Fort Wayne Area
5910 Homestead Road, Fort Wayne, IN 46814
Tel: (260) 435-3222

Employment Application - Clinical

AN EQUAL OPPORTUNITY EMPLOYER

It is the policy of our organization to provide employment, training and development, compensation, promotion, and all other conditions of employment without regard to race, color, religion, national origin, sex, sexual orientation, age, marital status, physical or mental disability or status as a disabled veteran. You may request any needed accommodation in order to complete this form. This application will be retained for one year.

"Visiting Nurse Staff are not permitted to smoke on VN property or grounds"

Position(s) Applied For *

Date of Application

Referral Source

Name of Source

Last Name *

First Name *

Middle Name *

Address *

City *

State *

Zip Code *

Telephone Number(s) *

Email Address *

Have you ever been employed with us? *

If yes, under what name?

If yes, dates of employment?

From

Are you currently employed?

Can you, with or without accomodation, perform the duties of the job for which you have applied? *

Are you legally eligible for employment in this country? (Proof of U.S. citizenship or immigration status will be required upon employment.) *

On what date would you be available for work? *

Type of employment desired:

Full time

Part Time

Weekends

Evenings

Nights

Are you currently on 'lay-off' status and subject to recall? *

Can you travel if a job requires it? *

Have you ever been convicted of a felony or misdemeanor other than a traffic violation? (Prior to hiring we must obtain a criminal history report by Indiana State Law) Conviction will not necessarily disqualify an applicant from employment. *

If yes, please explain

Do you have a valid driver's license? *

Driver's license number (Upon hiring, we will run a Motor Vehicle Report (MVR) check to verify license and driving record.) *

State *

General Skills

Please check the items that are applicable to the position for which you are applying. Unrelated items may be checked at your discretion.

Filing

Calculator

Typing

Switchboard

Data Entry

WPM

Copy Machine

Medical Terminology

Fax machine

Home Health Aide Tasks Inventory

Please indicate experience level in each of the following areas

Admin/Assist with Bed/Bath

Perform Catheter Care - Female

Count Pulse Rate

Admin/Assist with Tub/Shower

Perform Catheter Care - Male

Take Blood Pressure

Perform Oral Hygiene-Conscious Patient

Apply male External Catheter

Compute and Record Intake and Output

Perform Oral Hygiene-Unconscious Patient

Empty Catheter Drainage Bag

Care of Patient in Isolation

Give Back Rub

Collect Voided Urine Specimen

Care of Terminally Ill Patient

Bedmaking - Unoccupied

Collect Urine Specimen from Catheter

Care of Psychiatric Patient

Bedmaking - Occupied

Collect Stool Specimen

Care of the Mentally Retarded

Transfer Patient Bed to Wheelchair and Return

Collect Sputum Specimen

Care of the Geriatric Patient

Transfer Patient Bed to Commode and Return

Change Ostomy Appliance

Care of Newborns and Infants

Assist with ROM Exercise

Prepare Regular Diets

Care of Children

Assist Patient to Walk with Crutches/Walker/Cane

Prepare Special Diets

Care of the Physically Handicapped

Take Oral Temperature

Care of Stroke Patient

Assist Patient with Bedpan or Urinal

Take Auxiliary Temperature

Use of Hoyer Lift

Registered Nurse/Licensed Practical Nurse Skills Check List

Please indicate experience level

Care of the Quadriplegic Patient

Insertion of an Airway

Application of Ostomy Appliance

Care of the Paraplegic Patient

Perform CPR

Administer Enema or Douche

Application of Prosthesis

Use of Defibrillator

Perform Colostomy Irrigation

Use of Hoyer Lift

Perform Venipuncture

Foley Catheter Insertion/Female

Instruct in Ambulation with walker, cane, crutches

Application of Back, Neck, Leg Brace

Foley Catheter Insertion/Male

Carry out ROM Exercises

Perform Oral-Pharyngeal Suctioning

Foley Catheter Irrigation

Care of Patient with Neurological Disease

Assist with Bed, Chair, Tub Transfers

Irrigate Supraupubic Catheter

Insertion of N/G Tube

Assist with Renal or Peritoneal Dialysis

Perform Trachael Care

Function as Medication Nurse

Administer N/G tube Feedings

Administer Tracheostomy Care

Administer I.M. or S.C. Injection

Administer Gastrostomy Tube Feedings

Perform Shunt or Fistula Care

Start I.V. Infusion

Assist with Hyperailmentation

Care of Patient on Mechanical Ventilation

Care of the Pediatric Patient

Administer and Maintain I.V. Infusion

Interpret Cardiac Monitor Readings

Special Skills and Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience. Include any foreign languages you speak or sign language capability.*

Graduate School

Graduate School: Name and Location

Graduate School: Course of Study

Graduate School: No. of Years Completed

Graduate School: Did You Graduate?

