Apply – Olive Home Care Services

Register Online Before You Arrive.Application of Employment

Employee Application

Personal Information
Employment Desired

First Name

Last Name

Social security

Present Address

Street

City

State

Zip Code

Permanent Address

Street

City

State

Zip Code

Phone Number

If you are under 18, can you furnish a work permit?

Yes

Position

Date you can start

Salary($)

Are you employed now?

Yes

If so, may we inquire of your present employer?

Yes

Ever applied for this company before?

Yes

Where

When

Are you on layoff and subject to recall?

Yes

Will you travel if required?

Yes

Will you relocate if required?

Yes

Will you work overtime if required?

Yes

Are you able to meet the attendance requirements of this position?

Yes

Have you ever been Bonded?

Yes

Have you ever been convicted of a felony in the past 7 yrs?

Yes

Such a conviction may be relevant if job related but does not bar you from employment. If yes — explain

Driver’s license number

State

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with this company.

Date, Month and Year (From - To)

Name and Address of Employer 1

Salary ($)

Job Role

Reason for Leaving

Date, Month and Year (From - To)

Name and Address of Employer 2

Salary ($)

Job Role

Reason for Leaving

Date, Month and Year (From - To)

Name and Address of Employer 3

Salary ($)

Job Role

Reason for Leaving

Reference: Give names of three persons not relates to you whom you have known at least one year.

Referee Name 1

Address

Phone

Years Aquainted

Referee Name 2

Address

Phone

Years Aquainted

Referee Name 3

Address

Phone

Years Aquainted

List any foreign languages(s) and check the box that best describes your skill level.

Language 1

First Language

Read

Write

Language 2

Second Language

Read

Write

Emergency Contact

Full Name

Address

Phone

Relationship

Conditions of Employment – please read carefully

Reporting to work with impaired abilities; or the possession, consumption, or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to the physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of drug and alcohol policy will result in dismissal.

It is understood and agreed upon any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.

I give the employer the right to investigate all police, driving, and personal record and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other person, corporations, or organizations for furnishing such information.

The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, State, or Federal law.

Any controversy of any kind arising between parties under this agreement or otherwise ( or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to the medication and failing settlement in medication, to biding arbitration. Unless otherwise agreed a mediation and arbitration designated by staff professions will govern any medication and arbitration. The parties will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and govern by the provisions of the Federal Arbitration Act, 9 U.S.C Section 1-et seq. The parties hereto stipulated that this agreement involves matters affecting interstate commerce.

This application is current for 60 days. At the conclusion of this if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

Signature

Date

Nursing Assistant Self-Assessment of Skills.

PLEASE CHECK IF YOU HAVE PREFORMED AND CAN ADEQUATELY DEMONSTRATE THE FOLLOWING

Vital signs

Oral temperature

Rectal temperature

Pulse

Respiration

Blood pressure

Personal Hygiene

Bed bath

Sponge bath

Tub bat

Shower

Skin Care

Lotion

Powder

Back Ru

Basic Decubitus Ulcer Care

Position to relive pressure areas

Wash with soap & water

Air dry skin/Ulcer

Mouth Care

Brush teeth

Brush denture

Mouth care for unconscious patient

Hair Care

Shampoo/Comb

Use Shampoo Tray

Nutrition

Simple Meal Prep

Offering fluids to patient

Measuring Intake/output

Feeding patients with chewing and swallowing problems

Shaving

With electric razor

With safety razor

Nail Care

Clean and file Fingernails

Soak and file toenails

Assist with Clothing

Bedfast Patient

Wheelchair patient

Body Machines

Use of Transfer belt

Range of motion exercise

“STAND BY” Ambulation

Assist with canes

Cast/Slings

Neck brace

Bed Positioning

Side lay

Prone (back laying)

Use of trochanter rolls

Use of foot board

Use of draw sheet

Bed Making

Unoccupied

Occupied

House cleaning

Laundry

Home cleaning

Grocery shopping

Urinary

Use of regular bed pan

Use of fracture bed pan

Use of urinal/male

Cather

Foley catheter-empty bag

Cleaning perineum at catheter insertion point

Care/changing of leg bag

Application condom catheter

Bowel

Colostomy Care-empty

Soapsuds enema

Tap water enema

Fleets enema

Use of portable commode

Transfers

To and from bed bench

To and from wheelchair

Bed to wheelchair

Wheelchair to toilet

Wheelchair to tub

Transfer board

Hoyer lift

Other

Basic communication

Active listening

Assist with oxygen nasal prongs

Miscellaneous

Universal Precautions

CPR

First Aid

Documentation of Orientation

After reading the Olive Home Care Services employee packet, please initial the following statements and sign below:

I have read and understand the policies and procedures.

I have read and understand my assigned duties and responsibilities.

I understand to report client emergencies, problems and/or progress to supervisory nurse.

I understand that I must report suspected exposure of TB to the agency.

I have read and understand client rights.

I have read the procedures regarding handling of complaints and incidents.

CONFIDENTIALITY AGREEMENT FOR EMPLOYEES

I as an employee of the Olive Home Care Services, understand that I must maintain a strict confidentiality of client information and not disclose or cause any personal, financial, psychological or medical information relating to a client except to appropriate staff, the client’s representative, clients physical, the Department of Community Health or other individuals authorized by the consumer in writing or, as may be required by court subpoenas. I understand that breach of confidentiality may be interpreted as misconduct for which I may be disciplined and could result in the termination or my employment.

STATEMENT OF GOOD FAITH (CREDIBLE EVIDENCE STATMENT)

I do hereby certify that I have never been shown by credible evidence by a court, a department investigation, or other reliable evidence to have abused, neglected, sexually assaulted, exploited, deprived any person or to have subjected any serious injury as a result of intentional or grossly negligent misconduct as evident by an oral or written statement to this effect obtained at the time of application and have not made any material false statements concerning qualification requirement, either to the department or Olive Home Care Services. I understand that false or misleading information given in my application or interview(s) may result in discharge

STATEMENT OF UNDERSTANDING

understand and acknowledge that any false or, misleading information that I give Olive Care Home Services on my application and regarding my background checks will be grounds for immediate termination. I also agree to inform Olive Home Care Services of any new charges to my background history.