HOME HEALTH AIDE APPLICATION

Home Health Aide Application

Senior Caregivers
APPLICATION FOR EMPLOYMENT
Full Name*
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Zip Code*
Please enter your zip code.
SSN*
DOB- Date of birth*

MonthDayYear
Date
Preferred Email Address*
example@example.com
Cell Phone Number*
Home Phone Number
Additional Phone Number
Please enter a valid phone number.
Type Home or Cell
What languages are you fluent in*
Do you Speak American Sign Language?
Select One*
If so what level Beginner Intermediate or Fluent
Do you have a valid driver's license?*
Do you currently have a vehicle?*
Make and Model of Vehicle*
Type N/A if you do not drive at the moment.
Are you willing to provide some duties in your vehicle*
Type N/A if you do not drive at the moment.
Have you had a BCI Style Background Check for a Home Care Agency in the last 6 months or less?*
If you answered YES what was the month and year of your last fingerprints*
QUALIFICATIONS
HIGH SCHOOL/GED
Name of School + City and State*
AVAILABILITY
What days and times are you available to work?*
Preferred Time Windows of Work*

WeekendsWeekdaysMorningsAfternoonsEveningsOvernights
Do you have any of the following?
Do you have CPR or First Aid Certification?*
If yes, date of last certification?
Medication Administration Certification 1, 2, or 3? Type the number(s) or No if you do not have this certification*
Are you a CNA, STNA, or a Certified Medical Assistant? If yes, type which certifications you hold. If no, type No.
Desecalation Training?*
Any additional licenses or certifications not listed
PREFERENCES
Which counties are you willing to work in?
Type a question*

ClermontHamiltonButlerWarren
Are you willing to work with a client who has a cat*
Are you willing to work with a client who has a dog*
Are you willing to work with a client that does not speak English*
Are you willing to provide services to a client that smokes*
Which of the following duties do you have experience in?
Type a question*

AmbulationBathingHousekeepingBladder CareTransportationShoppingMeal PrepLaundrySocializationFeeding TubesMedication RemindersOral CareDressingGroomingSocialization
Are there any duties or activities of daily living which you are not willing or able to perform*
Have you ever been convicted of a Felony?
If so please explain. If No, type N/A.*
Do you have 6 or more points on your driving record?*
Please list the states that you have lived in the past seven years.*
EMPLOYMENT HISTORY
PLEASE INCLUDE AT LEAST 1 YEAR OR LONGER OF CAREGIVING EXPERIENCE WHERE YOU WORKED UNDER A SUPERVISOR. THIS CAN BE ONE COMPANY OR 2 COMBINED.
Employer # 1
START MONTH/YEAR*
END MONTH/YEAR
Employer Name*
City*
State*
Phone*
Are you still working for this employer?
Starting Salary*
Ending Salary*
Reason for leaving this employer*
Employer # 2
START MONTH/YEAR*
END MONTH/YEAR*
Employer Name*
City*
State*
Phone*
Are you still working for this employer?
Starting Salary*
Ending Salary*
Reason for leaving this employer*
STATEMENT OF AUTHORIZATION
Please read the information on this form carefully and completely.

| have applied for employment with Nattingham Home Care LLC and have provided information about my previous employment. I authorize Nattingham Home Care LLC to conduct a reference check with my present and/or previous employer(s).

I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary, and employment history.

My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment with Nattingham Home Care LLC, whether the information is positive or negative.

I knowingly and voluntarily release all former and current employers, references, and Nattingham Home Care LLC from any liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Nattingham Home Care LLC.

| further authorize Nattingham Home Care LLC to obtain feedback and references from my supervisors during my employment with Nattingham Home Care LLC.

I understand that subsequent and continued employment with Nattingham Home Care LLC may be subject to this feedback. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.
Employee Signature*

Clear
Employee Name Printed*
Date*

MonthDayYear
Date
EQUAL OPPORTUNITY EMPLOYER
It is the policy of Nattingham Home Care LLC, in accordance with all applicable laws, to recruit, hire, train, and promote persons in all job titles without regard to race, color, national origin, genetic information, religious beliefs, sex, gender identity, sexual orientation, age, marital status, pregnancy, disability, protected veteran status, or any other protected classifications, activities, or conditions as required by federal, state and local laws.

All employment decisions shall be consistent with the principle of equal employment opportunity, and only valid qualifications will be required.

By signing in the space provided below, you hereby acknowledge that you have been given a copy of the Nattingham Home Care LLC's Equal Opportunity Employer Statement and, that you have read the Statement and that you understand its contents.
Signature of Employee*

Clear
Employees Name Printed*
Date*

MonthDayYear
Date
Certification of Application Truths
I certify that the facts in the above employment application are true and complete to the best of my knowledge.

I understand that falsified statements on this application in any detail shall be considered sufficient cause for disqualification from further consideration for hire

False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment.

I also understand that due to the nature of the business, no amount of work can be guaranteed.

By signing in the space provided below, you hereby acknowledge that you have read the Statement above and that you understand its contents and agree to its contents.
Signature of Employee*

Clear
Employees Name Printed*
Date*

MonthDayYear
Date
5 YEAR OHIO RESIDENCY STATEMENT
Name*
Date of Birth*

MonthDayYear
Date
OHIO ADDRESS*
I certify that I am the person described above that I am a permanent resident of the state of Ohio, and that I have been residing in Ohio for at least 5 (five) years prior to today's date.
Employee Signature*

Clear
Date*

MonthDayYear
Date
CRIMINAL BACKGROUND CHECK AUTHORIZATION
Are you a U.S. Citizen*
If No, do you have the legal right and documents to work in the United States?*
Have you ever been convicted of, or pleaded guilty to a crime or felony, other than a minor traffic violation?*
If yes please explain*
If no type N/A.
By signing this document, you certify that you have not been convicted of any of the above statutes and understand that Nattingham Home Care is required by law to run an investigation of my Police Record.

I understand that my employment with Nattingham Home Care is CONDITIONAL for 60-90 DAYS, pending the final results of this investigation, and realize that my employment will be TERMINATED if the results indicate that I was convicted of, or pleaded guilty to, any of the offenses.

I further authorize Nattingham Home Care to release or otherwise make available to Clients, as required by FEDERAL or STATE REGULATIONS, any information that may be required from my PERSONAL FILES.

Applicants may not be employed if information exists that the applicant has committed or pleaded guilty to a CRIME or FELONY, or if the applicant refuses to submit fingerprints for a criminal background check.
Application Signature and Date*

Clear
REQUEST FOR COPY OF OHIO BACKGROUND CHECK:
REASON FINGERPRINTED ON LAST BACKGROUND CHECK
REASON FINGERPRINTED FOR THIS BACKGROUND CHECK
NAME must be the same name submitted with fingerprints
SSN
DOB

MonthDayYear
Date
SEND BACKGROUND RESULT TO:
NAME
STREET
CITY
STATE
ZIP CODE
Return this letter with your payment of $8 (if required), payable to Treasurer, State of Ohio. I hereby certify that I have given the above mentioned person or agency permission to obtain a copy of any conviction record pertaining to me in the files of the Ohio Bureau of Criminal Investigation.
*REQUIRED: APPLICANTS SIGNATURE:
APPLICANTS SIGNATURE*

Clear
DATE*

MonthDayYear
Date
APPLICANT'S PHONE NUMBER*
Should be Empty:

Home Health Aide Application

APPLICATION FOR EMPLOYMENT

QUALIFICATIONS

HIGH SCHOOL/GED

AVAILABILITY

PREFERENCES

EMPLOYMENT HISTORY

PLEASE INCLUDE AT LEAST 1 YEAR OR LONGER OF CAREGIVING EXPERIENCE WHERE YOU WORKED UNDER A SUPERVISOR. THIS CAN BE ONE COMPANY OR 2 COMBINED.

Employer # 1

Employer # 2

STATEMENT OF AUTHORIZATION

EQUAL OPPORTUNITY EMPLOYER

Certification of Application Truths

CRIMINAL BACKGROUND CHECK AUTHORIZATION

REQUEST FOR COPY OF OHIO BACKGROUND CHECK:

SEND BACKGROUND RESULT TO:

*REQUIRED: APPLICANTS SIGNATURE: