Registered Nurse (RN) + Practical Nurses (LPN) Application

Step 1 of 13

Registration Checklist

RN Or LPN Requirements

Nursing License

CPR

AIDS/HIV CEU (one time only)

Medication Errors

Alzheimer's In Service

Domestic Violence

Human Trafficking

Physical or Health Statement (Max 6 months or less)

TB test (Max 6 months or less)

2 Forms of identification (preferably FL driver's license)

Social Security Card

Information for 2 references (preferably work related)

Automobile insurance

Level II Background Screening

Background Check Consent Form

I hereby authorize Absolute Home Health Agency to receive any criminal history on file pertaining to me from any federal, state or local criminal justice agency.

Full Name

Street Address

City

State

Zip

Sex

Female

Male

Race

DOB

Social Security Number

Email Address

Phone Number:

Drivers License

Signature

*The above information is necessary to retrieve criminal history information.

Employment Application

ABSOLUTE HOME HEALTH is a drug free workplace

Position Desired

Date Available

MM slash DD slash YYYY

Type of Employment Desired

Part Time

Full Time

Personal Information

Please complete all sections

Last Name

First Name

M.I

Street Address

City

State/Zip

Home Phone

Alternate Phone

Email Address

Do you have a valid driver's license?

Female

Male

Class

CDL?

Female

Male

Have you ever served in the Military?

Yes

Do you speak any other language(s)?

Yes

Please Specify

Do you have the legal right to obtain employment in the United States?

Yes

Can you perform the essential functions and responsibilities of the position for which you are applying?

Yes

If not, explain

Do you have any special accomodation to perform required duties?

Yes

If yes, explain

Have you ever worked for ___(name of agency)?

Yes

If yes, state their name

List any current licenses, certifications, or registrations required for the position for which you are applying. Include date received.

Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation?

Yes

If yes, written documentation must be provided about criminal offenses from the clerck of court in the country in which the conviction was made and about any driving offenses other mnor traffic violations from the motor vehicles office.

You must provide atleast three current reference letters and/or the names of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowldge of your background and qualifications field.

Education & Skills

Level of education completed

Highschool

GED

College 0-3 years

Assoc

Bachelor

Masters

Degree

If Degree, specify major

Upload attachement

Max. file size: 512 MB.

Experience

List 5 years of work experience

From

MM slash DD slash YYYY

Beginning Salary

Ending Salary

Name of Employer #1

May we contact?

Yes

Address

City

State/Zip

Supervisor's Name

Phone

Title and Duties Performed

Reason for Leaving

From

MM slash DD slash YYYY

Beginning Salary

Ending Salary

Name of Employer #2

May we contact?

Yes

Address

City

State/Zip

Supervisor's Name

Phone

Title and Duties Performed

Reason for Leaving

Consent

I agree to carry out the designated responsibilities to the best of my ability. I have read the description. I am aware there is a conditional period of 3 months prior to permanent employment.

I caretify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorized investigation of statement made in this application and understand that false information may be ground for denial of my position and/or dismissal if I am employed.

Signature of Applicant

Date

MM slash DD slash YYYY

ATTESTATION OF COMPLIANCE with Background Screening Requirements

Authority: This form may be used by all employees to comply with:

the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND
the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which requires proof of compliance with level 2 screening standards that have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S., or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S., and in accordance with the standards in Section 408.809(2), F.S., if that agency is not currently implemented in the Care Provider Background Screening Clearinghouse.

Employee/Contractor Name

Health Care Provider/ Employer Name

Address of Health Care Provider

I hereby attest to meeting the requirements for employment and that I have not been arrested for or and been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:

Criminal offenses found in section 435.04, F.S.
(a) Section 393.135, relating to sexual misconduct with
certain developmentally disabled clients and reporting of
such sexual misconduct.

(b) Section 394.4593, relating to sexual misconduct with
certain mental health patients and reporting of such sexual
misconduct.

