aGapeKAREz - Caregiver application
aGapeKAREz currently has agreements to provide contract nurses to medical facilities. These facilities require basic information about the nurses who perform services at their facilities. In an effort to provide better services to both the contract nurses and facilities, We have assembled the information required by various facilities in this enclosed application. If you wish to contract your services through aGapeKAREZ , please fill out the application. We will in turn forward this information to any facility you choose to work with. Please advise our staff of your available shift times and areas/departments of preference. Thank you for choosing aGapeKAREz. If you have any questions, please contact our office at 727-746-8533.
Required Documents for contract nursing work
Drivers License, LPN/CNA license (RN verified online), Current certifications: BLS, ACLS, PALS, NALS, CPI, Current TB/PPD test or Chest X-ray, Current Vaccines: Hep B, MMR, Tetanus, Flu, Covid (or exemptions) (Titers)
Phone Number Home
Date of Birth
Date Picker Icon
RN ,LPN, CNA
RN - Registered Nurse
LPN - Licensed Practical Nurse
CNA- Certified Nursing Assistant
CMA- Certified Medical Assistant
< 6 months
Who is your recruiter or contact person?
Unknown - applied from indeed
Desired work availability: (Select all that apply)
Part-time / Per Diem / PRN
Desired work options
Assisted Living Facilities
Select areas of work experience:
Critical Care (ICU)
Have you been arrested for and/or convicted of a Felony?
Have you ever had any disciplinary action against your nursing license/certificates or currently hold any limitations on your nursing license?
Covid Vaccine Card
Upload TB/MMR/Varicella (or Titers)
Upload resume here
States licensed to practice (list)
Malpractice Insurance (optional)
HIPPA PRIVACY PROTECTION
In accordance with the privacy regulations promulgated under the Health Insurance Portability and Accountability Act, 45 (fort-five) CFR parts 160 and 164 (the "Privacy Regulations"), aGapeKAREz LLC and Nurse Employee/Contractor understand and agree to abide by the facility privacy policies and to not use or further disclose a patient's personal health information except as expressly permitted by the agreement or as otherwise authorized in writing by the patient through a consent or authorization meeting the requirements of the privacy regulations. aGapeKAREZ LLC and NURSE EMPLOYEE/CONTRACTOR may only use a patient's personal health information for the sole purpose of treatment, and/or health care operations and may not release any information to unauthorized parties. aGapeKAREz and NURSE EMPLOYEE/CONTRACTOR agree to implement appropriate safeguards to prevent the unauthorized use and disclosure of any patient's personal health information received by facility under this agreement. In addition aGapeKAREz LLC and NURSE EMPLOYEE/CONTRACTOR shall make available to the facility the protected health information for amendment purposes, should changes to the information be necessary or to provide an accounting of disclosure of the protected health information. If any unauthorized disclosure of personal health information occurs, aGapeKAREz LLC and NURSE EMPLOYEE/CONTRACTOR shall immediately contact facility to inform them of the disclosure and any remedial action taken to prevent further disclosures aGapeKAREz LLC and NURSE EMPLOYEE/CONTRACTOR understand that any unauthorized disclosure of a patient's personal health information is grounds for immediate termination of the agreement and/or staffing assignment.
HIPPA Privacy Protection Statement:
YES, agree to abide by the HIPPA PRIVACY PROTECTION terms. In doing so, I understand the risks of participating in any HIPPA infractions and will be IMMEDIATELY terminated upon any reported infractions.
In addition to HIPPA privacy protection, I agree to adhere to regulations listed in "CFR 42 part 2" (Confidentiality of Substance Use Disorder Patient Records). In doing so, I understand the risks of participating in any HIPPA infractions and will be IMMEDIATELY terminated upon any reported infractions.
You have the right to confidentiality - that means that the information given by you will not be released without your written consent, except to facilities in which you have or will work. We do not discriminate in the delivery of services. This means you will not be treated differently from others because of race, color, sex, age, disability, religion, nation origin, or political beliefs. This gives aGapeKAREz LLC permission to release any contracted facility the employee's/contractor credentials, including, but not limited to: background check, health screening, certifications and/or license, etc
YES, I agree to abide by the CONFIDENTIALITY STATEMENT
OSHA Standards and Safety Procedures
OSHA standards and regulations
OSHA standards in reference to: Fire Prevention and Evaluation, Body Mechanics, Chemical Hazards, Infection Control, Universal Precautions, AIDS, Exposure to Blood Borne Pathogen Standards
I hereby verify that I have been educated on and understand the OSHA standards and Safety Procedures.
Place check mark in box to continue:
I hereby verify that all of the above information is correct, true, and valid. If any information were to be found false, it may be grounds for immediate termination.
Final Application Nurse Signature
Should be Empty:
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