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PRECISION HEALTHCARE MS STAFFING

CNA APPLICATION

Instructions: Please view the application checklist, upload the required documents, and fill out the form below.
APPLICATION CHECKLIST
Name
I have read, understand, and received a copy of the above Job Description.
Full Name
Are you a U.S. Citizen?
Have you ever been a contractor with us?
CPR Certification?
High School Diploma or GED
College/Tech School:
Shift preference:
12 hours?
Name
Frequent or Severe Headaches, Head Injury or Stroke
Sinus Problems, Infections, Frequent Colds
Blurred vision, or feinting
Ear, Nose or Throat Problems or Hearing problems
Asthma
Chest or Lung Problems
Upper Respiratory Infection > 7-lO Days
Allergies or Hives
Reaction to Medication or Iodine
Frequent Hoarseness
Difficulty with Swallowing or Hiatal Hernia
Chest Pain, Shortness of Breath
Rapid or Irregular Pulse
Any Blood Pressure Problems
Taken Blood Pressure Medicine
Heart Problems of any kind
Swollen Legs, Ankles, Feet
Rectal bleeding or hemorrhoids
Frequent Diarrhea
Stomach, Liver or Intestinal Problems
Gall Bladder Problems
Blood in Bowel Movements
Rupture or Hernia
Goiter or Thyroid Problems
Diabetes
Ever taken Insulin
High Sugar or Albumin
Frequent or Excessive Thirst
Weight Gain of 10 lbs. or more in past year
Urinary, Bladder or Prostate Problem
Frequent or Painful Urination
Venereal Disease or Herpes
Kidney Infection, Stone, Blood in Urine
Arthritis, Gout or Rheumatism
Bursitis or Neuritis
Bone Infection, Disease or Cancer
Broken, Fractured or Dislocated Bone
Any Strained or Pulled Muscles
Any Shoulder, Elbow or Arm Problem
Any Finger, Hand, or Wrist Problem
Hip or Knee Problem
Foot or Ankle Problem
Neck Problems
Back or Spine Problems
Worn a Brace or Support
Unable to assume certain positions
Tumor or Cyst
Any type of Cancer
Paralysis
Epilepsy
Nervous Problems of any kind
Mental Illness of any type
Anemia or other Blood Condition
Hemophilia (Free-Bleeding) or any kind of Blood Problem
Frequent Insomnia
Skin Disease
Use tobacco product in past or present
Currently taking any Medication
Any problem with alcohol or prescription drugs
Used illegal drugs
Any Chronic Health Problem
Any Tuberculosis Test
Diagnosis of Tuberculosis or S/S below:
Frequent or Chronic Fatigue, Weakness, Malaise, Rashes
Abnormal Bleeding
Frequent episodes of fever
Unplanned weight loss over 10 lbs. in past year
Hepatitis, Jaundice, dark urine
Frequent Nausea, Vomiting, lndigestion or Anexorl
Night Sweats
Coughing up blood, Chronic Coughing w/ phlegm
Dizziness or unsteady gait
Breast Problems or Lumps
Abnormal Menstrual Periods
Are you presently Pregnant
Full Name
Check one of the following, then sign at the bottom.
Full Name
Full Name
Full Name
Full Name
Full Name
Full Name
Full Name
Middle Name
Applicant's Name
I have read, understand and received a copy of the above Job Description.
Full Name
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.
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.
SO AGREED, this date.
This application is NOT complete until all requested documents are uploaded.