(d) Section 777.04, relating to attempts, solicitation, and
conspiracy to commit an offense listed in this subsection.

(e) Section 782.04, relating to murder.

(f) Section 782.07, relating to manslaughter, aggravated
manslaughter of an elderly person or disabled adult, or
aggravated manslaughter of a child.

(g) Section 782.071, relating to vehicular homicide

(h) Section 782.09, relating to killing of an unborn quick
child by injury to the mother.

(i) Chapter 784, relating to assault, battery, and culpable
negligence, if the offense was a felony.

(j) Section 784.011, relating to assault, if the victim of the
offense was a minor.
(k) Section 784.03, relating to battery, if the victim of the
offense was a minor.
(l) Section 787.01, relating to kidnapping.

(m) Section 787.02, relating to false imprisonment.

(n) Section 787.025, relating to luring or enticing a child.

(o) Section 787.04(2), relating to taking, enticing, or
removing a child beyond the state limits with criminal intent
pending custody proceedings.

(p) Section 787.04(3), relating to carrying a child beyond the
state lines with criminal intent to avoid producing a child at a
custody hearing or delivering the child to the designated
person.

(q) Section 790.115(1), relating to exhibiting firearms or
weapons within 1,000 feet of a school.

(r) Section 790.115(2)(b), relating to possessing an electric
weapon or device, destructive device, or other weapon on
school property.

(s) Section 794.011, relating to sexual battery.

(t) Former s. 794.041, relating to prohibited acts of persons
in familial or custodial authority.

(u) Section 794.05, relating to unlawful sexual activity with
certain minors.
(v) Chapter 796, relating to prostitution.

(w) Section 798.02, relating to lewd and lascivious behavior.

(x) Chapter 800, relating to lewdness and indecent
exposure.

(y) Section 806.01, relating to arson.

(z) Section 810.02, relating to burglary.

(aa) Section 810.14, relating to voyeurism, if the offense is
a felony.

(bb) Section 810.145, relating to video voyeurism, if the
offense is a felony.

(cc) Chapter 812, relating to theft, robbery, and related
crimes, if the offense is a felony.

(dd) Section 817.563, relating to fraudulent sale of controlled
substances, only if the offense was a felony.

(ee) Section 825.102, relating to abuse, aggravated abuse,
or neglect of an elderly person or disabled adult.

(ff) Section 825.1025, relating to lewd or lascivious
offenses committed upon or in the presence of an elderly
person or disabled adult.

(gg) Section 825.103, relating to exploitation of an
elderly person or disabled adult, if the offense was a
felony.

(hh) Section 826.04, relating to incest.

(ii) Section 827.03, relating to child abuse,
aggravated child abuse, or neglect of a child

(jj) Section 827.04, relating to contributing to the
delinquency or dependency of a child.

(kk) Former s. 827.05, relating to negligent treatment
of children.

(ll) Section 827.071, relating to sexual performance by a
child.

(mm) Section 843.01, relating to resisting arrest with violence.

(nn) Section 843.025, relating to depriving a law
enforcement, correctional, or correctional probation officer
means of protection or communication.

(oo) Section 843.12, relating to aiding in an escape.

(pp) Section 843.13, relating to aiding in the escape of
juvenile inmates in correctional institutions.

(qq) Chapter 847, relating to obscene literature.

(rr) Section 874.05(1), relating to encouraging or recruiting
another to join a criminal gang.

(ss) Chapter 893, relating to drug abuse prevention and
control, only if the offense was a felony or if any other person
involved in the offense was a minor.

(tt) Section 916.1075, relating to sexual misconduct with
certain forensic clients and reporting of such sexual
misconduct.

(uu) Section 944.35(3), relating to inflicting cruel or
inhuman treatment on an inmate resulting in great bodily
harm.

(vv) Section 944.40, relating to escape.

(ww) Section 944.46, relating to harboring, concealing, or
aiding an escaped prisoner.

