Step 1 of 24
Days and Hours available Mon Tue Wed Thurs. Fri Sat Sun
Personality:
friendly
average
quiet
Verbal skills:
excellent
poor
Communicates:
clear
somewhat clear
not very clear
Flexibility:
very flexible
somewhat
not flexible
Skill level:
higher skilled
moderately skilled
lower skilled
Appearance:
professional
semi-professional
not professional
Good Candidate for Employment:
yes no
PLEASE NOTE:It is important that you complete all parts of the application. If your application is incomplete or does not clearly show the experience and/or training required, your application may not be accepted. If you have no information to enter in a section, please write N/A.
Pleaseinclude name, phone number, and circumstances of your acquaintance. Exclude relatives and former employers.
I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated.
I UNDERSTAND THAT I AM ON PROBATION AS AN EMPLOYEE FOR THE FIRST NINETY DAYSOF MY EMPLOYMENT WHICH STARTED___________ ON I UNDERSTAND THAT MY EMPLOYER MAY DISCHARGE ME FOR UNSATISFACTORY WORK PERFORMANCE. I ACKNOWLEDGE THAT I SIGNED THIS FORM WITHIN SEVEN (7) DAYS OF MY EMPLOYMENT.
We comply with Disabilities nondiscrimination. During the interview process, you may be asked questions concerning your ability, to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employeesin the same job category will be subjected to the same medical questionnaire and/or examination and all information will be kept confidential and in separate files. We are an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, sex, national origin, handicap, or marital status. We assure you that your opportunity for employment with us depends solely upon your qualifications. PLEASE READ AND SIGN STATEMENT BELOW I understand that I will be placed on a 90 day probation period. I further understand that if I am terminated for unsatisfactory work performance within the 90 day probationary period, my employer may seek to contest any unemployment benefit I might attempt to obtain as a result of my termination. I understand and agreed that all policies, procedures, and the Employee Handbook may be modified, amerced, or deleted by my employer with or without notice to me of such amendment, modification or deletion; that the policies and procedures are not intended to be a contract of employment nor do they give me a right of continued employment, and that my employment may be terminated at my option or that the option of my employer with agreements, or understandingsregarding the terms of employment. Theremay be no amendments or exceptions to this statement unless they are in writing and signed by the president. I certify that all information given on this employment application, any resume that I submit to the company, and any related papers and answers given during oral interviews are true and correct. I understand that my employer will make a thorough investigation of my work and personal history. I authorize the giving and receiving of any such information requested by my employer during the course of such investigation. I understand that falsification of any information given by others during the course of this investigation of any derogatory information discovered as a result of this investigation my-subject-me – to – immediate-dismissal. I hereby release from liability all persons who provide information to my employer during the course of any such investigation
It has been explained to me that I am being offered employment by Cora Healthcare Services with the understanding that I have personal protective equipment (PPE) to use, such as mask, gloves, goggles, gown, etc. I also agree to use available PPE to provide care to any patient
I HAVE BEEN FORMALLY INSTRUCTED IN MAINTAINING THE CONFIDENTIALITY OF THE MEDICAL RECORDS AND UNDERSTAND THAT THE MEDICAL INFORMATION REGARDING THE PATIENT MAY NOT BE DISCUSSED WITH ANYONE, EITHER INSIDE OR OUTSIDE THE AGENCY (EXCEPT AN NEEDED TO CONDUCT THE BUSINESS OF THE DAY). I UNDERSTAND THAT NO MEDICAL RECORDS ARE TO BE REMOVED FROM THE HOME HEALTH AGENCY UNLESS A “RELEASE OF INFORMATION” FORMS HAS BEEN COMPLETED AND SIGNED BY THE PATIENT. IT IS IN MY UNDERSTANDING THAT SUCH DISCUSSION OR RELEASE OF INFORMATION IS CAUSE FOR DISMISSAL. I HAVE BEEN FORMALLY INSTRUCTED IN THE POLICIES AND PROCEDURES OF CORA HEALTHCARE SERVICES, ALSO INFORMED REGARDING THE AGENCY’S POLICY FOR CONFIDENTIALITY COMPLIANCE, AND I HAVE READ AND SIGNED A JOB DESCRIPTION FOR MY SPECIFIC CLASSIFICATION.
I, the undersigned, have read and understand Cora Healthcare Services, (hereinafter referto policy on confidentiality Policy which is in accordance with relevant legislation. I also acknowledge that I am aware of and understand the policies of Abik Health Services, regarding the security of personal health information including the policies relating to the use, collection, disclosure, storage and destruction of personal health information. In consideration of my employment or association with Cora Healthcare Services, and as anintegral part of the terms and conditions of my employment or association, I hereby agree, pledge and undertake that I will not at any time, during my employment or association with Cora Healthcare Services, or after my employment or association within or outside Abik Healthcare Services, any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicable Legislation and Cora Healthcare Services, policies governing proper release of information. I understand that my obligations outlined above will continue after my employment/contract/association appointment with Cora Healthcare Services, ends. I further understand that my obligations concerning the protection of the confidentiality of PHI relate to all personal health information whether I acquired the information through my employment or contract or association or appointment with Cora Healthcare Services, orwith any of the entities, which have an association with Cora Healthcare Services. If for any reason I must complete any clinical documentation for any of my patient at later time, or at my residence, I assure that no Protected Health Information will be left unattended in any vehicle. In my residence, it will be placed in a secure location where children or any family member will not have access to it at any time. All family members will be alerted about the Confidentiality status of such records. I also understand that unauthorized use or disclosure of such information will result in a disciplinary action up to and including termination of employment or contract or association or appointment, the imposition of fines pursuant to relevant legislation, and a report to my professional regulatory body
Cora Healthcare Services does not exclude, deny benefits to or otherwise discriminate against any person on the grounds of race, color, national origin, disability or age in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein, whether carried out by our Agency directly or through a contractor or any other entity with which our Agency arranges to carry out its programs and activities. In case of questionplease contact the Agency’s Administrator.
Our Agency strives to maintain a work environment that is free of discrimination, intimidation, hostility, or other offenses that might interfere with work performance. In keeping with this desire, we will not tolerate any unlawful harassment of employees by anyone, including any supervisor, co-worker, vendor, client, or customer.
What Is Harassment? Harassment consists of unwelcome conduct, whether verbal, physical, or visual, that is based upon a person’s protected status, such as color, disability, gender, national origin, race, religion, age or other legally protected status. We will not tolerate harassing conduct that affects tangible job benefits, that interferes unreasonably with an individual’s work performance, or that creates an intimidating, hostile, or offensive working environment. Harassment can take many forms, including, but not limited to: words, signs, jokes, pranks, intimidation, physical contact, or violence
It is the policy of our Agency that home health care providers will adhere to the following, when delivering care to all patients. By adhering to the following universal precautionary measures, the risk of transmission of disease is decreased when the infection status of the patient is unknown. Gloves must be worn when delivering patient care, handling specimens, doing domestic cleaning, and handling items that may be soiled with blood or body fluids. Gloves or aprons must be worn during procedures or while managing a patient situation when there will be exposure to body fluids, blood, draining wounds or mucous membranes. Gloves are to be worn when handling all specimens to prevent contamination from body specimen fluids or blood. Mask and protective eyewear or face shield must be worn during procedures that are likely to generate droplets of body fluids, blood or when the patient is coughing excessively. Hands and other skin surfaces must be washed immediately and thoroughly if contaminated with body fluids or blood and after all patient care activities. Home Health Care providers, who have open cuts, sores, or dermatitis on their hands must wear gloves for all patient contact.
I have been formally instructed that my Physical Examination Form, and any medical and/or Criminal Background screening data is maintaining confidentially and understand that the medical information regarding my health status may not be discussed with anyone, either inside or outside the agency (except an needed to conduct the business of the day). I understand that no medical data are to be removed from the agency unless a “Release of Information” form has been completed and signed for me. It is my understanding that such Release of Information (THIS FORM), authorize the Agency to release my Physical/Background Information data to surveyors at their request if needed for conduct the annual survey or any necessary investigation. I have been formally instructed in the Personnel Policies and Regulations, and I have read and signed a job description for my specific classification.
For your wellbeing, and the wellbeing of your patient, we outline the following procedures to guard against infection.
I have read and understand The Agency, Personnel Policy Manual. In compliance with those policies, I agree to conform to the following:
Voluntarily authorize blood and urine testing as required. I agree to allow such samples and testing to be completed at a time and place to be chosen by my employer. I further authorize the results of samples/testing to be released to my employer.
It is the policy of The Agency that weekly Progress Notes shall be written on each of our patients, preferably each Friday. Such a Progress Note, to be written on our standard “Progress Notes” form, shall be written by a Skilled Nurse/Professional/field staff, who also should supervise the case in review, together with Supervisor RN/Staff if applicable. Completed progress notes, along with other pertinent patient records, shall be submitted to the Director of Nursing (at the office) once every week (Tuesday before 5:30pm). During that period a note faxed from employee may be used in place of the original, until the regular 1 week delivery time frame, progress note is received in the office. Home health care staff members will ensure complete concise documentation of services, issues and conditions occurring during the period of services rendered to the client. It is our Policy that we allow the use of automotive mechanism to help our staff to complete their Progress Notesreport like typing by Typewriter, Word Processor, or Computer Software, in compliance with the following steps:
1-Ensure the compliance of confidential regulations and guidelines, including the care of the Patient’s Privacy Rights. 2-Don’t allow another person access to any Patient Information needed to complete the work, if necessary finish the Notes at the staff’s residence. 3-Destroy all Patient Information after completing the Progress Notes 4-Inform immediately to the Agency’s Privacy Officer if any breach of confidential guidelines for Patient’s Privacy Rights is suspected. 5-In the use of Computer Software or any electronic device to help complete the progress note, the staff cannot save any Patient Information in the Staff Personal Computer/tablet, is the patient’s information is used, the Staff must delete the information, immediately after completing their work.
This Agreement is made this day of_______, 200____ , by and between Cora Healthcare Services hereinafter called the “corporation” having its principal place of business in and residing at ______ City of_____ , State of ________, a nurse, and public independent contractor of his/her nurse services to the health care field, hereinafter called the “contractor, by which the partiesintended and agree, that their relationship shall be one of corporation and independent contractor respectively and that said contractor shall enjoy all rights and privileges, and be obligated and responsible to corporation, for all the duties normally assumed and/or incurred by those commonly referred to, accepted as, and holding themselves to the public as independent contractor in commerce and general business. Whereas corporation and contractor desire to enter into an agreement whereby corporation will contract with third party clients, hereinafter referred to as “clients”, to utilize the services of certain independent nurse contractors from time to time, and whereby said corporation herein will make available his/her servicesto said client(s) by, from time to time, offering compensation to contractor for his/her services whereby contractor will supply his/her services to third party client(s). Corporation and contractor will always be and remain in a relationship of corporation and independent nurse contractor, therefore, corporation and contractor herein agree further, that each shall be governed during said arrangement, and for purposes of this contract, by the provisions set out herein below:
a) The corporation hereby agrees that it has and will contract with certain hospitals, nursing homes, health institutions, (clients), to provide the availability of independent contract nurses to said client(s). The corporation further hereby agrees to utilize contractor, on an independent contractual basis, in providing said services to said client(s), whenever, wherever, and however, said client(s) requires; provided that contractor is competent with regard to, and familiar with the services requested by client(s). b) Should contractor agree to provide his/her services to client(s) for a designated shift and/or designated time, contractor is bound by this agreement to provide said services. Should contractor not be able to fulfill his/her obligations to the client(s), he/she shall notify corporation not less than four (4) hours prior to the beginning of said nursing shift. In the event contractor is absent for a shift which he/she agreed to fulfill, and should contractor fail to notify corporation four (4) hours prior to start of said shift, corporation shall have the option of immediately terminating this agreement, without regard to circumstances or reason leading to contractor’s absence and/or failure to notify corporation c) While contractor is performing said nursing duties, he/she is representing himself/herself and utilizing professional judgment as an independent nurse contractor. This professional judgment is in the sole discretion of the contractor, and is to include all routines, practices and subjective decisions necessary to fulfill the contracted service. Contractor also agrees not to perform duties outside of his/her scope of practice/licensure d) The corporation will provide forms for the contractor to systemically document proof of school, licensure, knowledge, skills, and experience to enable the client(s) to place the contractor in the proper area to be serviced. The corporation and the client(s) will keep a record of this information, if client(s) so desires e) The contractor will not, under any circumstances, act as an agent of the corporation. The contractor shall be solely responsible for his/her own professional training and cost ofsuch training. The contractor shall also be solely responsible for maintaining his/her licenses and for costs of such. The corporation should have no right and shall not direct, supervise, oversee, or control or be responsible for the supervision, direction, or control of the contractor while said contractor is performing services for the client(s), either as to the result to be accomplished. The contractor is responsible for furnishing his/her own uniforms, transportation, tools, instruments, and written material of a professional nature required in the practice of professional nursing. f) Corporation and contractor hereby agree that the client(s) has the authority to direct, supervise, oversee and/or control contractor and can prohibit contractor from working in its facility, if it deems contractor is unfit, rendersinadequate service. In this event, the contractor’sthen existing contract with the corporation shall be automatically terminated, and shall become null and void as of the end of the last day of work by contractor for client(s). Contractor shall be entitled to charge corporation for the time and services actually rendered to the client
aa) The corporation and contractor herein, shall mutually agree upon services to be provided on a daily, weekly, or monthly basis, depending on the corporation’s client(s) requirements and the contractor’s desired work volume and availability. Subject to any pre-existing work commitments to others, which contractor shall be permitted to engage in under the terms of this agreement, contractor hereby agrees to make available his/her services to corporation’s client(s), in not less than four and not more than sixteen hour increments per day, at any of corporations client location mutually agreed upon by corporation and contractor herein, during the terms of this agreement. Unless otherwise provided herein, the terms of this agreement will be valid for a period of one year from date of execution, and will renew each year automatically
bb) Either party upon thirty (30) days advance written notice to the other party may terminate this agreement, contractor understandsthat during that 30 day period he or she can be considered inactive in status
cc) The contractor shall be compensated for services rendered to client(s) on a bi-weekly basis. The corporation shall advance to the contractor full payment subject to the collection and/or reimbursements from the client(s), for the corporation’s charges covering the contractor’s service fees. In the event the corporation’s client(s) fail or refuse to make payment to the corporation for any services previously rendered by the contractor herein, the contractor hereby agrees to reimburse the corporation for any such fee payments previously advanced. dd) Contractor agrees that he/she shall be paid___________per hour ofservices provided to corporation’s clients.
Contractor hereby states his/her rights and intention to represent himself/herself as an independent nurse contractor to the general public, and to operate his own independent business, as an independent nurse contractor. Furthermore, contractor understands, acknowledges and agrees that he/she shall be solely responsible for complying with all Federal and State Income Tax and Payroll Tax Laws, requirements, and payments, resulting from his/her services. Contractor understands, acknowledges, and agrees that he/she may be required to pay quarterly estimated taxes, or pay a penalty for failing to do so. Said contractor shall complete an Internal Revenue Service Form W-9 (Request for Tax Payer’s Identification Number and Certification).