Graduate School: Degree or Diploma

College

College: Name and Location

College: Course of Study

College: No. of Years Completed

College: Did You Graduate?

College: Degree or Diploma

Business/Trade/Technical School

Business/Trade/Technical: Name and Location

Business/Trade/Technical: Course of Study

Business/Trade/Technical: No. of Years Completed

Business/Trade/Technical: Did You Graduate?

Business/Trade/Technical: Degree or Diploma

High School

High School: Name and Location*

High School: Course of Study*

High School: No. of Years Completed*

High School: Did You Graduate?*

High School: Degree or Diploma*

Elementary School

Elementary: Name and Location

Elementary: Course of Study

Elementary: No. of Years Completed

Elementary: Did You Graduate?

Elementary: Degree or Diploma

Have you ever been known by another name? *

If yes, by what name(s)?

Are you currently under any legal or contractual restrictions that would prevent you from accepting employment with our organization? if yes, please explain.*

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)

Organization 1

Offices Held 1

Organization 2

Offices Held 2

Organization 3

Offices Held 3

Licensure

Must be completed by individuals applying for positions that require professional registration or licensure.

Professional (RN, LPN, B/MSW)

Professional: License/Certificate Number (As applicable)

Professional: Date of Issue

Professional: Expiration Date

Professional: State

Certification (HHA, CNA)

Certification: License/Certificate Number (As applicable)

Certification: Date of Issue

Certification: Expiration Date

Certification: State

Other

Other: License/Certificate Number (As applicable)

Other: Date of Issue

Other: Expiration Date

Other: State

Employment

Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.

Employer 1

Company Name*

Telephone*

Address*

Employed (month/year) From*

To*

Name of Supervisor*

Weekly Pay Beginning*

Ending*

State Job Title and Describe Your Work*

Reason for Leaving*

Employer 2

Company Name

Telephone

Address

Employed (month/year) From

Name of Supervisor

Weekly Pay Beginning

Ending

State Job Title and Describe Your Work

Reason for Leaving

Employer 3

Company Name

Telephone

Address

Employed (month/year) From

Name of Supervisor

Weekly Pay Beginning

Ending

State Job Title and Describe Your Work

Reason for Leaving

Employer 4

Company Name

Telephone

Address

Employed (month/year) From

Name of Supervisor

Weekly Pay Beginning

Ending

State Job Title and Describe Your Work

Reason for Leaving

Do Not Contact

We may contact the employers listed above unless you indicate those you do not want us to contact.

Employer Number(s)

Reason

References

List name, address and telephone number of three references who are not related to you and are not previous employers.

Name 1*

Address 1*

Telephone 1*

Years Known 1*

Name 2*

Address 2*

Telephone 2*

Years Known 2*

Name 3*

Address 3*

Telephone 3*

Years Known 3*

Applicant Certification and Agreement

By submitting this application, I agree to the terms in the section below and acknowledge that this is a digital signature.

Enter your full name to confirm digital signature*

I certify that the information provided in this application is true and complete. I authorize Visiting Nurse to investigate all statements contained in my application for employment and understand that any false or misleading statements or material omissions are cause for refusal to hire or cause separation of employment, if employed. I hereby authorize former and present employers, except as I have otherwise indicated in writing, as well as physicians, medical personnel, references and others to provide or verify any information they have regarding me or my employment with them to this organization (hereinafter called the “Agency”) or its representatives and release them from any liability arising from the furnishing of any employment history or medical information to the Agency.

I further agree and understand that except as governed by existing federal, state or local law, where applicable, my employment or an offer of employment establishes no guarantee or promise of continued employment or set hours of work or any other obligation on the part of the Agency beyond pay for actual work performed at the agreed upon rate and that the employment relationship may be terminated at any time, by myself or the Agency, at either party’s option and will.

I understand that the needs of the Agency may require that I be assigned increased hours, decreased hours, shift work, overtime work, weekend work, rotation shifts or other work schedule arrangements or changes in my work schedule or hours and I hereby agree to accept any such work schedule or hours or any such changes in work schedule or hours as a condition of employment with the Agency.

I agree to accept and abide by the policies of the Agency as may from time to time be established or amended. I understand that only the President of the Agency may amend this Agreement and that such amendment must be in writing.

I also understand that this is an Application for Employment only and that I have not been offered employment by this organization.

Employment Application - Clinical

General Skills

Home Health Aide Tasks Inventory

Registered Nurse/Licensed Practical Nurse Skills Check List

Special Skills and Qualifications

Education

Licensure

Employment

Do Not Contact

References

Applicant Certification and Agreement