(xx) Section 944.47, relating to introduction of contraband
into a correctional facility.

(yy) Section 985.701, relating to sexual misconduct in
juvenile justice programs.

(zz) Section 985.711, relating to contraband introduced into
detention facilities

(3) The security background investigations under this
section must ensure that no person subject to this section
has been found guilty of, regardless of adjudication, or
entered a plea of nolo contendere or guilty to, any offense
that constitutes domestic violence as defined in s. 741.28,
whether such act was committed in this state or in another
jurisdiction.

Criminal offenses found in section 408.809(4), F.S.
(a) Any authorizing statutes, if the offense was a felony.
(b) This chapter, if the offense was a felony.
(c) Section 409.920, relating to Medicaid provider fraud.
(d) Section 409.9201, relating to Medicaid fraud.
(e) Section 741.28, relating to domestic violence.
(f) Section 777.04, relating to attempts, solicitation, and
conspiracy to commit an offense listed in this subsection.
(g) Section 817.034, relating to fraudulent acts through
mail, wire, radio, electromagnetic, photoelectronic, or
photooptical systems.
(h) Section 817.234, relating to false and fraudulent
insurance claims.
(i) Section 817.481, relating to obtaining goods by using a
false or expired credit card or other credit device, if the
offense was a felony.
(j) Section 817.50, relating to fraudulently obtaining goods
or services from a health care provider.
(k) Section 817.505, relating to patient brokering.
(l) Section 817.568, relating to criminal use of personal
identification information.

(m) Section 817.60, relating to obtaining a credit card
through fraudulent means.
(n) Section 817.61, relating to fraudulent use of credit cards, if
the offense was a felony.
(o) Section 831.01, relating to forgery.
(p) Section 831.02, relating to uttering forged instruments.
(q) Section 831.07, relating to forging bank bills, checks,
drafts, or promissory notes.
(r) Section 831.09, relating to uttering forged bank bills,
checks, drafts, or promissory notes.
(s) Section 831.30, relating to fraud in obtaining medicinal
drugs.
(t) Section 831.31, relating to the sale, manufacture,
delivery, or possession with the intent to sell, manufacture,
or deliver any counterfeit controlled substance, if the offense
was a felony
(u) Section 895.03, relating to racketeering and collection of
unlawful debts.
(v) Section 896.101, relating to the Florida Money
Laundering Act

Consent

I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA).

Date of Decision

MM slash DD slash YYYY

Consent

I have been granted an Exemption from Disqualification through the Florida Department of Health.

Date of Decision:

MM slash DD slash YYYY

If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.

Purpose of Prior Screening

Screening conducted by

Date of Prior Screening

MM slash DD slash YYYY

Untitled

Agency for Healthcare Administration

Department of Health

Agency for Persons with Disabilities

Department of Elder Affairs

Department of Financial Services

Department of Children and Family Services

Attestation

Under penalty of perjury, I,

hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.

Employee/Contractor Signature

Title

Date

MM slash DD slash YYYY

NURSING PROFICIENCY SKILLS CHECKLIST

The following is a list of skills that you may or may not have had experience with. It is essential that you answer honestly so that we may determine which skill you ara proficient in and which skills you may need assistance with.

Please mark the box the most accurately reflect your ability in the area.

The skills with an asterisk (*) are not considered essential for performance of nursing in the home health setting. You will be required to demonstrate your skill in theses areas prior to performing them unsupervised. The preceptor will initial the box labeles "competent" or "re-evaluate" during your orientation period. Skills marked "re-evaluate" will have to be prepared prior to performing them unsupervised.

Handwashing*

Experienced

Needs Review

Competent

Re-evaluate

Bag Technique*

Experienced

Needs Review

Competent

Re-evaluate

Vital Signs*

Experienced

Needs Review

Competent

Re-evaluate

Assessment of neuro siens*

Experienced

Needs Review

Competent

Re-evaluate

Assessment of puplis

Experienced

Needs Review

Competent

Re-evaluate

Assessment of LOC

Experienced

Needs Review

Competent

Re-evaluate

Assessment of CMS

Experienced

Needs Review

Competent

Re-evaluate

Neuro Trauma

Experienced

Needs Review

Competent

Re-evaluate

Overdose

Experienced

Needs Review

Competent

Re-evaluate

Seizure Activity

Experienced

Needs Review

Competent

Re-evaluate

Spinal Cord Injury

Experienced

Needs Review

Competent

Re-evaluate

Heart Sounds*

Experienced

Needs Review

Competent

Re-evaluate

Peripheral pulses*

Experienced

Needs Review

Competent

Re-evaluate

Edema*

Experienced

Needs Review

Competent

Re-evaluate

Apical pulse*

Experienced

Needs Review

Competent

Re-evaluate

Capillary refill time*

Experienced

Needs Review

Competent

Re-evaluate

Post-op Cardio patient

Experienced

Needs Review

Competent

Re-evaluate

Post-op Vascular surgery

Experienced

Needs Review

Competent

Re-evaluate

Post-op aneaysm

Experienced

Needs Review

Competent

Re-evaluate

Post MI*

Experienced

Needs Review

Competent

Re-evaluate

CHF*

Experienced

Needs Review

Competent

Re-evaluate

Auscultation of breath sounds*

Experienced

Needs Review

Competent

Re-evaluate

Oxygen Аdministration

Experienced

Needs Review

Competent

Re-evaluate

Preparing well-balanced meals

Experienced

Needs Review

Competent

Re-evaluate

Diabetic diet exchange system

Experienced

Needs Review

Competent

Re-evaluate

Low salt & other restricted diets

Experienced

Needs Review

Competent

Re-evaluate

Methods of serving to the ill

Experienced

Needs Review

Competent

Re-evaluate

Radial Pulse*

Experienced

Needs Review

Competent

Re-evaluate

Respiration*

Experienced

Needs Review

Competent

Re-evaluate

Ambulation with walker/cane

Experienced

Needs Review

Competent

Re-evaluate

Bed to chair*

Experienced

Needs Review

Competent

Re-evaluate

Chair to bed

Experienced

Needs Review

Competent

Re-evaluate

Into shower

Experienced

Needs Review

Competent

Re-evaluate

Active*

Experienced

Needs Review

Competent

Re-evaluate

Passive*

Experienced

Needs Review

Competent

Re-evaluate

Knowledge of proper body mechanics*

Experienced

Needs Review

Competent

Re-evaluate

Trensfer Board

Experienced

Needs Review

Competent

Re-evaluate

Use Hover Lift

Experienced

Needs Review

Competent

Re-evaluate

Laundry and cleaning

Experienced

Needs Review

Competent

Re-evaluate

Principles of cleanliness

Experienced

Needs Review

Competent

Re-evaluate

Patient environment*

Experienced

Needs Review

Competent

Re-evaluate

Fire Safety*

Experienced

Needs Review

Competent

Re-evaluate

Mmgt of incidents in pt home*

Experienced

Needs Review

Competent

Re-evaluate

Emergency & first aide proced*

Experienced

Needs Review

Competent

Re-evaluate

Understanding family and relationship differences.

