CNA Employment Application
When applying via mobile, ensure a seamless process by either having your documents readily available on your phone or being prepared to capture clear pictures of them. For computer users, have your necessary files already stored on your device. To expedite your application, diligently complete all sections, providing accurate and comprehensive information. Keep in mind that you won't be able to progress in the application process until all required documents and details have been submitted. Your prompt and thorough response is greatly appreciated, as it helps us efficiently evaluate your candidacy. Please give yourself 10-15 minutes to complete this application.
Identifying Information
Name (last, first, middle)
Maiden/Other
Street Address
City
State
Zip Code
County
E-mail
example@example.com
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Emergency Contact Name and Phone #
Secondary Emergency Contact Name and Phone #
Date Available
-
Month
-
Day
Year
Date
Preferred Shift
Please Select
First (6:00am - 2:00pm)
Second (2:00pm - 10:00pm)
Third (10:00pm - 6:00am)
Any
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Professional Credentials
Please ensure that you have all relevant certifications and state licenses, as submitting without these documents may result in delays in processing and potential work commencement restrictions until they are provided.
Education
College or University / Location
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Degree Earned
Education
College or University / Location
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Degree Earned
Professional License Number
Please upload your BLS/CPR Certification
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Submitting this application without your BLS/CPR may result in delays in processing and potential work commencement restrictions until it is provided.*
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Please upload your Dependent Adult Abuse Certificate
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Submitting this application without your certificate may result in delays in processing and potential work commencement restrictions until it is provided. Note: a recirtification course must be accompanied by the original 2.4 hour course.*
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Long Term Care CNA Skills Checklist
Vital Measurments
Rows
1
2
3
4
Blood Glucose Monitoring
Measure Blood Pressure
Measure Orthostatic Blood Pressure
Measure Pulse
Measure Respirations
Measure Temperature - Axillary
Measure Temperature - Oral
Measure Temperature - Rectal
Measure Temperature - Tympanic
Type a question
Rows
1
2
3
4
Bed Making occupied
Bed Making Unoccupied
Bedside Commode
Care of a Combative Patient
Care of a Suicidal Patient
Care of a Confused Patient
Denture Care
Foley Care
Foot Care
Post Mortem Care
Shower with Assistance
Transfer Techniques
Rows
1
2
3
4
Gait Belt
Weight bearing
Hoyer/Easystand
Two-person Transfer
Pivot
Wheelchair
Nutrition/Hydration
Rows
1
2
3
4
Encourage fluids per patient orders
Types of diet
Assist in feeding
Feeding techniques
Measure and record intake and output
I hereby certify that ALL information I have provided to FILL IN THE BLANK on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
Name (Please Print)
(First, MI, Last)
Today's Date
-
Month
-
Day
Year
Date
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Employment History
Please provide a complete 7-year work history. Please explain any gaps in employment. Submitting this application without the complete work history will result in delays in processing and potential work commencement restrictions until it is provided.*
Facility
Position Held
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Immediate Supervisor
Reason for leaving
Facility
Position Held
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Immediate Supervisor
Reason for leaving
Facility
Position Held
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Immediate Supervisor
Reason for leaving
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Legal Questionnaire
1. Have you ever been named as a defendant in a malpractice action?
Yes
No
If yes, when?
2. Have you had a license or certification in any jurisdiction limited, suspended, revoked or voluntarily relinquished?
Yes
No
If yes, when?
In what state?
3. Have you been licensed or practiced professionally under a different name?
Yes
No
If yes, under what name? What state?
4. Are you eligible to work in the U.S.?
Yes
No
Alien ID number (if applicable):
5. Have you ever been denied a license?
Yes
No
If yes, what state? When?
6. Have you ever been convicted by misdemeanor, felony including traffic violations?
Yes
No
If yes, when and what state?
7. Have you ever been arrested and are you out on bail on your own recognizance and still awaiting trial?
Yes
No
8. Have you ever been released or discharged from employment or resigned to avoid such release or discharged?
Yes
No
9. Have you ever had your driver’s license suspended or revoked?
Yes
No
If yes, when?
My signature certifies that all information contained within my application is correct and maybe verified by Just In Time Medical Staffing LLC, in compliance with the Iowa Law. It also acknowledges that I am aware that it is my responsibility to review the policy and procedure documents of each hospital/facility in which I work, prior to beginning my initial shift.
