbForm->Initial_Dose_Site4; } ?>

Lab Work Performed
DATE TYPE RESULTS ACTION TAKEN
lab_date1)) { echo $hbForm->lab_date1; } ?> lab_type1)) { echo $hbForm->lab_type1; } ?> lab_result1)) { echo $hbForm->lab_result1; } ?> lab_action1)) { echo $hbForm->lab_action1; } ?>
lab_date2)) { echo $hbForm->lab_date2; } ?> lab_type2)) { echo $hbForm->lab_type2; } ?> lab_result2)) { echo $hbForm->lab_result2; } ?> lab_action2)) { echo $hbForm->lab_action2; } ?>
lab_date3)) { echo $hbForm->lab_date3; } ?> lab_type3)) { echo $hbForm->lab_type3; } ?> lab_result3)) { echo $hbForm->lab_result3; } ?> lab_action3)) { echo $hbForm->lab_action3; } ?>
lab_date4)) { echo $hbForm->lab_date4; } ?> lab_type4)) { echo $hbForm->lab_type4; } ?> lab_result4)) { echo $hbForm->lab_result4; } ?> lab_action4)) { echo $hbForm->lab_action4; } ?>

DECLINATION

I 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.

_______________________________ ________________________________
Signature Date

_______________________________ ________________________________
Supervisor’s Signature/Title Date

Pre- employment Clinical Competency Assessment RN / LPN

Name : Status :
Signature : Date :
Employee is able to describe or demonstrate the skill for each item :
Please initial all the skills that you can perform independently. :
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
Additional Skills:





RN/LPN Reviewer________________________________________ Date:____________________
Comment :________________________________________