Experienced

Needs Review

Competent

Re-evaluate

Skin and foot care*

Experienced

Needs Review

Competent

Re-evaluate

Abnormal s/s to be reported*

Experienced

Needs Review

Competent

Re-evaluate

Foot soak

Experienced

Needs Review

Competent

Re-evaluate

Abllity to detect swelling of ankles*

Experienced

Needs Review

Competent

Re-evaluate

Positioning of legs when in a sitting position, if edema is present

Experienced

Needs Review

Competent

Re-evaluate

Aware of s/s to be reported*

Experienced

Needs Review

Competent

Re-evaluate

Weigh patient

Experienced

Needs Review

Competent

Re-evaluate

Tracheostomy*

Experienced

Needs Review

Competent

Re-evaluate

Paraplegia

Experienced

Needs Review

Competent

Re-evaluate

Ventilators*

Experienced

Needs Review

Competent

Re-evaluate

Seizures

Experienced

Needs Review

Competent

Re-evaluate

Ted Hose

Experienced

Needs Review

Competent

Re-evaluate

Colostomy

Experienced

Needs Review

Competent

Re-evaluate

Name of Employee

Date

MM slash DD slash YYYY

Signature of Employee

Signature of Preceptor

Initials

Date

MM slash DD slash YYYY

Emergency Contact

Name

Home Phone

Cell Phone

Address

Relation

Please, sign the following indicating that you fully understand our application process here at Absolute Home Health Agency, Inc.

"l understand that the company has a drug-free workplace policy and submission to blood/urine testing is a condition of employment and continued employment and I hereby agree to submit to such testing or examination at the employer's expense at any time during the hiring process and my employment. I understand that my refusal to do so or my failure of the test(s) may result in my employer's refusal to hire me or my Immediate termination."

Applicant Signature

Date

MM slash DD slash YYYY

"I understand that the company will do a criminal background check on me prior to hiring; and I hereby agree, as a condition of application for and, if hired, employment and continued employment, to have such checks run at any time. I understand that my refusal to so agree or the presence of a negative report may result in my immediate termination or refusal of employment.

Applicant Signature

Date

MM slash DD slash YYYY

"l understand that I will be placed on a 90-day probationary period; and further understand that, if I am terminated during this period for inability to perform, the employer's unemployment account shall not be charged for any unemployment Applicant's paid to me.

Applicant Signature

Date

MM slash DD slash YYYY

"I certify that answers given herein are true and complete to the best of my knowledge. It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation ofthis application and/or separation from this employer's service if I have been employed. Further, I understand thatjust as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or 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 references and to secure additional information about me if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information."

Applicant Signature

Date

MM slash DD slash YYYY

Employment Eligibility Verification

Form I-9

Section 1. Employee Information and Attestation

(Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

MM slash DD slash YYYY

U.S. Social Security Number

Employee's E-mail Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Untitled

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work

(Alien Registration Number/USCIS Number)

until (expiration date, if applicable, mm/dd/yyyy)

Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number

2. Form I-94 Admission Number

3. Foreign Passport Number

Country of Issuance

Signature of Employee

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Conflict of Interest Form

1. Any outside interest that could possibly involve conflict of interest (directly or indirectly) with any person, vendor, family, purchaser or competitor will be disclosed.

The Nature of outside interest may be determined as:
- Ownership in competing agency/company
- Entertainment
- Money or gift (other than of normal value) Loans
- Employment status, e.g., working with competitor
- Related staff members

2. For Governing body: if a conflict of interest or a potential conflict of interest does exist, it will immediately be disclosed to all other members of the Governing Body verbally and/or in writing.
Governing Body member(s) with a conflict of interest will refrain from voting on all matters where a conflict of interest exists.

3. If a conflict potential conflict of interest arises for a staff member, the staff member must immediately reveal the conflict to his/her immediate supervisor verbally and/or in writing

4. The agency will review it's relationship and staff's relationship with other care providers, educational institutions and payers to ensure that those relationships are according to applicable law and regulation and to determine if conflict of interest exists.

My signature indicates that this policy has been discussed wth me and I hereby agree to disclose any conflict or interest or potential conflict of interest.

Name

Date

MM slash DD slash YYYY

Signature

Consent and Contract Agreement

This agreement is between Absolute Home Health II LLC, and Patient/Guardian:

Print First Name and Last Name

Patient Name

Agree that I will not attempt to privately contact or request services from the caregiver or nurse without the knowledge and written consent of Absolute Home Health II LLC. Any attempt to breach any terms of this agreement will result in a lawsuit against the client and the caregiver/nurse that will be filed by Absolute Home Health II LIC. And will result in an immediate fine of $5,000, each to both client and employee individually. In addition, a lawsuit resulting between $7,000 to $50,000 in damages against the said employee involved.