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Voluntary Self-Identification of Disability
Completing this section is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete this section and your answer will not harm you in any way. If you want to learn more about this section, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. To read what constitutes a disability, or how to know you have a disability, visit www.dol.gov/sites/dolgov/files/OFCCP/regs/compliance/sec503/Self_ID_Forms/503Self-IDForm.pdf
Please check one of the options below:
I have a disability, or have had one in the past
I do not have a disability and have not had one in the past
I do not wish to answer
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Authorization to Disclose information on Employment file, Background check, Medical Records and Drug Screening
By affixing my signature hereunder, I authorize Just In Time Medical Staffing, LLC to release any and all confidential employment background check and medical information contained in my employment file to any medical facility or entity with which Just In Time Medical Staffing LLC, has staffing agreement, and to any other governmental or regulatory agency such agency's request. For all other purposes, Just In Time Medical Staffing LLC, shall keep my employment confidential and shall advise any medical facility or other entity to which records have been provided to also keep such record confidential. I hereby hold Just In Time Medical Staffing LLC, harmless for any result (s) that arises with regards to the release of this confidential information by Just In Time Medical Staffing LLC, Medical records information is confidential and Just In Time Medical Staffing LLC, will instruct client facilities and/or other entities to treat the provided information confidential as well.
STATE OF IOWA Criminal History Record Check Request Form
I hereby give permission for the above (Just In Time Medical Staffing, LLC) requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law. I understand this can include information concerning completed deferred judgements and arrests without dispositions.
Name
First Name
Last Name
Gender
Male
Female
Signature
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Authorization for Release of Child and Dependent Adult Abuse Information
Iowa Department of Human Services
I understand that my signature authorizes the requester to receive information to verify whether I am named on the Child Abuse or Dependent Adult Abuse Registry as having abused a child (Iowa Code section 235A. 15) or dependent adult (Iowa Code section 235B.6). To the best of my knowledge, the information contained in this section of this form is correct.
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Employee Vaccination Status
Please indicate your Flu vaccination status by selecting the appropriate option below:
I have received the Flu vaccine for the current season.
I have not received the Flu vaccine for the current season but would like to receive it.
I do not want to receive the Flu vaccine
Reason for Declination (if applicable):
If applicable, please upload your Flu vaccination
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Submitting this application without your Flu results may result in delays in processing and potential work commencement restrictions until it is provided.
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Please indicate your COVID-19 vaccination status by selecting the appropriate option below:
I have received the complete COVID-19 vaccination series.
I have received some doses of the COVID-19 vaccine but not the complete series.
I have not received any doses of the COVID-19 vaccine but would like to receive it.
I do not want to receive the COVID-19 vaccine.
Reason for Declination (if applicable):
If applicable, please upload your COVID-19 vaccination
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Please indicate your Hepatitis B vaccination status by selecting the appropriate option below:
I have completed the entire Hepatitis B vaccination series.
I have had the Hepatitis B vaccination series but cannot find my documentation.
I do not want to receive the Hepatitis B vaccination.
Reason for Declination (if applicable):
If applicable, please upload your Hepatitis B vaccination
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Submitting this application without your Hep B results may result in delays in processing and potential work commencement restrictions until it is provided.
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Signature
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TB QUESTIONNAIRE
Please answer the following TB Questionnaire
1. Unplanned loss of weight (>10% of body weight)?
Yes
No
2. Night sweats?
Yes
No
3. Fever lasting several weeks?
Yes
No
4. Frequent coughing in the absence of a cold or flu?
Yes
No
5. Coughing blood-streaked sputum?
Yes
No
6. Unusual tiredness or weakness lasting weeks?
Yes
No
7. Pain in chest when taking a breath?
Yes
No
8. Have you been recently diagnosed with diabetes, silicosis, HIV disease, renal disease or liver disease?
Yes
No
9. Have you been recently been exposed to a family member or other with active TB?
Yes
No
10. If you checked YES to any of the above questions, are you currently treating with a physician?
Yes
No
Please upload your TB 2-step or your chest x-ray results. *Chest x-ray must be accompanied by positive TB proof documentation
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Submitting this application without your TB or chest x-ray results may result in delays in processing and potential work commencement restrictions until it is provided.
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Direct Deposit Agreement Form
Authorization Agreement I hereby authorize Just In Time Medical Staffing LLC, to initiate automatic deposits to my account at the financial institution named below. I also authorize Just In Time Medical Staffing LLC, to make withdrawals from this account in the event that a credit entry is made in error. Further, I agree not to hold Just In Time Medical Staffing LLC. responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account This agreement will remain in effect until Just In Time Medical Staffing LLC, receives a written notice of cancellation from me or my financial institution. or until I submit a new direct deposit form to the Payroll Department.
Name of Financial Institution
Routing Number
Account Number
Checking
Savings
Signature
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