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wecuro_blog/application/modules/caregivers/views/rnLpnForm.php

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<?php //echo $id; die; ?>
<!DOCTYPE html>
<html>
<head>
<style type="text/css">
.sub_head_1{
font-size: 20px;
}
.page-wrap { width: 800px; margin: 0 auto; }
td.text-center.table-heading-name {
width: 250px;
}
.print_table { width: 100%; }
.print_row_sub { width: 90%; border: thin solid #000; }
.print_row_header{
text-decoration: underline;
}
.condition{
}
</style>
<title> </title>
</head>
<body body onload="window.print()">
<!-- <body body > -->
<link rel="stylesheet" type="text/css" href="https://stackpath.bootstrapcdn.com/bootstrap/4.5.2/css/bootstrap.min.css">
<!--
<link rel="stylesheet" type="text/css" href="<?php echo base_url(); ?>common/app-assets/css/vendors.css">
<link rel="stylesheet" type="text/css" href="<?php echo base_url(); ?>common/app-assets/css/app.css">
-->
<div class="container page-wrap">
<div class="row">
<div class="col-sm-12 pull-right">
<!-- <button onclick="printPage()">Print</button> -->
</div>
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p><br />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: </p>
<p>
<ul>
<li>NYS Nursing Registration Certificate (Every 3 years)</li>
<li>Malpractice Insurance Policy (Annual)</li>
<li>CPR Card (Every 2 years)</li>
<li>Annual Physical Exam including . . .</li>
<ul>
<li>PPD/ Mantoux Skin Test for TB OR</li>
<li>Chest X-Ray for TB (if history of + PPD every 3 years)</li>
<li>Drug Screen (Annual)</li>
<li>Rubeola and Rubella Titre</li>
</ul>
<li>Annual Health Assessment</li>
<li>Medical History Questionnaire</li>
<li>NPI Number</li>
<li>Social Security Card and Picture ID or Passport</li>
<li>Resume and 2 References</li>
</ul>
</p>
<p><br />In addition, I am required to fulfill Complete Home Care Services Inc.’s In-service Education
Program annually in a timely manner.</p>
<br>
<br>
<p>Employee Name :<u><?php echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname; ?></u> &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; Date :__________________________</p>
<!-- <p> &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; Date </p> -->
<br>
<br>
<br>
<p>Witness Name :__________________________ &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; Date :__________________________</p>
<!-- <p>Employee Name &nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Date </p> -->
</div>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<div class="row">
<div class="col-sm-12 text-center">
<h1><strong>INTERVIEW DOCUMENTATION</strong></h1>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<table class="table">
<tbody>
<tr>
<td><strong>Name:</strong> <?=$nurse->fname." ".$nurse->mid_name." ".$nurse->lname ?> </td>
<td><strong>Title #: <?=$nurse->patient_id?></strong> </td>
</tr>
</tbody>
</table>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<table width="100%" border="1">
<tr>
<td rowspan="5" class="text-center table-heading-name">APPEARANCE</td>
<td>..</td>
<td>Indifferent to attire and grooming, sloppy, unkempt</td>
</tr>
<tr>
<td>..</td>
<td>Careless in attire</td>
</tr>
<tr>
<td>..</td>
<td>Functional attire, neatly groomed</td>
</tr>
<tr>
<td>..</td>
<td>Well groomed</td>
</tr>
<tr>
<td>..</td>
<td>Immaculate attire and grooming</td>
</tr>
</table>
</div>
<div class="col-sm-12">
<table width="100%" border="1">
<tr>
<td rowspan="5" class="text-center table-heading-name">BEARING</td>
<td>..</td>
<td>No bearing, lacks confidence, slovenly posture</td>
</tr>
<tr>
<td>..</td>
<td>Often appears uncertain, poor posture</td>
</tr>
<tr>
<td>..</td>
<td>Holds self well, self confident</td>
</tr>
<tr>
<td>..</td>
<td>Sure of self, does reflect confidence</td>
</tr>
<tr>
<td>..</td>
<td>Highly confident, inspire others, asserts presence</td>
</tr>
</table>
</div>
<div class="col-sm-12">
<table width="100%" border="1">
<tr>
<td rowspan="5" class="text-center table-heading-name">EXPRESSION</td>
<td>..</td>
<td>Uncommunicative, confused thoughts, poor vocabulary</td>
</tr>
<tr>
<td>..</td>
<td>Poor speaker, hazy thoughts, ideas</td>
</tr>
<tr>
<td>..</td>
<td>Speaks well, expresses ideas adequately</td>
</tr>
<tr>
<td>..</td>
<td>Speaks, thinks clearly with confidence</td>
</tr>
<tr>
<td>..</td>
<td>Exceptional, speaks clearly, concisely with confidence, ideas well thought out </td>
</tr>
</table>
</div>
<div class="col-sm-12">
<table width="100%" border="1">
<tr>
<td rowspan="5" class="text-center table-heading-name">JOB KNOWLEDGE</td>
<td>..</td>
<td>None as pertains to this position</td>
</tr>
<tr>
<td>..</td>
<td>Will need considerable training</td>
</tr>
<tr>
<td>..</td>
<td>Basic but will learn the job</td>
</tr>
<tr>
<td>..</td>
<td>Well versed in position, little training needed</td>
</tr>
<tr>
<td>..</td>
<td>Extremely well versed, able to work without training</td>
</tr>
</table>
</div>
<div class="col-sm-12">
<table width="100%" border="1">
<tr>
<td rowspan="5" class="text-center table-heading-name">MOTIVATION</td>
<td>..</td>
<td>None, apathetic, indifferent, disinterested</td>
</tr>
<tr>
<td>..</td>
<td>Doubtful interest in position</td>
</tr>
<tr>
<td>..</td>
<td>Sincere desire to work</td>
</tr>
<tr>
<td>..</td>
<td>Strong interest in position, asks question</td>
</tr>
<tr>
<td>..</td>
<td>Highly motivated, eager to work, asks many questions</td>
</tr>
</table>
</div>
<div class="col-sm-12">
<table width="100%" border="1">
<tr>
<td rowspan="5" class="text-center table-heading-name">PERSONALITY</td>
<td>..</td>
<td>Unpleasant</td>
</tr>
<tr>
<td>..</td>
<td>Slightly objectionable</td>
</tr>
<tr>
<td>..</td>
<td>Likeable</td>
</tr>
<tr>
<td>..</td>
<td>Pleasing</td>
</tr>
<tr>
<td>..</td>
<td>Extremely pleasing, charming individual</td>
</tr>
</table>
</div>
<div class="col-sm-12">
<p><center><h4>Overall impression: | Unsatisfactory | Marginal | Satisfactory | Very Good | Excellent</h4></center></p>
</div>
<div class="col-sm-12">
<table width="100%">
<tr>
<td></td>
<td class="text-center">_____________________________</td>
<td class="text-center">_____________________________</td>
<td></td>
</tr>
<tr>
<td></td>
<td class="text-center">Interviewer Signature </td>
<td class="text-center">Date</td>
<td></td>
</tr>
</table>
</div>
</div>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<h1>AUDIT SHEET</h1>
<table class="print_table">
<tr>
<td class="print_row" width="40%"><span class="print_label">Name:</span> <?=$nurse->fname." ".$nurse->mid_name." ".$nurse->lname?></td>
<td class="print_row" colspan='2'><span class="print_label">Title #: </span> <?php if($nurse->qualification_type == 4){
echo "RN"; }
elseif($nurse->qualification_type == 5){
echo "LPN";
}
elseif($nurse->qualification_type == 6){
echo "PCA";
}
elseif($nurse->qualification_type == 7){
echo "HHA";
}
?> </td>
</tr>
<tr>
<td class="print_row_header" colspan="3">Side One: Credentials</td>
</tr>
<tr>
<td class="print_row" colspan='2'><span class="print_label">Requirements : </span></td>
<td class="print_row" ><span class="print_label">I-9 : </span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">License / Cert.#: <?= $nurse->lic_no; ?></span></td>
<td class="print_row" width="30%"><span class="print_label">Verified: <?= $nurse->lic_state; ?></span></td>
<td class="print_row" width="30%"><span class="print_label">License Exp: <?= $nurse->lic_exp_date; ?></span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">NPI#: <?= $nurse->NPI_Number; ?></span></td>
<td class="print_row" ><span class="print_label">Verified: </span></td>
<td class="print_row" ><span class="print_label">E-Verify: </span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Malpractice:<?= $nurse->NPI_Number; ?></span></td>
<td class="print_row" colspan="2"></td>
</tr>
<?php $physical_exam_form=json_decode($nurse->physical_exam_form) ?>
<tr>
<td class="print_row" ><span class="print_label">CPR Exp:</span></td>
<td class="print_row sub_parts" colspan="2" rowspan="10" align="right">
<table class="print_row_sub" width="90%">
<tr>
<td class="print_row head"><u>Employee Medical</u></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Initial Medical:</span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Annual Medical Exp:</span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Hep. B Vaccine Exp:<?= $physical_exam_form->HB3 ?></span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label"></span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Rubeola Titre:<?= $physical_exam_form->rubeola_resultDate ?></span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Rubella Titre:<?= $physical_exam_form->RubellaVaccine ?></span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">PPD Exp:<?= $physical_exam_form->ppd1_resultDate ?></span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Chest X-Ray Exp:<?= $physical_exam_form->xray_resultDate ?></span></td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">CHRC:</span></td>
</tr>
<tr>
<td class="print_row_header">Side Two: Application</td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">2 Page Applications:</span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Interview:</span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">References:</span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Test:</span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Pre-Employment:</span></td>
</tr>
<tr>
<td class="print_row" ><span class="print_label">Skills Check List:</span></td>
</tr>
<tr>
<td class="print_row_header">Side Three: Orientation</td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Verification of Orientation:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Do’s and Don’ts:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Agreement Form:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Addendum:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Employee Handbook:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">HIPPA:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Confidentiality:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Infection & Safety:</span></td>
</tr>
<tr>
<td class="print_row" colspan="3" ><span class="print_label">Payment Auth w/ W4:</span></td>
</tr>
<tr>
<td class="print_row_header" colspan="3">Side Four: Annual</td>
</tr>
<tr>
<td class="print_row" colspan='2'><span class="print_label">In-service Cert : </span></td>
<td class="print_row" ><span class="print_label">I-9 : </span></td>
</tr>
<tr>
<td class="print_row" colspan='2'><span class="print_label">Competency Grid : </span></td>
<td class="print_row" ><span class="print_label">CLIA : </span></td>
</tr>
<tr>
<td class="print_row" colspan='2'><span class="print_label">Supervision : </span></td>
<td class="print_row" ><span class="print_label">Performance Evaluation : </span></td>
</tr>
<tr>
<td class="print_row" colspan="3" >&nbsp;</td>
</tr>
<tr>
<td class="print_row" colspan='2'><span class="print_label">Date Audited : </span></td>
<td class="print_row" ><span class="print_label">DOH : </span></td>
</tr>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<h1 class="text-center">APPLICATION FOR EMPLOYMENT</h1>
<table class="table">
<tr>
<td><strong>Last Name:</strong> <?=$nurse->lname?></td><td></td>
<td><strong>First Name #: <?=$nurse->fname?></strong> </td><td></td>
<td><strong>Middle Name #: <?=$nurse->mid_name?></strong> </td><td></td>
<td></td><td></td>
</tr>
<tr>
<td><strong>Home Address :</strong> <?=$nurse->address1?></td><td></td>
<td><strong>City : <?=$nurse->city1?></strong> </td><td></td>
<td><strong>State : <?=$nurse->state1?></strong> </td><td></td>
<td><strong>Zip : <?=$nurse->zipcode1?></strong> </td><td></td>
</tr>
<tr>
<td><strong>Telephone :</strong> <?=$nurse->phone ?></td><td></td>
<td><strong>Alternate #: <?=$nurse->phone ?></strong> </td><td></td>
<td><strong>Social Security #: <?=$nurse->soc_sec ?></strong> </td><td></td>
<td><strong>Sex #: <?=$nurse->gender ?></strong> </td><td></td>
</tr>
<tr>
<td><strong>Date of Birth :</strong> <?=$nurse->dob ?></td><td></td>
<td><strong>Maiden Name : <?=$nurse->maiden_name?></strong> </td><td></td>
<td><strong>Email Address : <?=$nurse->email?></strong> </td><td></td>
<td></td><td></td>
</tr>
</table>
<?php $citizen = json_decode($nurse->citizen); ?>
<table width="100%">
<tr>
<td>Are you a citizen of the United States? </td>
<?php if($citizen->citizen ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td>If not, do you have the right to remain permanently and work in the United States? </td>
<?php if($citizen->remain_permanently ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td>Do you have authorization to work? </td>
<?php if($citizen->authorization_to_work ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td>Are you involved as a defendant in any professional litigation? </td>
<?php if($citizen->involved_as_defendant ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td>Have you ever been convicted of a crime? If yes please explain </td>
<?php if($citizen->convicted ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td>Have you ever been convicted for negligence? </td>
<?php if($citizen->convicted_for_negligence ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td>Do you have any criminal convictions? </td>
<?php if($citizen->criminal_convictions ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td colspan="3"><u><?= $citizen->criminal_convictions_details ?></u></td>
</tr>
<tr><td></td></tr>
<tr>
<td>Valid New York Drivers License </td>
<?php if($citizen->criminal_convictions ==1) { ?>
<td>YES</td>
<?php } else { ?>
<td>NO</td>
<?php } ?>
</tr>
<tr>
<td colspan="3">
<table width="100%">
<tr>
<td width="16%">License No: <?= $nurse->lic_no; ?></td>
<td width="16%"> </td>
<td width="16%">State: <?= $nurse->lic_state; ?></td>
<td width="16%"> </td>
<td width="16%">Expiration Date: <?= $nurse->lic_exp_date; ?></td>
<td width="16%">: </td>
</tr>
<tr>
<td colspan="2">Title: </td>
<td colspan="4"> <?php if($nurse->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";
}
?>
</td>
</tr>
<tr>
<td colspan="2">Position Applied For: </td>
<td colspan="4"><?= $nurse->position_applied; ?></td>
</tr>
<tr>
<?php $availability=explode("/",$nurse->availability); ?>
<td colspan="2">Availability:: </td>
<td colspan="4">
<?php if (in_array(1, $availability)) {echo 'Sunday'; } ?>,
<?php if (in_array(2, $availability)) {echo 'Monday'; } ?>,
<?php if (in_array(3, $availability)) {echo 'Tuesday'; } ?>,
<?php if (in_array(4, $availability)) {echo 'Wednesday'; } ?>,
<?php if (in_array(5, $availability)) {echo 'Thursday'; } ?>,
<?php if (in_array(6, $availability)) {echo 'Friday'; } ?>,
<?php if (in_array(7, $availability)) {echo 'Saturday'; } ?>
</td>
</tr>
<tr>
<td >Preferred Shifts: </td>
<td colspan="2"><u> <?= $nurse->preferred_shifts ?></u></td>
<!-- <td >Hours: </td>
<td colspan="2">______________</td> -->
</tr>
<tr>
<td >Languages spoken: </td>
<td colspan="5"><?= $nurse->preferred_shifts ?> </td>
</tr>
<tr>
<?php $availability_borough=explode("/",$nurse->availability_borough); ?>
<td colspan="2">Boros: </td>
<td colspan="4">
<?php if (in_array(BK, $availability_borough)) {echo 'BK'; } ?>,
<?php if (in_array(QU, $availability_borough)) {echo 'QU'; } ?>,
<?php if (in_array(BX, $availability_borough)) {echo 'BX'; } ?>,
<?php if (in_array(MAN, $availability_borough)) {echo 'MAN'; } ?>,
<?php if (in_array(SI, $availability_borough)) {echo 'SI'; } ?>,
<?php if (in_array(NA, $availability_borough)) {echo 'NA'; } ?>
</td>
</tr>
<tr>
<td colspan="6"><h4>EDUCATION BACKGROUND</h4></td>
</tr>
<tr>
<td colspan="2">School Name</td>
<td colspan="2">Location of school</td>
<td >Years</td>
<td >Major Subject</td>
</tr>
<?php
$edu = json_decode($nurse->educationBackground);
foreach($edu as $educationBackground){ ?>
<tr>
<td colspan="2"><u><?= $educationBackground->school ?></u></td>
<td colspan="2"><u><?= $educationBackground->location_school ?></u></td>
<td ><u><?= $educationBackground->edu_years ?></u></td>
<td ><u><?= $educationBackground->major_subject ?></u></td>
</tr>
<?php } ?>
<tr>
<td colspan="6">.</td>
</tr>
<tr>
<td colspan="6">.</td>
</tr>
<tr>
<td colspan="5">.</td>
<td>
<table border="1">
<tr>
<td>Employee ID #:</td>
<td>_______________</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
<table>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<h1>EMPLOYMENT HISTORY</h1>
<table>
<?php $employementHistory = json_decode($nurse->employementHistory); ?>
<tr>
<td colspan="8">
<p>List your job history, last two employers. Start with your present status and note any periods in which you were not employed.</p>
</td>
</tr>
<tr>
<td colspan="2">Name of Employer :</td>
<td colspan="6"><u><?= $employementHistory->name_of_employeer;?></u></td>
</tr>
<tr>
<td colspan="2">Address of Employer: </td>
<td colspan="6"><u><?= $employementHistory->address_of_employer;?></u></td>
</tr>
<tr>
<td colspan="2">Telephone Number of Employer: </td>
<td colspan="6"><u><?= $employementHistory->tel_of_employer; ?></u></td>
</tr>
<tr>
<td colspan="2">Type of work performed: </td>
<td colspan="6"><u><?= $employementHistory->work_performance; ?></u></td>
</tr>
<tr>
<td colspan="2">Reason for leaving: </td>
<td colspan="6"><u><?= $employementHistory->reasonForLeaving; ?></u></td>
</tr>
<tr>
<td colspan="8">.</td>
</tr>
<tr>
<td colspan="2">Name of Employer :</td>
<td colspan="6"><u><?= $employementHistory->name_of_employeer1; ?></u></td>
</tr>
<tr>
<td colspan="2">Address of Employer: </td>
<td colspan="6"><u><?= $employementHistory->address_of_employer1; ?></u></td>
</tr>
<tr>
<td colspan="2">Telephone Number of Employer: </td>
<td colspan="6"><u><?= $employementHistory->tel_of_employer1; ?></u></td>
</tr>
<tr>
<td colspan="2">Type of work performed: </td>
<td colspan="6"><u><?= $employementHistory->work_performance1; ?></u></td>
</tr>
<tr>
<td colspan="2">Reason for leaving: </td>
<td colspan="6"><u><?= $employementHistory->reasonForLeaving1; ?></u></td>
</tr>
<tr>
<td colspan="8">.</td>
</tr>
<tr>
<td colspan="8"><h1>PHYSICAL RECORD :</h1></td>
</tr>
<tr>
<td colspan=8>Do you have any physical defects that preclude you from performing any work for which you are being considered? :</td>
<td><?php
if($nurse->physicaldefects == 1){
echo "YES";
}else{
echo "NO";
}
?></td>
</tr>
<tr>
<td colspan=8><u><?php $nurse->$nurse->physicaldefects_details; ?></u></td>
</tr>
<tr>
<td colspan=6>Were you ever injured?</td>
<td colspan=2><?php
if($nurse->injured == 1){
echo "YES";
}else{
echo "NO";
}
?></td>
</tr>
<tr>
<td colspan=8><u><?php $nurse->$nurse->injuryDetails; ?></u></td>
</tr>
<tr>
<td colspan="3">Have you any defects in hearing? Yes  No</td>
<td colspan="3">In vision <?php
if($nurse->inVision == 1){
echo "YES";
}else{
echo "NO";
}
?></td>
<td colspan="3">In speech <?php
if($nurse->speach == 1){
echo "YES";
}else{
echo "NO";
}
?></td>
</tr>
<tr>
<td colspan="3">In case of emergency notify: </td>
<td colspan="3"></td>
<td colspan="3">Relationship: <?= $nurse->Emergency_Contact_Relationship ?></td>
</tr>
<tr>
<td colspan="3">Name: <?= $nurse->Emergency_Contact_Name ?></td>
<td colspan="3">Address:<?= $nurse->Emergency_Contact_Address.",".$nurse->Emergency_Contact_Country.",".$nurse->Emergency_Contact_State.",".$nurse->Emergency_Contact_City.",".$nurse->Emergency_Contact_zipcode ?></td>
<td colspan="3">Telephone: <?= $nurse->Emergency_Contact_Telephone ?></td>
</tr>
<tr>
<td colspan="3">2ND emergency contact: </td>
<td colspan="3"></td>
<td colspan="3">Relationship: <?= $nurse->Emergency_Contact_Relationship1 ?></td>
</tr>
<tr>
<td colspan="3">Name: <?= $nurse->Emergency_Contact_Name1 ?></td>
<td colspan="3">Address:<?= $nurse->Emergency_Contact_Address1.",".$nurse->Emergency_Contact_Country1.",".$nurse->Emergency_Contact_State1.",".$nurse->Emergency_Contact_City1.",".$nurse->Emergency_Contact_zipcode1 ?></td>
<td colspan="3">Telephone: <?= $nurse->Emergency_Contact_Telephone1 ?></td>
</tr>
<tr>
<td colspan="9">
<p>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.<br></p>
<p>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.<br>
</p>
</td>
</tr>
<tr>
<td colspan="3">Applicant’s Signature:__________________________ </td>
<td colspan="3"></td>
<td colspan="3">Date: ___________________ </td>
</tr>
<tr>
<td colspan="9">
<center>
<table border="1">
<tr>
<td>
<h5>HR USE ONLY. DO NOT WRITE BELOW THIS LINE</h5>
</td>
</tr>
</table>
</center>
</td>
</tr>
<tr>
<td colspan="9">
Comments by Interviewer :___________________________________________________________________
</td>
</tr>
<tr>
<td colspan=9>____________________________________________________________________________________________</td>
</tr>
<tr>
<td colspan="9">
Approved by HR management :___________________________________________________________________
</td>
</tr>
<tr>
<td colspan=9>____________________________________________________________________________________________</td>
</tr>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<h4 class="text-center">WRITTEN REFERENCE</h4>
<table width="100%" border=1>
<tr>
<td width="50%">
To: _____________________________________<br>
___________________________________________<br>
Attn :______________________________________<br>
___________________________________________<br>
</td>
<td width="50%">
<p>I authorize the release of any information requested on the form.</p><br>
Applicant: ________________________________<br>
Soc. Sec. No: <?= $nurse->soc_sec; ?><br>
Signature: ________________________________<br>
</td>
</tr>
</table>
<p>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.