This agreement will be enforced to the fullest extent of the law.

Patient/Guardian

Agent

Witness

Date

MM slash DD slash YYYY

EMERGENCY NOTIFICATION FORM

Name

Date

MM slash DD slash YYYY

IN CASE OF AN EMERGENCY PLEASE CONTACT MY NEXT OF KIN:

Name

Relationship

Address

City

State

Zip

Phone

Cell

SECOND EMERGENCY CONTACT

Name

Relationship

Address

City

State

Zip

Phone

Cell

Hepatitis Vaccine Requirements

I, (Print First and Last Name)

acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself. It is my decision to:

Consent

request that I receive the Hepatitis vaccine

Consent

refuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to me.

Consent

provide written proof of immunity (attach)

Consent

provide written proof of previous vaccination (attach)

Consent

provide written proof of medical contraindication (attach)

Signature

Date

MM slash DD slash YYYY

ACKNOWLEDGMENT

I acknowledge that I have received a copy of the Alzheimer’s disease and related Dementias handout, and I do commit to read this information.

I am aware that if, at any time, I have questions regarding this handout I should direct them to my Director of Nursing or the Administrator.

Employee’s Printed Name

Position

Employee’s Signature

Date

MM slash DD slash YYYY

PLEDGE OF CONFIDENTIALITY

I, the undersigned, have read and understand ABSOLUTE HOME HEALTH AGENCY, INC. (hereinafter "the registry" policy describing confidentiality of personal health information (PHI) as described in the Confidentiality Policy which is in accordance with relevant state and federal legislation.

I also acknowledge that I am aware of and understand the policies regarding the security of personal health information including the policies relating to the use collection, disclosure, storage and destruction of personal health information.

In consideration of my contract or association with the registry and as an integral part of the terms and conditions of my contract or association, I hereby agree, pledge and undertake that I will not at any time, during my contract of association with this registry or after my contract or association ends, access or use personal health information, or reveal or disclose to any person within or outside, any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicable legislation and policies governing proper release of information.

I understand that my obligations outined above will continue after my coltract/association/ appointment with this registry ends.

I further understand that my obligations concerning the protection of the confidentiality of PHI relate to all personal health information whether I acquired the information through my contact or association or appointment with this registry or with any of the entities, which have an association with this registry.

Signature

Date

MM slash DD slash YYYY

Witness

Date

MM slash DD slash YYYY

Work Reference

Employee Name

Employer

Reference Telephone

Reference Name

I autorize Absolute Home Heaith Agency, Ine, to gather information about my worls. Please, answer ali questions. I release you from amy liablity.

Employee Signature

Date of Employment

MM slash DD slash YYYY

(Please, do not answer the following questions about the employee if your company does not allow you to fill out the bottom part. Dates of employment verification are appreciated.)

Would you re-hire the employee?

Yes

Average

Did the Employee leave in good-standing?

Yes

Average

Was the employee dependable?

Yes

Average

Was the company overall satisfied with the employee?

Yes

Average

I am signing this form to ensure that my informatien is true and will only be used for empioyment considerat

Employee Signature

Registered Nurse (RN) + Practical Nurses (LPN) Application

Registration Checklist

Background Check Consent Form

Employment Application

Personal Information

Education & Skills

Experience

ATTESTATION OF COMPLIANCE with Background Screening Requirements

Attestation

NURSING PROFICIENCY SKILLS CHECKLIST

Emergency Contact

Employment Eligibility Verification

Section 1. Employee Information and Attestation

Conflict of Interest Form

Consent and Contract Agreement

EMERGENCY NOTIFICATION FORM

Hepatitis Vaccine Requirements

ACKNOWLEDGMENT

PLEDGE OF CONFIDENTIALITY

Work Reference

Quick Inquiry