New HealthLink Home Care Employment Application

REFERENCES

Provide two references. ***ONE MUST BE A PROFESSIONAL REFERENCE***

References can be any of the following:

Former or current employers, managers or supervisors
Former or current coworkers
Industry colleagues
Advisors, teachers or instructors
Reference #1 Name*

First NameLast Name
Reference #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
Friends, family, spouses and significant others are not valid
Reference #2 Name*

First NameLast Name
Reference #2 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
Friends, family, spouses and significant others are not valid

Employment History
Employer #1*
Name, Address, Phone
Employment Begin Date*

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Reason for Leaving (if not still employed)*
Pay*
Job Title and Responsibilities*
Supervisor Name*
YesNo
Supervisor Contact Information
Phone number or email address
Employer #2*
Name, Address, Phone
Employment Begin Date*

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Reason for Leaving*
Pay*
Job Title and Responsibilities*
Supervisor Name*
YesNo
Supervisor Contact Information
Phone number or email address
Please list any additional skills, qualifications, certifications, or training that you feel is relevant to this position (e.g., speak a foreign language, CPR, or other training or special education)
Upload Resume (optional)

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Document Collection
Driver's License (or other State Issued ID)*

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BBP - Blood Borne PathogenBLS - Basic Life SupportCPRTB TestCNA LicenseNoneOther
File Upload*

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Social Security Card*

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Initials*
HealthLink Home Care, LLC is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with HealthLink Home Care, LLC depends solely on your qualifications. Thank you for completing this application form and your interest in our business.
Signature with Credentials*
Date*

MonthDayYear
Date
Should be Empty:

Rows	Unfamiliar	Familiar	Practiced	Expert
Use of Bed Pan
Bowel Program
Use of Bedside Commode
Measure Urine Output
Empty Foley Catheter Drainage Bag

Rows	C = Competent	T = Needs Training	N/A = Not Applicable
Bathing - Assists with or provides full bath, shower, or sponge bath
Dressing - Assists with selecting appropriate clothing and dressing
Grooming - Assists with oral care, hair care, shaving, etc.
Toileting - Assists with use of toilet, bedpan, incontinence care, foley catheter care
Ambulation - Assists with walking, use of walker/cane, transfers
Transfers - Bed to chair, toilet, tub, etc. (with or without assistive devices
Feeding - Assists with feeding or cueing for self-feeding
Continence Care - Monitors and supports bladder/bowel management
Positioning - Reposition clients in bed or chair for comfort and pressure relief
Skin Integrity Monitoring - Observes for pressure sores, rashes, etc
Use of Assistive Devices - Applies knowledge of gait belts, Hoyer lifts, etc.
Documentation - Accurately records care tasks and client observations

Rows	Unfamiliar	Familiar	Practiced	Expert
Care of Alzheimer Client
Care of Client with Respiratory Difficulties
Care of Client with Stroke
Care of Client with Head Injury
Care of Paraplegic or Quadriplegic Client
Diabetic Care
Care of Amputee Client
Care of Bed Bound Client

Rows	C = Competent	T = Needs Training	N/A = Not Applicable
Meal Preparation - Plans, prepares, and serves meals safely and nutritiously
Housekeeping - Cleans, does laundry, and maintains a safe living environment
Medication Reminders
Socialization / Companionship

Skills Checklist