All of the corporation’s clients demand proof of professional liability coverage on all nurse contractors, therefore, contractors shall be responsible for obtaining his/her own professional liability insurance at his/her expense. The limit must be $1,000,000 each person, $3,000,000 aggregate. The corporation will provide for its own professional liability insurance at its expense.
Contractor shall be responsible for obtaining his/her own general liability insurance at his/her own expense. The corporation will provide for its own general liability insurance at its expense.
Contractor agreesto waive his/her claim to Worker’s Compensation Insurance from Corporation.
a) Contractor shall be responsible for compliance with the policies and procedures of the client(s), as set forth by Joint Commission on Accreditation of Hospitals, HIPAA, and the State Board of Nursing in the state where he/she is working. Contractor is also responsible for complying with current education requirements as indicated by the State Board of Nursing in the state that said continuing education is required.
b) The corporation recognizes and agrees that contractor may provide itsservices to any other person or entity, and contractor hereby agrees to use his/her best good faith efforts to perform under the condition of this agreement. IN WITNESS WHEREOF, the parties hereto have executed this agreement on this _ day of, _, 20_ , the effective date of this agreement is to be as herein above first indicated.
To ensure employees participate in the Agency’s effort to avoid/prevent any FRAUD activity that may Conflict with the interests of the agency, and any Emirates programs.
The Agency expects all of its employees to understand and be aware of potential situations where the FRAUD will not be tolerated.
PURPOSE:
To ensure employees avoid any personal interest that may conflict with the interest of the agency.
POLICY:
The Agency expects all of its employees to understand and be aware of potential situations where their personal interests may conflict with the business interests of the Agency.
Certified nursing assistant is an individual who has completed a board-approved Certified Nursing Assistant training program and certified as Certified Nursing Assistant. (CNA). The position is responsible for providing a high quality of in home health care to adults and children with various medical needs under the supervision of registered nurse. Certified nursing assistant would be able to give written account of allservices provided to clients as well as pertinent medical information necessary to provide care. Position must be committed with deep sense of pride in a client’s progress and wants to make a difference
Certified medication technician is an individual who has completed a board – approved medication technician training program and certified by the board as a medication technician. The CMT may perform nursing functions that are routinely delegated and supervised by registered nurse and must clearly understand the legal and ethical limits of their position. CMT would be able to give written accounts of all services provided to client by the agency as well as all pertinent medical information necessary to provide care. Medication aides must read and understand the rights and routes of all medication. Registered nurses will train, delegate, and supervise the administration of all medications by CMT/Aides, and shall verify and document the requisite education, training and competency before assignment of duties
The medication aide's role is providing routine daily medications, either prescription or nonprescription, to patients whose condition and drug regimen are stable. The aide must administer medications in the indicated dosage at the correct time, routes and frequency. The aide must ensure the patient actually swallows the medications, which can be an issue with rebellious patients or those with dementia. A warm and encouraging manner can be useful to win the patient's willing compliance. If the medication aide observes a change in the patient's vital signs or behavior, or any other indication of adverse effects from a medication, it must be reported to the RN supervisor immediately
A CMT must obtain formal training and have passed the certification exam by Maryland Board of Nursing as a Certified Medication Technician/Aide in Medication Administration. The CMT must be able to read, and write clearly and have strong communication skill. Must understand and follow the physician’s order before administering medication Qualifications: Certified by the Board of Nursing as Certified Medication Technician Experience: Two or more years in Home Health care, nursing home or Hospital setting. Home health experience preferred currently licensed as: Certified Medication Technician Valid Driving License and Social Security Card or valid US Passport Current CPR/First Aide Cards Physical Exam within the last 12 months (without limitations) PPD or Chest X-Ray within the last 12 months (with negative results) Background Check (with no Criminal Records) and employment/character references Proof of Hepatitis B Vaccination or a signed declination (Vaccination will be provided at no cost to employee).
Dear Sir or Madam,
is applying to our office as
until we have thoroughly checked her/his cooperation in completing the information requested.
I authorize Cora Healthcare Services, to gather any information - concerning my qualification and past performances. Please reply to their questions. I hereby release you from any and all liability
To be completed by Previous Employer:
PLEASE ADVICE IF: ABOVE AVERAGE, SATISFACTORY. BELOW AVERAGE OR COMMENTS.
The applicant named below has submitted an application for employment with Cora Healthcare Services. Please verify character information to the best of your knowledge. Your feedback will be kept confidential. Thank you
how you know the applicant (example; Friend, neighbor, relation, etc.)
Please check the most appropriate box regarding applicant’s abilities;
Please read and complete this form in its entirety and sign in the space provided below. Your written consent is necessary for completion of the employment application process. Thank you
By execution of this document, I acknowledge that I have been informed by Cora Healthcare Services. that a criminal history check will be performed on my name. I have informed Cora Healthcare Services. of all names (for example, maiden name, aliases) that I have used in the past. I understand that I have been employed on an emergency basis and that my employment is temporary pending the results of the criminal history check. I also understand that if I have been convicted of the following offenses, that I may not be employed by Cora Healthcare Services. I also understand that Cora Healthcare Services. will search the Employee Misconduct Registry and the Nurse Aide Registry (if applicable) to determine whether any acts of abuse, neglect or exploitation have occurred and whether my name is designated on either registry. If my name is designated on either registry I understand Cora Healthcare Services must deny me employment.
Offenses which constitute a bar to employment and for which an administrative review is not available, are offenses under:
A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice of an offense containing elements that are substantially similar to the elements of an offense listed under the above Subdivision.
I understand that all information obtained by Cora Healthcare Services. regarding any criminal history will remain confidential. By signing this form, I certify that the information on this form contains no willful misrepresentation and that the information is true and complete to the best of my knowledge.
Please review the following list of topic and circle a rating on a range of 1 to 4 to indicate your level of experience. Also indicate the approximate date you last performed each task. Skill level
Identifies correct medication, patient dose, time, and route before administering medication.
Please print your name, title and then sign and date the form to indicate that you have received a copy of the Cora Healthcare Services policy for the administration of Influenza vaccine to Adage Healthcare employees, dated____________. You are responsible for reading and adhering to the policy
Please send signed Acknowledgement of Receipt to: Office of Human Resources. Cora Healthcare Services.
I am aware of the influenza policy and have a chance to have my questions answered about influenza vaccination. I understand the benefits and risks of the vaccine and:
For questions for the influenza vaccination, please call CDC Hotline: 1800-232-4636
In accordance with OSHA requirements, employers must make hepatitis B vaccinations available at no cost to employees who have occupational exposure to the hepatitis B virus (HBV). Body art practitioner is required to submit evidence of current hepatitis B immunity in conjunction with registration materials. This includes records of hepatitis B vaccinations and booster shots. If a practitioner declines to be vaccinated against HBV, he/she must submit signed declination agreement from his/her employer. A sample declination statement is provided below. Contact Occupational Safety & Health Administration (www.osha.gov) for additional information.
I______________ understand that due to my occupational exposure to blood or other potentially infectious materials OPIM, 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 have occupational exposure to blood or OPIM and I want to be vaccinated with hepatitis B vaccine; I can receive the vaccination series at no cost to me.
The duties of have been explained to me in details. I have read and fully understand the duties and work history requirements as outlined in the Cora Healthcare Services policy and procedure and acknowledge the receipt of the job description as stated.
I have received a copy of the job description, and understand that failure to strictly implement assigned duties / directives may result in termination of my appointment with Cora Healthcare Services Inc.
I_________ have read, understand and agree to the terms and conditions specified in this job description for the (RN)_____ (PT)_____ (OT)_____ (LPN)_____ (PTA)_____ (CNA/CMT)_____position I presently applied for. A copy of this job description has been given to me.
I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.
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