CNA APPLICATION Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth
Date
Year
Month
Day
3
Social Security Number* This field is required.
4
Email* This field is required.
example@example.com
5
Phone Number* This field is required.
Please enter a valid phone number.
6
What state are you licensed to work in
MA
RI
ME
OTHER
7
CNA Licence Number
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
School Attended* This field is required.
10
Year Graduated/Certificate/Degree
11
State Of Residency* This field is required.
MA
ME
RI
OTHER
12
Select your qualification
RN
LPN
CNA
STNA
OTHER
13
How many years of experience do you have?
0-6months
1-2 years
3- 5 years
5-10 years
10-20 years
over 20 years
14
First Name
Last Name
15
First Reference Relationship
16
First Reference Phone
17
Second Reference Name
First Name
Last Name
18
Second Reference Phone number
19
Second Reference Relationship
20
In which geographical area are you most likely to work?
Boston - Cambridge -Newton
Worcester
Barnstable
Springfiled
Providence
Middleborough/Brockton/Taunton
Others
21
Are you willing and able to work in long-term care and assisted living environments?
Yes
NO
22
How did you hear about us?
Social Media
Search Engine ( google)
Job Boards (Indeed, Zip recruiter)
Dignity Care Member
Email
Mail
23
NameWhat is name of Dignity care member who referred you to us. He or She is Eligible for referral bonus of $100 once you have completed your 40 hours with us.
First Name
Last Name
24
Emergency Contact Name* This field is required.
First Name
Last Name
25
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
26
Relationship with Emergency contact* This field is required.
27
Periodically, we may receive a request from a facility to run a state level background check. By acknowledging this statement, you are allowing us to run your information through your state's proprietary background check system.
Acknowleged
28
Basic CNA Skills Check

We are thrilled to have you be part of our Dignity Medical Staffing LLC. Just a few more things to check off the list.

To get you to the next step, take 5 minutes (really, just 2 minutes!) to complete your self-assessment and you’ll be one step closer to booking shifts on YOUR terms and meeting new friends in the nursing community.
29
1.Vital signs (i.e. Oral-Temp, Blood Pressure, Pulse (Radial-Apical), 02 Saturation, Respirations / Mid Rate)
Experienced
some experience
Expert
Limited Experience
30
2. Universal Precautions (i.e. Gowning, putting on gloves, and hand hygiene)
Experienced
some experience
Expert
Limited Experience
31
3. ADL (i.e Bathing, Feeding, Denture care, Decubitus care)
Experienced
some experience
Expert
Limited Experience
32
4. Fall Precautions and Prevention: (i.e. Bed alarms, frequent rounding, fall risk bracelets)
Experienced
some experience
Expert
Limited Experience
33
5. Transfers (i.e. Hoyer / Easystand, two person assists, pivot)
Experienced
some experience
Expert
Limited Experience
34
6. Positioning/Turning (i.e. Supine, side laying and use of draw sheet)
Experienced
some experience
Expert
Limited Experience
35
7. Specimen Collection (i.e. Urine, sputum, stool, culture)
Experienced
some experience
Expert
Limited Experience
36
8. Specimen Collection (Obtain Urine Culture, Obtain Sputum Specimen, Obtain Foley Cath Specimen)
Experienced
some experience
Expert
Limited Experience
37
8. Alzheimer Disease/Dementia
Experienced
some experience
Expert
Limited Experience
38
9. CPR/Heimlich Maneuver
Experinced
some experience
Expert
Limited Experience
39
9. CPR/Heimlich Maneuver
Experienced
some experience
Expert
Limited Experience
40
10. Aspiration Precautions: (Thin, nectar, thick, honey thick consistency)
Experienced
some experience
Expert
Limited Experience
41
11. I + O’s (i.e. Emptying drainage bags)
Experienced
some experience
Expert
Limited Experience
42
12. Weighing Patients (Standing, wheelchair, and bed scale)
Experienced
some experience
Expert
Limited Experience
43
13. Observations, Reporting & Documentation (Change in body functions, behavior or routines)
Experienced
some experience
Expert
Limited Experience
44
14. Safety Devices (i.e. Vest restraints, soft ankle, wrist restraints)
Experienced
some experience
Expert
Limited experience
45
15. Ambulating (i.e. Cane, crutches, walker, standby assistant)
Experienced
some experience
Expert
Limited Experience
46
Offer Letter

Pay and Benefits Offer

Hourly Payrate for Certified Nursing assisstant is $25/hr to $28

1.5x holiday pay, Crisis/hazard pay and bonuses (for select shifts

Position- Per Diem Certified Nursing Aide (CNA)

Benefits Include

Online community support

Continued education program

Dignity care swag

More compensation includes:

1.5X Overtime Pay for every hour worked over 40 hours per week

$100 Referral Bonus when a friend you referred to Dignity Medical Staffing LLC works their first 40 Hrs
$500 Facility Referral Bonus when a facility you referred to Dignity Medical becomes a partner
47
Accept Offer * This field is required.
YESNO
48
Upload your Credentials. CPR
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
49
Upload Government Issued ID
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
50
Upload TB/PPD Test OR Chest X-Ray
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
51
Upload Yearly Physical
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
52
Current or Most Recent Employer
53
Current Employer Address/Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
54
Job Title
55
Job Description
Huge
Large
Normal
Small
Ok
Ok
56
Start Date and End Date
57
Do you have a Dementia Training Certificate?
YESNO
58
Upload Dementia Certificate
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
59
Please provide your Clinical License Number
60
Clinical License Expiration Date
Date
Year
Month
Day
61
Upload Clinical License Picture
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
62
Please upload a picture of your Photo ID
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
63
Second Most Recent Employer
64
Address of Second Most Recent Employer
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
65
Job Title
66
Job Description
Huge
Large
Normal
Small
Ok
Ok
67
Start Date
Date
Year
Month
Day
68
End Date
Date
Year
Month
Day
69
COVID-19 Vaccination Requirement The new federal vaccine mandate states that all health care workers must be fully vaccinated and boostered by Feb 28, 2022. * This field is required.
Dose 1 Pfizer and Moderna only
Dose I Johnson and Johnson only
Dose 2 Moderna and Pfizer only
Fully vaccinated
Declination
Covid Vaccine Booster 1
Covid vaccine Booster 2
70
Upload Covid Vaccination Proof
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
71
Upload Certification
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: