Pearl Home Care Application

Pearl Home Care LLC

2530 Meridian parkway, Durham, NC 27713 | 919-931-1029 | pearlhomecarellc.com | salimabdulhaqq304@gmail.com
Employee Application Form

(Compliant with North Carolina Home Care AgencyRequirements)
Applicant Information
Full Legal Name
Other Names Used if any
Current Address
CityStateZip
Phone Number
Email
example@example.com
Social Security Number last 4 digits
Date of Birth

MonthDayYear
Date
Emergency Contact Name
Relationship
Phone
Position Applying For:

Personal Care Aide (PCA)Home Health Aide (HHA)Certified Nursing Assistant I (CNA I)Certified Nursing Assistant II (CNA II)Other
Available Start Date

MonthDayYear
Date
Desired Employment Type:

Full TimePart TimePRN/As Needed
Work Eligibility
Are you legally authorized to work in the US? (If not, additional background checks may be required perNC DHHS regulations.)

YesNo
Have you lived in NC for the past 5 years? (If not, additional background checks may be required perNC DHHS regulations.)

YesNo
Background Screening Requirements (NC-Compliant)

North Carolina home care agencies must performmandatory background checks.
Have you ever been convicted of a misdemeanor or felony?

YesNo
Explain:
Are you listed on any state or federal abuse or neglect registry?

YesNo
Explain if Yes:
Driver's License #:
State
Do you have reliable transportation?

YesNo
Motor Vehicle Record Check Consent

I authorize release of my driving record.
Certifications and Training

Provide copies of certifications as required by NC homecare regulations. Ex: CNA I/II, CPR/First Aid, TB Test, Immunizations, Other
File Upload

Cancelof
Work Experience

List Your Last 3 Employers
Employer 1 Name* Street Address Address Line 2 City State Zip Position Area Code* Phone Number* Employment Dates: Start Date* to End Date* Reason for Leaving*
Employer 2 Name* Street Address Address Line 2 City State Zip Position Area Code* Phone Number* Employment Dates: Start Date* to End Date* Reason for Leaving*
Employer 3 Name* Street Address Address Line 2 City State Zip Position Area Code* Phone Number* Employment Dates: Start Date* to End Date* Reason for Leaving*
Check all that apply to your experience?
Health Screening Requirements (NC-Compliant)

North Carolina requires: - TB testing - Assessment ofcommunicable diseases - Compliance with infection control policies
Do you agree to complete all required health screenings?

YesNo
References (Minimum 2 Required)
Reference 1: Reference* Relationship Type a label* Phone Number*
Reference 2: Reference* Relationship Type a label* Phone Number*
Reference 3: Reference Relationship * Phone Number*
Please Read and Check Each Item:

I certify that all information provided is complete and truthful.I understand that falsification may result in immediatetermination.I authorize Pearl Home Care LLC to performbackground checks, registry checks, employment verification, and credentialverification as required by NC law.I agree to comply with all agency policies,including HIPAA and client confidentiality.I attest that I have received the employee handbookI have read the employyee handbookI have received job description letter
I Accept/Decline Hepatitis B Vaccination (Vaccinations are Offered)

AcceptDecline
Please Read and Check Each Item:

Had Bloode Borne Pathogen TrainingEmployee Training AttestationEmployee Training Dementia/Cognitive DevelopmentUnderstand HIPPA ConfidentialityHad Training in Abuse and NeglectHad Accident Incident TrainingUnderstand Client Bill of Rights
Applicant Signature*

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Date

MonthDayYear
Date
For Office Use Only:
Application Reviewed (Name/Date):
Background Check Completed:

YesNo
Registry Checks Completed

YesNo
Health Screening Complete:

YesNo
Orientation Scheduled
Hiring Decision

HiredNot Hired
Pearl Home Care LLC

Committed to high quality compassionate home care in North Carolina
Should be Empty:

Pearl Home Care LLC

Employee Application Form

Applicant Information

Work Eligibility

Background Screening Requirements (NC-Compliant)

Certifications and Training

Work Experience

Health Screening Requirements (NC-Compliant)

References (Minimum 2 Required)

For Office Use Only:

Pearl Home Care LLC