CNA APPLICATION

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PRECISION HEALTHCARE MS STAFFINGCNA APPLICATION

Instructions: Please view the application checklist, upload the required documents, and fill out the form below.

APPLICATION CHECKLIST

Name

CNA Job Description

I have read, understand, and received a copy of the above Job Description.

Phone Number

TB Date

Full Name

Tax ID/SSN

Address: City, State, Zip Code

Cellphone Number

Phone Number

Date of Birth

Are you a U.S. Citizen?

Have you ever been a contractor with us?

If yes, what dates? Which state(s)?

PROFESSIONAL INFORMATION

State(s) where license:

CPR Certification?

Expiration Date

Other Medical Certification:

EDUCATION

High School Diploma or GED

Graduation Date

College/Tech School:

Graduation Date

AVAILABILITY

Shift preference:

1st Shift

2nd Shift

3rd Shift

12 hours?

EMPLOYMENT HISTORY

Company Name

Phone Number

Address: City, State, Zip Code

Job Title

Supervisor

Dates From/To

Reason for leaving

Company Name

Phone Number

Address: City, State, Zip Code

Job Title

Supervisor

Dates From/To

Reason for leaving

Company Name

Phone Number

Address: City, State, Zip Code

Job Title

Supervisor

Dates From/To

Reason for leaving

Company Name

Phone Number

Address: City, State, Zip Code

Job Title

Supervisor

Dates From/To

Reason for leaving

CONTRACTOR'S STATEMENT OF HEALTH STATUS

Name

Date

Social Security Number

Date of Birth

Position

Have you ever had, or do you now have any of the following?

Frequent or Severe Headaches, Head Injury or Stroke

Yes

Sinus Problems, Infections, Frequent Colds

Yes

Blurred vision, or feinting

Yes

Ear, Nose or Throat Problems or Hearing problems

Yes

Asthma

Yes

Chest or Lung Problems

Yes

Upper Respiratory Infection > 7-lO Days

Yes

Allergies or Hives

Yes

Reaction to Medication or Iodine

Yes

Frequent Hoarseness

Yes

Option 2

Difficulty with Swallowing or Hiatal Hernia

Yes

Chest Pain, Shortness of Breath

Yes

Rapid or Irregular Pulse

Yes

Any Blood Pressure Problems

Yes

Taken Blood Pressure Medicine

Yes

Heart Problems of any kind

Yes

Swollen Legs, Ankles, Feet

Yes

Rectal bleeding or hemorrhoids

Yes

Frequent Diarrhea

Yes

Stomach, Liver or Intestinal Problems

Yes

Gall Bladder Problems

Yes

Blood in Bowel Movements

Yes

Rupture or Hernia

Yes

Goiter or Thyroid Problems

Yes

Diabetes

Yes

Ever taken Insulin

Yes

High Sugar or Albumin

Yes

Frequent or Excessive Thirst

Yes

Weight Gain of 10 lbs. or more in past year

Yes

Urinary, Bladder or Prostate Problem

Yes

Frequent or Painful Urination

Yes

Venereal Disease or Herpes

Yes

Kidney Infection, Stone, Blood in Urine

Yes

Arthritis, Gout or Rheumatism

Yes

Bursitis or Neuritis

Yes

Bone Infection, Disease or Cancer

Yes

Broken, Fractured or Dislocated Bone

Yes

Any Strained or Pulled Muscles

Yes

Any Shoulder, Elbow or Arm Problem

Yes

Any Finger, Hand, or Wrist Problem

Yes

Hip or Knee Problem

Yes

Foot or Ankle Problem

Yes

Neck Problems

Yes

Back or Spine Problems

Yes

Worn a Brace or Support

Yes

Unable to assume certain positions

Yes

Tumor or Cyst

Yes

Any type of Cancer

Yes

Paralysis

Yes

Epilepsy

Yes

Nervous Problems of any kind

Yes

Mental Illness of any type

Yes

Anemia or other Blood Condition

Yes

Hemophilia (Free-Bleeding) or any kind of Blood Problem

Yes

Frequent Insomnia

Yes

Skin Disease

Yes

Use tobacco product in past or present

Yes

Currently taking any Medication

Yes

Any problem with alcohol or prescription drugs

Yes

Used illegal drugs

Yes

Any Chronic Health Problem

Yes

Any Tuberculosis Test

Yes

Diagnosis of Tuberculosis or S/S below:

Yes

Frequent or Chronic Fatigue, Weakness, Malaise, Rashes

Yes

Abnormal Bleeding

Yes

Frequent episodes of fever

Yes

Unplanned weight loss over 10 lbs. in past year

Yes

Hepatitis, Jaundice, dark urine

Yes

Frequent Nausea, Vomiting, lndigestion or Anexorl

Yes

Night Sweats

Yes

Coughing up blood, Chronic Coughing w/ phlegm

Yes

Dizziness or unsteady gait

Yes

*THIS PART IS FOR WOMEN

Breast Problems or Lumps

Yes

Abnormal Menstrual Periods

Yes

Are you presently Pregnant

Yes

Applicant/Employee:

Applicant/Acknowledgement:

Date

I have met the annual review requirements in the following areas:

JCAHO Annual In-services

Fire Safety in Healthcare Facilities

Electrical Safety in Healthcare Facilities

Lifting and Moving Patients Safely

Universal Precautions

Age Specific Competency

Restraints

Pain Management

Hazardous Materials in Healthcare

Infection Control

Blood borne Pathogens

Domestic Violence

Child, spouse, and elder abuse Patient Teaching

TB and transmission of TB

Note: If you do not have your competency requirements up to date, we can help you meet those requirements. Give us a call at the office.

