Employment Opportunities

To apply for employment please fill out the forms below in full.

Application For Employment











EDUCATION







TRAINING

PREVIOUS EMPLOYERS














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

Rubella Screening
Rubella Screening

Rubeola Screening
Rubeola Screening

Employee Birth Year:

Initial TB Screening
Initial TB Screening

IGRA blood test

2-step Mantoux Screening

Annual Mantoux
after initial 2-step (Month due: )

Date of chest x-ray
TB questionnaire
Date of Chest Xray

Date of TB questionarire

Annual TB Screening
Date of Annual TB Screening

Hepatitis B Vaccine
Date accepted/declined

Influenza Vaccine (if warranted)

Periodic Physicals (if required by agency)

Designated Reviewer

Name:
Title:

---

Name:
Title:

---

Name:
Title:


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

Coughing up sputum (phlegm)

Coughing up blood

Loss of appetite

Weakness/fatigue/tiredness

Night sweats

Unexplained weight loss

Fever

Chills

Chest pain

Have you recently spent time with someone who has infections tuberculosis?

Any other complaints?

Nurse Reviewer Recommendation