</p>
<br>
<table width="100%">
<tr>
<td width="50%">
Position Applied For: __________________________________
</td>
<td width="50%">
Personnel Coordinator: __________________________________
</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td class="text-center">EMPLOYMENT VERIFICATION TO BE COMPLETED BY THE EMPLOYER</td>
</tr>
</table>
<table width="100%">
<tr>
<td width="50%">Applicant’s Name:</td>
<td width="50%">Position In Your Employment:</td>
</tr>
<tr>
<td colspan="2">Employment Dates:(From) ____________________________ (To) _______________________________</td>
</tr>
<tr>
<td colspan="2">Reason for Leaving: ____________________________________________</td>
</tr>
<tr>
<td colspan="2">Would you rehire:  YES  NO If no, please explain: ____________________________________________</td>
</tr>
<tr>
<td colspan="2">Additional Comments: : ____________________________________________</td>
</tr>
<tr>
<td>Signature: : ____________________________________________</td>
<td align="right">Title: _______________ Date :________________</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td class="text-center">PERSONAL REFERENCE</td>
</tr>
</table>
<table width="100%">
<tr>
<td colspan="2">
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:
</td>
</tr>
<tr>
<td colspan="2">_________________________________________________________________________</td>
</tr>
<td colspan="2">_________________________________________________________________________</td>
</tr>
<tr>
<td>Signature: : ____________________________________________</td>
<td align="right"> Date :________________</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td class="text-center">HR USE ONLY. DO NOT WRITE BELOW THIS LINE</td>
</tr>
</table>
<table width="100%">
<tr>
<td>Date Mailed: ____________________________________________</td>
<td align="right"> Date Received :________________</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td colspan="2">
<h5>APPLICANT'S STATEMENT</h5><br>
<p>I certify that answers given herein are true and complete</p>
<p>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.
</p>
<p>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.
</p>
<p>
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
</p>
</td>
</tr>
<tr>
<td width="50%">Signature: </td>
<td width="50%">Date: </td>
</tr>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<h4 class="text-center">WRITTEN REFERENCE</h4>
<table width="100%" border=1>
<tr>
<td width="50%">
To: _____________________________________<br>
___________________________________________<br>
Attn :______________________________________<br>
___________________________________________<br>
</td>
<td width="50%">
<p>I authorize the release of any information requested on the form.</p><br>
Applicant: ________________________________<br>
Soc. Sec. No: ________________________________<br>
Signature: ________________________________<br>
</td>
</tr>
</table>
<p>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.
</p>
<br>
<table width="100%">
<tr>
<td width="50%">
Position Applied For: __________________________________
</td>
<td width="50%">
Personnel Coordinator: __________________________________
</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td class="text-center">EMPLOYMENT VERIFICATION TO BE COMPLETED BY THE EMPLOYER</td>
</tr>
</table>
<table width="100%">
<tr>
<td width="50%">Applicant’s Name:</td>
<td width="50%">Position In Your Employment:</td>
</tr>
<tr>
<td colspan="2">Employment Dates:(From) ____________________________ (To) _______________________________</td>
</tr>
<tr>
<td colspan="2">Reason for Leaving: ____________________________________________</td>
</tr>
<tr>
<td colspan="2">Would you rehire:  YES  NO If no, please explain: ____________________________________________</td>
</tr>
<tr>
<td colspan="2">Additional Comments: : ____________________________________________</td>
</tr>
<tr>
<td>Signature: : ____________________________________________</td>
<td align="right">Title: _______________ Date :________________</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td class="text-center">PERSONAL REFERENCE</td>
</tr>
</table>
<table width="100%">
<tr>
<td colspan="2">
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:
</td>
</tr>
<tr>
<td colspan="2">_________________________________________________________________________</td>
</tr>
<td colspan="2">_________________________________________________________________________</td>
</tr>
<tr>
<td>Signature: : ____________________________________________</td>
<td align="right"> Date :________________</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td class="text-center">HR USE ONLY. DO NOT WRITE BELOW THIS LINE</td>
</tr>
</table>
<table width="100%">
<tr>
<td>Date Mailed: ____________________________________________</td>
<td align="right"> Date Received :________________</td>
</tr>
</table>
<table width="100%" border="1">
<tr>
<td colspan="2">
<h5>APPLICANT'S STATEMENT</h5><br>
<p>I certify that answers given herein are true and complete</p>
<p>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.
</p>
<p>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.
</p>
<p>
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
</p>
</td>
</tr>
<tr>
<td width="50%">Signature: </td>
<td width="50%">Date: </td>
</tr>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<h4 class="text-center">Physical Examination Form</h4>
<table width="100%" border="1">
<?php $physical_exam_form=json_decode($nurse->physical_exam_form); ?>
<td width="50%">Name:<?php
if (!empty($nurse->fname)) {
echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname;
}
?></td>
<td width="50%">Date of Birth:<?php
if (!empty($nurse->dob)) {
echo $nurse->dob;
}
?></td>
</table>
<table width="100%">
<tr>
<td colspan="6">General Physical Findings:</td>
</tr>
<?php
if(!empty($physical_exam_form->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='';
?>
<tr>
<td>Height: <?= $height.",".$height_inches; ?></td>
<td>Blood Pressure: <?php
if (!empty($physical_exam_form->blood_pressure)) {
echo $physical_exam_form->blood_pressure;
}
?></td>
<td>Pulse: <?php
if (!empty($physical_exam_form->pulse)) {
echo $physical_exam_form->pulse;
}
?></td>
<td>Respiration: <?php
if (!empty($physical_exam_form->respiration)) {
echo $physical_exam_form->respiration;
}
?></td>
<td>Weight: <?php
if (!empty($physical_exam_form->weight)) {
echo $physical_exam_form->weight;
}
?>lbs</td>
</tr>
<tr>
<td>Heart: <?php
if (!empty($physical_exam_form->heart)) {
echo $physical_exam_form->heart;
}
?></td>
<td>Lungs: <?php
if (!empty($physical_exam_form->lungs)) {
echo $physical_exam_form->lungs." ".$nurse->lungs;
}
?></td>
<td colspan="4">Muscular-Skeletal: <?php
if (!empty($physical_exam_form->muscular_skeleta)) {
echo $physical_exam_form->muscular_skeleta;
}
?></td>
</tr>
<tr>
<td colspan="3">GU: <?php
if (!empty($physical_exam_form->gu)) {
echo $physical_exam_form->gu;
}
?></td>
<td colspan="3">GI: <?php
if (!empty($physical_exam_form->gi)) {
echo $physical_exam_form->gi;
}
?></td>
</tr>
<tr>
<td colspan="3">
<table>
<tr>
<td colspan="4"><b>Tests Required by Law of ALL Males & Females<b></td>
</tr>
<tr>
<td></td>
<td>Test Date</td>
<td>Result in mm</td>
<td>Result Date</td>
</tr>
<tr>
<td>PPD(Mantoux) </td>
<td><u><?php
if (!empty($physical_exam_form->ppd1_testDate)) {
echo $physical_exam_form->ppd1_testDate;
}
?></u></td>
<td><u><?php
if (!empty($physical_exam_form->ppd1_result)) {
echo $physical_exam_form->ppd1_result;
}
?></u>mm</td>
<td><u><?php
if (!empty($physical_exam_form->ppd1_resultDate)) {
echo $physical_exam_form->ppd1_resultDate;
}
?></u></td>
</tr>
<tr>
<td>PPD (Mantoux) 2nd</td>
<td><u><?php
if (!empty($physical_exam_form->ppd2_testDate)) {
echo $physical_exam_form->ppd2_testDate;
}
?></u></td>
<td><u><?php
if (!empty($physical_exam_form->ppd2_result)) {
echo $physical_exam_form->ppd2_result;
}
?></u>mm</td>
<td><u><?php
if (!empty($physical_exam_form->ppd2_resultDate)) {
echo $physical_exam_form->ppd2_resultDate;
}
?></u></td>
</tr>
<tr>
<td>X-Ray if positive PPD</td>
<td><u><?php
if (!empty($physical_exam_form->xray_testDate)) {
echo $physical_exam_form->xray_testDate;
}
?></u></td>
<td><u><?php
if (!empty($physical_exam_form->xray_result)) {
echo $physical_exam_form->xray_result;
}
?></u></td>
<td><u><?php
if (!empty($physical_exam_form->xray_resultDate)) {
echo $physical_exam_form->xray_resultDate;
}
?></u></td>
</tr>
<tr>
<td>Rubella Titre</td>
<td><u><?php
if (!empty($physical_exam_form->rubella_testDate)) {
echo $physical_exam_form->rubella_testDate;
}
?></u></td>
<td><u><?php
if (!empty($physical_exam_form->rubella_result)) {
echo $physical_exam_form->rubella_result;
}
?></u></td>
<td><u><?php
if (!empty($physical_exam_form->rubella_resultDate)) {
echo $physical_exam_form->rubella_resultDate;
}
?></u></td>
</tr>
<tr>
<td>Rubeola Titre (If born after 11/1/57 Rubeola verified)</td>
<td><?php
if (!empty($physical_exam_form->rubeola_testDate)) {
echo $physical_exam_form->rubeola_testDate;
}
?></td>
<td><u><?php
if (!empty($physical_exam_form->rubeola_result)) {
echo $physical_exam_form->rubeola_result;
}
?></u></td>
<td><u><?php
if (!empty($physical_exam_form->rubeola_resultDate)) {
echo $physical_exam_form->rubeola_resultDate;
}
?></u></td>
</tr>
<tr>
<td colspan="4"><u><?php
if (!empty($physical_exam_form->rubeola_details)) {
echo $physical_exam_form->rubeola_details;
}
?></u></td>
</tr>
<tr>
<td>Influenza Vaccine Site:</td>
<td><u><?php
if (!empty($physical_exam_form->influenza_testDate)) {
echo $physical_exam_form->influenza_testDate;
}
?></u></td>
<td colspan="2"><u><?php
if (!empty($physical_exam_form->influenza_resultDate)) {
echo $physical_exam_form->influenza_resultDate;
}
?></u></td>
</tr>
<tr>
<td>Lot Number:</td>
<td><u><?php
if (!empty($physical_exam_form->lot_num)) {
echo $physical_exam_form->lot_num;
}
?></u></td>
<td>Expiration :</td>
<td><u><?php
if (!empty($physical_exam_form->lot_exp)) {
echo $physical_exam_form->lot_exp;
}
?></u></td>
</tr>
</table>
</td>
<td colspan="3">
<table>
<tr>
<td colspan="4"><b>Specify Disease Immunization or Test</b> (May be requested by state or client)</td>
</tr>
<tr>
<td></td>
<td colspan="3">Dates</td>
</tr>
<tr>
<td>Diphtheria</td>
<td colspan="3"><u><?php
if (!empty($physical_exam_form->Diphtheria)) {
echo $physical_exam_form->Diphtheria;
}
?></u></td>
</tr>
<tr>
<td>Tetanus</td>
<td colspan="3"><u><?php
if (!empty($physical_exam_form->Tetanus)) {
echo $physical_exam_form->Tetanus;
}
?></u></td>
</tr>
<tr>
<td>Mumps</td>
<td colspan="3"><u><?php
if (!empty($physical_exam_form->Mumps)) {
echo $physical_exam_form->Mumps;
}
?></u></td>
</tr>
<tr>
<td>Rubella Vaccine </td>
<td colspan="3"><u><?php
if (!empty($physical_exam_form->RubellaVaccine)) {
echo $physical_exam_form->RubellaVaccine;
}
?></u></td>
</tr>
<tr>
<td>Measles Vaccine </td>
<td>1.<u><?php
if (!empty($physical_exam_form->MeaslesVaccine1)) {
echo $physical_exam_form->MeaslesVaccine1;
}
?></u></td>
<td>2.<u><?php
if (!empty($physical_exam_form->MeaslesVaccine2)) {
echo $physical_exam_form->MeaslesVaccine2;
}
?></u></td>
<td></td>
</tr>
<tr>
<td>HB Vaccine : </td>
<td>1.<u><?php
if (!empty($physical_exam_form->HB1)) {
echo $physical_exam_form->HB1;
}
?></u></td>
<td>2.<u><?php
if (!empty($physical_exam_form->HB2)) {
echo $physical_exam_form->HB2;
}
?></u></td>
<td>3.<u><?php
if (!empty($physical_exam_form->HB3)) {
echo $physical_exam_form->HB3;
}
?></u></td>
</tr>
<tr>
<td>Drug Screen : </td>
<td>1.<u><?php
if (!empty($physical_exam_form->DrugScreen)) {
echo $physical_exam_form->DrugScreen;
}
?></u></td>
<td>2._____________</td>
<td>3._____________</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="6">
<table width="100%" style="border:1px solid;">
<tr>
<td colspan="2">
Specify any follow-up treatment needed for positive test results or delay due to pregnancy:
</td>
</tr>
<tr>
<td colspan="2"><u><?php
if (!empty($physical_exam_form->due_to_pregnancy)) {
echo $physical_exam_form->due_to_pregnancy;
}
?></u></td>
</tr>
<tr>
<td colspan="2">
Medications (List all medications prescribed on a continuing basis):
</td>
</tr>
<tr>
<td colspan="2"><u><?php
if (!empty($physical_exam_form->list_of_medications)) {
echo $physical_exam_form->list_of_medications;
}
?></u></td>
</tr>
<tr>
<td colspan="2"><b>Physical Limitations</b> (to the best of your knowledge):</td>
</tr>
<tr>
<td>a. Does this person require eyeglasses?
<?php if ($physical_exam_form->eyeglasses==1){
echo "YES"; } else { echo "NO"; }?></td>
<td> hearing aide? <?php if ($physical_exam_form->hearingAid==1){
echo "YES"; } else { echo "NO"; }?></td>
</tr>
<tr>
<td colspan="2">b. Has this person been treated for any disease entity or injury which hampered his/her ability to function normally for extended periods? <?php if ($physical_exam_form->extended_periods==1){
echo "YES"; } else { echo "NO"; }?></td>
</tr>
<tr>
<td colspan="2">If yes Explain </td>
</tr>
<tr>
<td colspan="2"><u><?php
if (!empty($setval)) {
echo set_value('extended_periods_explain');
}
if (!empty($physical_exam_form->extended_periods_explain)) {
echo $physical_exam_form->extended_periods_explain;
}
?></u></td>
</tr>
<tr>
<td colspan="2">______________________________________________________________________________________</td>
</tr>
<tr>
<td colspan="2">c. Is this person presently being treated for any disorders of a chronic or recurring nature? (Please include any history of back injury, congenital defect, brain or nervous disorders, etc.): <?php if ($physical_exam_form->disorders==1){
echo "YES"; } else { echo "NO"; }?></td>
</tr>
<tr>
<td colspan="2">If yes Explain </td>
</tr>
<tr>
<td colspan="2"><u><?php
if (!empty($setval)) {
echo set_value('extended_periods_explain');
}
if (!empty($physical_exam_form->extended_periods_explain)) {
echo $physical_exam_form->extended_periods_explain;
}
?></u></td>
</tr>
<tr>
<td colspan="2">______________________________________________________________________________________</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="6" align="left">
<p>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).
</p>
</td>
</tr>
<tr>
<td>Date:</td>
<td>________</td>
<td>Physician’s Name:</td>
<td>________</td>
<td>Signature :</td>
<td>________</td>
</tr>
<tr>
<td>Address:</td>
<td colspan="3">________</td>
<td>Phone:</td>
<td>________</td>
</tr>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<h4 class="text-center">REQUIRED EMPLOYEE HEALTH ASSESSMENT</h4>
<table width="100%" >
<?php $emp_health_assesment=json_decode($nurse->emp_health_assesment) ?>
<tr>
<td >Name:/td>
<td ><?php
if (!empty($nurse->fname)) {
echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname;
}
?><</td>
<td >Date of Birth:</td>
<td ><?php
if (!empty($nurse->dob)) {
echo $nurse->dob;
}
?></td>
<td >Sex:</td>
<td ><?php
if (!empty($nurse->gender)) {
echo $nurse->gender;
}
?></td>
</tr>
<tr>
<td >Address:</td>
<td colspan="5"><?php
if (!empty($nurse->address1)) {
echo $nurse->address1.",".$nurse->country1.",",$nurse->state1.",".$nurse->city1.",".$nurse->zipcode1;
}
?></td>
</tr>
<tr>
<td>Emergency Contact: </td>
<td colspan="3"><?php
if (!empty($nurse->Emergency_Contact_Name)) {
echo $nurse->Emergency_Contact_Name;
}
?></td>
<td>Relationship: </td>
<td><?php
if (!empty($nurse->Emergency_Contact_Relationship)) {
echo $nurse->Emergency_Contact_Relationship;
}
?></td>
</tr>
<tr>
<td>Emergency Address/Phone numbe: </td>
<td colspan="5"><?php
if (!empty($nurse->Emergency_Contact_Address)) {
echo $nurse->Emergency_Contact_Address;
}
?></td>
</tr>
<tr>
<td colspan="6">
Indicate if you are suffering from or have a history of the following conditions:
<table width="100%" border="1">
<tr>
<td width="46%"><b>CONDITION</b></td>
<td width="2%"><b>YES/NO</b></td>
<td width="46%"><b>CONDITION</b></td>
<td width="2%"><b>YES/NO</b></td>
</tr>
<tr>
<td>DIABETES</td>
<td><?php if ($emp_health_assesment->diabetes==1){
echo "YES"; } else { echo "NO"; }?></td>
<td>BACK PAIN</td>
<td><?php if ($emp_health_assesment->back_pain==1){
echo "YES"; } else { echo "NO" ;}?></td>
</tr>
<tr>
<td>KIDNEY DISEASE</td>
<td><?php if ($emp_health_assesment->kidney_disease==1){
echo "YES"; } else { echo "NO"; }?></td>
<td>PAIN ON URINATION</td>
<td><?php if ($emp_health_assesment->pain_urination==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>HEART DISEASE</td>
<td><?php if ($emp_health_assesment->heart_disease==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>CHANGE IN BOWEL HABITS</td>
<td><?php if ($emp_health_assesment->change_bowel_habit==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>HIGH BLOOD PRESSURE</td>
<td><?php if ($emp_health_assesment->high_blood_pressure==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>INCREASED THIRST</td>
<td><?php if ($emp_health_assesment->increased_thirst==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>ARTHRITIS</td>
<td><?php if ($emp_health_assesment->arthritis==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>PERSISTENT SORES/LUMPS</td>
<td><?php if ($emp_health_assesment->persistent_lumps==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>MENTAL ILLNESS</td>
<td><?php if ($emp_health_assesment->mental_illness==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>INFECTIOUS DISEASE</td>
<td><?php if ($emp_health_assesment->infectious_disease==1){
echo "YES" ;} else { echo "NO"; }?></td>
</tr>
<tr>
<td>EPILEPSY/CONVULSIONS</td>
<td><?php if ($emp_health_assesment->epilepsy==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>CANCER</td>
<td><?php if ($emp_health_assesment->cancer==1){
echo "YES" ;} else { echo "NO"; }?></td>
</tr>
<tr>
<td>SWELLING IN THE EXTREMITIES</td>
<td><?php if ($emp_health_assesment->swelling_extremities==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>ANY OTHER PHYSICAL DISABILITY</td>
<td><?php if ($emp_health_assesment->other_disability==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>ALLERGIES</td>
<td><?php if ($emp_health_assesment->allergies==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td></td>
<td></td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="6">
<h4 class="text-center">TURBERCULOSIS QUESTIONNAIRE</h4>
<h6 class="text-center">Indicate if you have been experiencing the following conditions:</h6>
<table width="100%" border="1">
<tr>
<td width="46%"><b>CONDITION</b></td>
<td width="2%"><b>YES/NO</b></td>
<td width="46%"><b>CONDITION</b></td>
<td width="2%"><b>YES/NO</b></td>
</tr>
<tr>
<td>PERSISTENT COUGH FOR < 3 WEEKS</td>
<td><?php if ($emp_health_assesment->cough_3_weeks==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>UNEXPLAINED WEIGHT LOSS</td>
<td><?php if ($emp_health_assesment->unexplained_weight_loss==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>BLOOD IN THE SPUTUM</td>
<td><?php if ($emp_health_assesment->blood_sputum==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>LOSS OF APPETITE</td>
<td><?php if ($emp_health_assesment->appetite_loss==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>SHORTNESS OF BREATH</td>
<td><?php if ($emp_health_assesment->shortness_breath==1){
echo "YES" ;} else { echo "NO" ;}?></td>
<td>HOARSENESS</td>
<td><?php if ($emp_health_assesment->hoarseness==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>NIGHT SWEATS </td>
<td><?php if ($emp_health_assesment->night_sweat==1){
echo "YES"; } else { echo "NO" ;}?></td>
<td>FATIGUE</td>
<td><?php if ($emp_health_assesment->fatigue==1){
echo "YES" ;} else { echo "NO" ;}?></td>
</tr>
<tr>
<td>CHEST PAIN</td>
<td><?php if ($emp_health_assesment->chest_pain==1){
echo "YES" ;} else { echo "NO"; }?></td>
<td>FEVER</td>
<td><?php if ($emp_health_assesment->fever==1){
echo "YES"; } else { echo "NO"; }?></td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="6">Have you had a positive PPD reading? : <?php if ($emp_health_assesment->positive_ppd==1){
echo "YES"; } else { echo "NO"; }?></td>
</tr>
<tr>
<td colspan="6">Are you under the care of a physician? : <?php if ($emp_health_assesment->under_care==1){
echo "YES"; } else { echo "NO"; }?> Reason :<u><?php
if (!empty($setval)) {
echo set_value('under_care_explain');
}
if (!empty($emp_health_assesment->under_care_explain)) {
echo $emp_health_assesment->under_care_explain;
}
?></u></td>
</tr>
<tr>
<td colspan="6">Do you take depressants, stimulants, narcotic drugs that alter your behavior? : <?php if ($emp_health_assesment->change_behaviour==1){
echo "YES"; } else { echo "NO"; }?> </td>
</tr>
<tr>
<td colspan="6">Do you take prescription medications? <?php if ($emp_health_assesment->prescription_medications==1){
echo "YES"; } else { echo "NO"; }?> If yes, which medications? <u><?php
if (!empty($setval)) {
echo set_value('prescription_medications_explain');
}
if (!empty($nurse->prescription_medications_explain)) {
echo $nurse->prescription_medications_explain;
}
?></u> </td>
</tr>
<tr>
<td colspan="6">If required in your position, would you be willing to have screening test for drugs/alcohol done on your blood /urine as a condition for employment? <?php if ($emp_health_assesment->screening_test==1){
echo "YES"; } else { echo "NO"; }?> </td>
</tr>
<tr>
<td colspan="6">Have you had any operations or hospitalization for illnesses past 5 years?<?php if ($emp_health_assesment->past_illness==1){
echo "YES"; } else { echo "NO"; }?> Reason:<?php
if (!empty($setval)) {
echo set_value('past_illness_explain');
}
if (!empty($emp_health_assesment->past_illness_explain)) {
echo $emp_health_assesment->past_illness_explain;
}
?></td>
</tr>
<tr>
<td>Name of Physician: :</td>
<td colspan="2"></td>
<td>Telephone:</td>
<td colspan="2"></td>
</tr>
<tr>
<td colspan="6">
<p>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
</p>
</td>
</tr>
<tr>
<td><b>Employee Signature:</b></td>
<td colspan="2"></td>
<td colspan="2"><b>Date:</b></td>
<td ></td>
</tr>
<tr>
<td><b>RN Signature:</b></td>
<td colspan="2"></td>
<td colspan="2"><b>Date:</b></td>
<td ></td>
</tr>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<table width="100%" >
<?php $hbForm=json_decode($nurse->hb_form);
?>
<tr>
<td><h6 class="text-center">SECTION III</h6></td>
<td colspan="5"><b><h5 class="text-center">HEPATITIS B VACCINE ACEPTANCE / DECLINATION</h5></b></td>
</tr>
</table>
<table>
<tr>
<td colspan="5"></td>
<td width="40%">Employee Name :_________________________</td>
</tr>
<tr>
<td colspan="5"></td>
<td width="40%"># :_________________________</td>
</tr>
</table>
<table>
<tr>
<td colspan="6">
<p>I <?php echo $nurse->fname." ".$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.</p>
<br>
<br>
</td>
</tr>
<tr>
<td colspan="2" width="33%">.</td>
<td colspan="2" width="33%">_______________________</td>
<td colspan="2" width="33%">_______________________</td>
</tr>
<tr>
<td colspan="2" width="33%">.</td>
<td colspan="2" width="33%">Signature/Title</td>
<td colspan="2" width="33%">Date</td>
</tr>
<tr>
<td colspan="2" width="33%">Allergies:<?php echo $hbForm->Allergies; ?></td>
<td colspan="2" width="33%">Date of Exposure:<?php echo $hbForm->date_of_exposure; ?></td>
<td colspan="2" width="33%">Location :<?php echo $hbForm->location; ?></td>
</tr>
<tr>
<td colspan="6" >Type of exposure :<u><?php echo $hbForm->type_of_exposure; ?></u></td>
</tr>
<tr>
<td colspan="6" >_____________________________________________________</td>
</tr>
<tr>
<td colspan="3" >Incident Report Completed : <?php if($hbForm->incident_report==1) {
echo "YES"; } else { echo "No"; } ?> </td>
<td colspan="3" >Worker’s Compensation Report Completed : <?php if($hbForm->report_completed==1) {
echo "YES"; } else { echo "No"; } ?> </td>
</tr>
<tr>
<td colspan="6" ><br></td>
</tr>
<tr>
<td colspan="6" >
<table border=1 width="100%">
<tr>
<td class="text-center">Hepatitis B <br> Vaccine</td>
<td class="text-center">TYPE</td>
<td class="text-center">DATE</td>
<td class="text-center">DOSE</td>
<td class="text-center">SITE</td>
<td class="text-center">SIGNATURE OF NURSE</td>
</tr>
<tr>
<td class="text-center">Initial Dose</td>
<td class="text-center"><?php
if (!empty($hbForm->Initial_Dose_Type)) {
echo $hbForm->Initial_Dose_Type;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->Initial_Dose_Date)) {
echo $hbForm->Initial_Dose_Date;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->Initial_Dose)) {
echo $hbForm->Initial_Dose;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->Initial_Dose_Site)) {
echo $hbForm->Initial_Dose_Site;
}
?></td>
<td class="text-center"></td>
</tr>
<tr>
<td class="text-center">Second Dose</td>
<td><?php
if (!empty($hbForm->Initial_Dose_Type2)) {
echo $hbForm->Initial_Dose_Type2;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose_Type2)) {
echo $hbForm->Initial_Dose_Type2;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose2)) {
echo $hbForm->Initial_Dose2;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose_Site2)) {
echo $hbForm->Initial_Dose_Site2;
}
?></td>
<td class="text-center"></td>
</tr>
<tr>
<td class="text-center">Third Dose</td>
<td><?php
if (!empty($hbForm->Initial_Dose_Type3)) {
echo $hbForm->Initial_Dose_Type3;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose_Type3)) {
echo $hbForm->Initial_Dose_Type3;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose3)) {
echo $hbForm->Initial_Dose3;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose_Site3)) {
echo $hbForm->Initial_Dose_Site3;
}
?></td>
<td class="text-center"></td>
</tr>
<tr>
<td class="text-center">Booster Dose</td>
<td><?php
if (!empty($hbForm->Initial_Dose_Type4)) {
echo $hbForm->Initial_Dose_Type4;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose_Type4)) {
echo $hbForm->Initial_Dose_Type4;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose4)) {
echo $hbForm->Initial_Dose4;
}
?></td>
<td><?php
if (!empty($hbForm->Initial_Dose_Site4)) {
echo $hbForm->Initial_Dose_Site4;
}
?></td>
<td class="text-center"></td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="6" ><br></td>
</tr>
<tr>
<td colspan="6" >Lab Work Performed</td>
</tr>
<tr>
<td colspan="6" >
<table border=1 width="100%">
<tr>
<td class="text-center">DATE</td>
<td class="text-center">TYPE</td>
<td class="text-center">RESULTS</td>
<td class="text-center">ACTION TAKEN</td>
</tr>
<tr>
<td class="text-center"><?php
if (!empty($hbForm->lab_date1)) {
echo $hbForm->lab_date1;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_type1)) {
echo $hbForm->lab_type1;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_result1)) {
echo $hbForm->lab_result1;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_action1)) {
echo $hbForm->lab_action1;
}
?></td>
</tr>
<tr>
<td class="text-center"><?php
if (!empty($hbForm->lab_date2)) {
echo $hbForm->lab_date2;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_type2)) {
echo $hbForm->lab_type2;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_result2)) {
echo $hbForm->lab_result2;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_action2)) {
echo $hbForm->lab_action2;
}
?></td>
</tr>
<tr>
<td class="text-center"><?php
if (!empty($hbForm->lab_date3)) {
echo $hbForm->lab_date3;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_type3)) {
echo $hbForm->lab_type3;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_result3)) {
echo $hbForm->lab_result3;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_action3)) {
echo $hbForm->lab_action3;
}
?></td>
</tr>
<tr>
<td class="text-center"><?php
if (!empty($hbForm->lab_date4)) {
echo $hbForm->lab_date4;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_type4)) {
echo $hbForm->lab_type4;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_result4)) {
echo $hbForm->lab_result4;
}
?></td>
<td class="text-center"><?php
if (!empty($hbForm->lab_action4)) {
echo $hbForm->lab_action4;
}
?></td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="6" ><br></td>
</tr>
<tr>
<td colspan="6" align="left"><B>DECLINATION</B></td>
</tr>
<tr>
<td colspan="6" align="left">
<p>I <u><?= $nurse->fname." ".$nurse->mid_name." ".$nurse->lname ?></u> , 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.</p>
</td>
</tr>
<tr>
<td colspan="2"></td>
<td colspan="2" class="text-center">_______________________________</td>
<td colspan="2" class="text-center">________________________________</td>
</tr>
<tr>
<td colspan="2"></td>
<td colspan="2" class="text-center">Signature</td>
<td colspan="2" class="text-center">Date</td>
</tr>
<tr>
<td colspan="6" ><br></td>
</tr>
<tr>
<td colspan="2"></td>
<td colspan="2" class="text-center">_______________________________</td>
<td colspan="2" class="text-center">________________________________</td>
</tr>
<tr>
<td colspan="2"></td>
<td colspan="2" class="text-center">Supervisor’s Signature/Title</td>
<td colspan="2" class="text-center">Date</td>
</tr>
</table>
</div>
</div>
<h3 style="page-break-before: always;"></h3>
<div class="container page-wrap">
<div class="col-sm-12" style="border: 1px solid black; padding: 30px;">
<table width="100%" >
<tr>
<td colspan="6"><b><h5 class="text-center">Pre- employment Clinical Competency Assessment RN / LPN</h5></b></td>
</tr>
<tr>
<td colspan="6"><br></td>
</tr>
<tr>
<td colspan="6">
<table border="1" width="100%">
<tr>
<td width="70%">Name :</td>
<td width="30%">Status :</td>
</tr>
<tr>
<td>Signature :</td>
<td>Date :</td>
</tr>
<tr>
<td>Employee is able to describe or demonstrate the skill for each item :<br></td>
<td>Please initial all the skills that you can perform independently. :</td>
</tr>
<tr>
<td>Physical assessments</td>
<td></td>
</tr>
<tr>
<td>Venipuncture</td>
<td></td>
</tr>
<tr>
<td>Foley insertion/care</td>
<td></td>
</tr>
<tr>
<td>IV Therapy</td>
<td></td>
</tr>
<tr>
<td>IV med administration</td>
<td></td>
</tr>
<tr>
<td>Pumps: Cadd, Gemstar, Kangaroo</td>
<td></td>
</tr>
<tr>
<td>Central line and dressing change</td>
<td></td>
</tr>
<tr>
<td>IV flush /care of central line</td>
<td></td>
</tr>
<tr>
<td>Port Access and Deaccess</td>
<td></td>
</tr>
<tr>
<td>IM/SC med administration</td>
<td></td>
</tr>
<tr>
<td>Wound care/dressing changes</td>
<td></td>
</tr>
<tr>
<td>S/P tube insertion/care</td>
<td></td>
</tr>
<tr>
<td>Care /maintenance of ostomy</td>
<td></td>
</tr>
<tr>
<td>Blood glucose monitoring/testing/teaching/cleaning/calibration</td>
<td></td>
</tr>
<tr>
<td>Collection and transport of lab specimens</td>
<td></td>
</tr>
<tr>
<td>Collection of urine specimens</td>
<td></td>
</tr>
<tr>
<td>Use of assistive devices /patient teaching</td>
<td></td>
</tr>
<tr>
<td>Insertion/maintenance of NG tubes</td>
<td></td>
</tr>
<tr>
<td>Maintenance of G tubes/ J Tube</td>
<td></td>
</tr>
<tr>
<td>Insertion/maintenance of enema/suppository</td>
<td></td>
</tr>
<tr>
<td>Chest PT</td>
<td></td>
</tr>
<tr>
<td>Special consideration</td>
<td></td>
</tr>
<tr>
<td>Pulse Oximetry</td>
<td></td>
</tr>
<tr>
<td>Vent dependent</td>
<td></td>
</tr>
<tr>
<td>Pediatric Nursing</td>
<td></td>
</tr>
<tr>
<td>HHA orientation/supervision</td>
<td></td>
</tr>
<tr>
<td>Additional Skills:</td>
<td></td>
</tr>
<tr>
<td><br></td>
<td><br></td>
</tr>
<tr>
<td><br></td>
<td><br></td>
</tr>
</table>
</td>
</tr>
<tr ><td colspan="6"><br></td></tr>
<tr >
<td colspan="3" aligh="left">RN/LPN Reviewer________________________________________</td>
<td colspan="3" aligh="right">Date:____________________</td>
</tr>
<tr >
<td colspan="6" aligh="left">Comment :________________________________________</td>
</tr>
</table>
</div>
</div>
</body>
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