Full Name

Date

Patient’s Bill of Rights

Signature

Date

Hepatitis B Virus Vaccine Consent or Declination

Check one of the following, then sign at the bottom.

Date

Full Name

OSHA Regulations and Guidelines

Full Name

Date

This contract entered this day by and between Precision Healthcare Staffing (herein after referred to as Agency) and (thereafter referred to as Contractor)

Contractor Agreement

Full Name

Date

Independent Healthcare Professional Confidentiality Agreement

Date

Full Name

Consent for Drug Screening

Date

Full Name

Disclaimer

Date

Full Name

Authority for Release of Information

Full Name

Middle Name

Social Security Number

Date of Birth

State Currently Living In

County

Sex

RACE

I hereby release said agency and persons from any and all liability, which may be incurred as a result of furnishing such information.

References

Company Name

Supervisor

Address: City, State, Zip Code

Phone Number

Applicant's Name

Job Title

Tax ID/SSN

I hereby authorize the employer named above to provide any requested information to Precision Healthcare Staffing, LLC. and release them from all liabilities in responding to inquiries in connection with my application.

(Applicants do not fill out this part.) TO BE COMPLETED BY EMPLOYER

Text

Date

I have read, understand and received a copy of the above Job Description.

Certified Nurse Assistant Skills Checklist

Date

Social Security Number

Full Name

Please indicate all areas that you have had actual work experience in. Your answer in these areas indicates that you are proficient in performing these tasks.

Temperature

Pulse

Respiratory

Weight Patient

Bed Bath

Tub Bath

Shower

Skin Care/ Oral Care

Shave/ Shampoo

Foot Care/ Nail Care

Dress (assist with)

Ambulation

Transfers/ ROM

Assist to BSC/Toilet

Bedpan

Catheter Care

Incontinent Care

Ostomy Care

Record I&O

Meal Planning/ Diets

Meal Preparation

Maintain/Clean Equipment

Oral Suction

Elastic Stockings

TASKS: MEDICATIONS

Assist

Supervise/ Remind

TASKS: HOME MANAGEMENT

Kitchen

Linen Change

Laundry

Bathroom/ Bedroom

Grocery Shopping

Transport Client

TASKS: WORK AREAS

Pediatrics

Psychiatric Patients

Oncology Patients

Isolation

Burn

HIV

CVA(Stroke Patients)

Orthopedics

Respiratory

Please answer the following statements True or False F.

NURSING PERSONNEL ARE NOT RESPONSIBLE FOR DOUBLE CHECKING TRAYCARDS TO AVOID SERVING THE WRONG TRAY TO A PATIENT.

IT IS IMPORTANT THAT DIABETIC RESIDENTS EAT ONLY THOSE FOODS ORDERED BY THE DOCTOR OR DIETICIAN AND NOT EAT SUCH FOODS AS CANDY OR CAKES.

ALL RESTRAINTS MUST BE ORDERED BY THE DOCTOR

IT IS UNPROFESSIONAL TO DISCUSS A RESIDENT’S CONDITION WITH OTHER RESIDENTS OR VISITORS.

IF YOU FIND A RESIDENT UNCONSCIOUS ON THE FLOOR YOU SHOULD PUT HIM/HER BACK TO BED.

IF A RESIDENT COMPLAINS OF GAS PAINS YOU SHOULD TELL THE NURSE

YOU SHOULD GIVE AN ENEMA QUICKLY SO THE RESIDENT WON’T HAVE TO WAIT LONG

IF YOU ARE EXERCISING A RESIDENT, AND HE/SHE COMPLAINS OF SHORTNESS OF BREATH, YOU SHOULD KEEP GOING BECAUSE HE/SHE PROBABLY JUST DOESN’T WANT TO EXERCISE

RANGE OF MOTION EXERCISES KEEP RESIDENTS FROM GETTING STIFF OR FROZEN JOINTS.

IF THE RESIDENT IS NPO FOR TEST TOMORROW MORNING, IT’S OK TO LET HIM/HER HAVE A GLASS OF WATER AFTER MIDNIGHT IF HE OR SHE IS THIRSTY.

IF A FOLEY CATHETER BAG COMES APART AND THE TUBING FALLS ON THE FLOOR, IT IS OK TO WIPE IT OFF AND PUT IT BACK TOGETHER.

EXTREME DEHYDRATION CAN LEAD TO DEATH.

A RESIDENT WHO IS INCONTINENT SHOULD BE CHECKED AT LEAST EVERY TWO HOURS.

A NORMAL BLOOD PRESSURE IS 80/50 FOR SOMEONE WHO IS ASLEEP

A NORMAL HEART RATE SHOULD BE BETWEEN 60 AND 100 BEATS PER MINUTE

A RESIDENT WHO HAS HAD A STROKE DOES NOT NEED ANY SPECIAL HELP.

IT IS OK TO LEAVE A RESIDENT UNATTENDED WHILE RUNNING HIS/ HER BATH WATER.

YOU SHOULD PUT A HEATING PAD NEXT TO THE SKIN, WITHOUT A COVER FOR BEST RESULTS.

IF A RESIDENT SAYS, “I FEEL LIKE I’M GOING TO DIE”, YOU SHOULD JUST IGNORE HIM/HER.

Service Description for Certified Nursing Assistant

Click here to view

Date

I have read and understand that the physical, sensory, and mental requirements outlined below are necessary of the services to be performed. I affirm I am able to perform the service without limitation and have not knowingly withheld any information relating to these requirements.

Agreement and Covenant not to Compete

Date

SO AGREED, this date.

Full Name

This application is NOT complete until all requested documents are uploaded.

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PRECISION HEALTHCARE MS STAFFING

CNA APPLICATION

Thank you!

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Heading

PRECISION HEALTHCARE MS STAFFING

CNA APPLICATION

Thank you!

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