Employment Opportunities To apply for employment please fill out the forms below in full. Application For Employment EDUCATION TRAINING PREVIOUS EMPLOYERS I hereby authorize TLC COMPANIONS HOME HEALTH CARE, LLC, to request and receive from all prior employers within THREE (3) years of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. Employee Skills Checklist Directions: Please carefully assess your strengths and select the appropriate experience level for each skill. Please put appropriate skill level next to all skills mentioned below. 1 = Expert 2 = Experienced 3 = Familiar 4 = No Experience Personal Care ADL Bed Bath Sponge Bath Tub Bath Shower Nail & Skin Care Hair Care Oral Hygiene Brush Denture Care Shave/Razor Assist w/ dressing Meal Preparation Assist w/ Feeding Diabetic Diet Low Sodium Diet Special Diet Instructions Client Transportation Assist in/out of wheelchair Use of manual wheelchair Use of electric wheelchair Transfers Assisting from chair to stand Stand to a chair Assisting in/out shower Elimination Use of bed pan Use of bedside commode Housekeeping Duties Washing clothes Folding clothes Dishes Mop Floors Vacuum Grocery Shopping/Errands Dusting Health Attestation Form Date of First Case: (first day worked) Post-Offer Physical Post-Offer Physical Signature/Title Rubella Screening Rubella Screening Signature/Title Rubeola Screening Rubeola Screening Employee Birth Year: Signature/Title Initial TB Screening Initial TB Screening Signature/Title IGRA blood test Signature/Title 2-step Mantoux Screening Signature/Title Annual Mantoux after initial 2-step (Month due: ) Signature/Title Date of chest x-ray TB questionnaire Date of Chest Xray Signature/Title Date of TB questionarire Signature/Title Annual TB Screening Date of Annual TB Screening Signature/Title Hepatitis B Vaccine Date accepted/declined Signature/Title Influenza Vaccine (if warranted) Signature/Title Periodic Physicals (if required by agency) Signature/Title Designated Reviewer Name: Title: I attest that the above information is truthful and correct pursuant to my review of the health records for the above employee. --- Name: Title: I attest that the above information is truthful and correct pursuant to my review of the health records for the above employee. --- Name: Title: I attest that the above information is truthful and correct pursuant to my review of the health records for the above employee. Alternate Assessment - TB Screening Questionnaire This form is completed annually for those employees who have documentation of a negative chest x-ray following a positive Mantoux screening test, and whose medical evaluation and chest x-ray indicate that no further Mantoux screening is required. Do you experience any of the following: Bad cough that lasts longer than 2 weeks YesNo Coughing up sputum (phlegm) YesNo Coughing up blood YesNo Loss of appetite YesNo Weakness/fatigue/tiredness YesNo Night sweats YesNo Unexplained weight loss YesNo Fever YesNo Chills YesNo Chest pain YesNo Have you recently spent time with someone who has infections tuberculosis? YesNo Any other complaints? YesNo The above health statements are accurate to the best of my knowledge. I have been inserviced on the signs and symptoms of tuberculosis and been advised to seek medical care if any of the symptoms develop at any time. Nurse Reviewer Recommendation Refer employee for medical evaluation immediately, before continuing work.No action to be taken at this time. RN SIGNATURE
