Limitless Love Home Care, LLC application for Employment

Limitless Love Home Care, LLC Application for Employment
How did you hear about Limitless Love Home Care, LLC?*

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Employee Information

This form is a professional document and must be complete, true, and accurate. This information may, upon request, be furnished to those facilities which receive services from an employee nurse. Please fill in all the blanks.
Employee Name*

First NameMiddle NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail Address*
Primary Number*

Area CodePhone Number
Secondary Number*

Area CodePhone Number
Social Security Number*
Date of Birth*

MonthDayYear
Preferred Shifts:*

DaysNightsWeekdaysWeekendsAny/All ShiftsOther
Work History

Begin with most recent held job
Name of Company #1*
Address of Company #1*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number of Company #1*

Area CodePhone Number
Date Started of Company #1*

MonthDayYear
Date Ended of Company #1*

MonthDayYear
Name of Company #2
Address of Company #2

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number of Company #2

Area CodePhone Number
Date Started of Company #2

MonthDayYear
Date Ended of Company #2

MonthDayYear
Education

Please list any post high school education
School Name #1*
School Address #1*

Street Address

Street Address Line 2

CityState

Zip Code
Date Completed School #1*

MonthDayYear
Degree/Diploma/Certificate Earned*
School Name #2
School Address #2

Street Address

Street Address Line 2

CityState

Zip Code
Date Completed School #2

MonthDayYear
Degree/Diploma/Certificate Earned
Malpractice Insurance (optional)
Malpractice Policy # (optional)
Skills Assessment

Please be truthful and complete with the following information.
Skills Assessment (select all that apply)*

Patient Bed MakingFeeding PatientsOral TempAxillary TempCount RespirationsRecord Blood PressureCount PulseTurning PatientsRange of MotionHot CompressOne on One contact with Psych patientComplete Bed BathPartial Bed BathDangle FeetRecord Intake/OutputApply StockingsPost-op CareRecognize Code SituationsShowerSetting up meal trayPlace pt in chairGive EnemasCalling a codeAnswer PhonesOther
List all areas you have worked as a Home Healthcare Worker: (Nursing Home, Hospital, Private Duty, etc)*
Pediatric Care*

YESNO
Adolscent Care*

YESNO
Adult Care*

YESNO
Geriatric Care*

YESNO
Background Check Authorization

With a background check, you will be required to complete a urine drug screen. A staff member will contact you on when to get a drug screen done.
Have you been arrested for/or convicted of FELONY charges?*

YESNO
HIPPA Privacy Protection

In accordance with the privacy regulations promulgated under the Health Insurance Portability and Accountability Act, 45 CFR parts 160 and 164. Limitless Love Home Care, LLC understands 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.Limitless Love Home Care, LLC 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. Limitless Love Home Care, LLC agrees 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, Limitless Love Home Care, LLC 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 disclosures of the protection health information. If any unauthorized disclosure of personal health information occurs, Limitless Love Home Care, LLC shall immediately contact facility to inform them of the disclosure and any remedial action taken to prevent further disclosures Limitless Love Home Care, LLC understands 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*

YES, I agree to abide by the HIPPA Privacy Protection Statement
Vaccination Declination

I understand that due to my occupational exposure to blood and other potential infectious materials I may be at risk of acquiring an infectious disease. I have been given the opportunity to be vaccinated by the physician of my choice or facility of my choice at my own expense. If I have already received all required vaccines, I agree to provide documentation to verify to LimitlessLoveHomeCare, LLC.I understand that declining vaccines, I continue to be at risk of acquiring a serious disease. If in the future I continue to have occupational exposure to blood or potentially infectious materials and I want to be vaccinated, I can receive the vaccines from a physician and/or facility of my choice at my own expense.Below I hereby indicate that I decline the following vaccines or will provide documentation for any vaccines I have received in the past.
I Decline the following Vaccines:*

Tetanus (TDaP)MMRFluHep B (3 shot series)I will provide proof of any vaccines.
I will provide proof of the following vaccines:*

Tetanus (TDaP)MMRFluHep B (3 shot series)I will DECLINE any vaccines and I understand the risks of doing so
Confidentiality Statement

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, sex, age, disability, religious beliefs, nation origin, or political beliefs.
Confidentiality Statement (please place check mark in the box to continue)*

YES, I agree to give Limitless Love Home Care, LLC permission to release any contracted facility the employee's credentials, including, but not limited to: background check, health screening, certifications, and/or licenses, etc.
OSHA Standards and Saftey Procedures
OSHA standards in reference to: Fire Prevention and Evaluation, Body Mechanics, Chemical Hazards, Infection Control, Universal Precautions, AIDS, Exposure to Blood Borne Pathogen Standards*

YES, I verify that I have been educated on and understand the OSHA standards and Safety Procedures.
Complete Application
Application Completed (place check mark in box to continue)*

YES, I hereby verify that my application for employement with Limitless Love Home Care, LLC is complete and truthful. If any information were to be found false, it may be grounds for immediate termination.
Please be sure all required documents are submitted:

Drivers License, Social Security Card, Background Check .Thank you
Employee Printed Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Employee Signature*
Should be Empty:

Limitless Love Home Care, LLC Application for Employment

Employee Information

Work History

Education

Skills Assessment

Background Check Authorization

HIPPA Privacy Protection

Vaccination Declination

Confidentiality Statement

OSHA Standards and Saftey Procedures

Complete Application

Please be sure all required documents are submitted: