Private Duty Home Care LPN or RN
Initial Application for Employment
Demographics
Full Name (First & Last)
Preferred Name / Goes By
Street Address
City, State, Zip
Email
Mobile Phone
Nursing License #
License Type
LPN
RN
License State
NC
SC
Other
Were you referred by a nurse?
Yes
No
What is the name of the nurse who referred you?
Self-Assessment of Skills
G-Tube Maintenance & Care
Highly Proficient
Mostly Proficient
Somewhat Proficient
Not Proficient
G-Tube Medication Administration
Highly Proficient
Mostly Proficient
Somewhat Proficient
Not Proficient
Years of G-Tube Experience
Trach Care
Highly Proficient
Mostly Proficient
Somewhat Proficient
Not Proficient
Years of Trach Experience
Ventilator Care
Highly Proficient
Mostly Proficient
Somewhat Proficient
Not Proficient
Years of Ventilator Experience
Direct Care (ADLs, ROM, etc.)
Highly Proficient
Mostly Proficient
Somewhat Proficient
Not Proficient
Years Direct Care Experience
Briefly describe your work experience as related to the above skills and/or private-duty home care:
Please indicate any/all shifts you would be interested in working. Shift times are approximate and vary by patient.
1st Shift (Day Shift, 7a - 3p)
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
2nd Shift (Afternoon/Evening, 3p - 11p)
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
3rd Shift (Overnight, 11p - 7a)
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Desired Employment
Full-Time (32+ hrs/week, generally 3-5 shift/week commitment)
Part-Time (16+ hrs/week, minimum 2 shift/week commitment)
PRN (minimum 2 shift/month commitment)
Employment History
#1: Employer / Company Name (Current / Most Recent)
Job Title / Role
Employed From (Month-Year) to (Month-Year)
Supervisor Name
Supervisor Phone
May we contact this employer as a reference?
Yes
No
#2: Employer / Company Name (Prior to Most Recent / Current)
Job Title / Role
Employed From (Month-Year) to (Month-Year)
Supervisor Name
Supervisor Phone
May we contact this employer as a reference?
Yes
No
Have you previously applied for employment or worked for HHC?
I have previously applied for employment with HHC
I have previously worked for HHC
I have never applied or worked for HHC
Personal References (Non-Family)
#1 Reference Name
Relationship
Years Known
Phone
#2 Reference Name
Relationship
Years Known
Phone
Personal Background
Has your Nursing license ever been revoked, suspended or placed on probation?
Yes
No
Have you ever been convicted of a crime or pled guilty or no contest to any criminal charge?
Yes
No
Are you aware of any circumstances, which may result in a malpractice claim or suit being made or brought against you?
Yes
No
Has any malpractice claim or suit ever been brought against you?
Yes
No
Have you ever been the subject of a reprimand or disciplinary action or refused employment or admission to a professional society or had professional privileges suspended by any court or administrative agency or ever been the subject of any ethics investigation at local, state or national level?
Yes
No
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By signing below, I attest that statements and information provided in this application are true to the best of my knowledge. I understand that any falsification will be the basis for disqualification of employment. I authorize Helms Home Care, LLC to verify the information I have provided and to contact past employers and references concerning my ability, character and employment records. I release all such persons from liability for furnishing said information. Nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between Helms Home Care, LLC and the applicant for either employment or for providing of any benefit. All offers of employment are conditional upon the applicant's proving employment authorization and identity in accordance with the Immigration Reform and Control Act of 1986.
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