Nattingham Home Care Home Health Aide Employment Application
This streamlined application is intended for Home Health Aide applicants completing the form on mobile, tablet, or desktop devices.
Applicant Information
Full Name:
*
Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Street Address:
*
City/State/Zip:
*
Are you 18 years or older?
*
YES
NO
Do you have a valid driver's license?
*
YES
NO
Do you have reliable transportation?
*
YES
NO
Counties willing to work in:
*
Hamilton
Clermont
Butler
Warren
Position & Availability
Position Applying For: Home Health Aide
Date Available to Start:
*
-
Month
-
Day
Year
Date
Preferred Schedule:
*
Full-Time
Part-Time
PRN
Preferred Shift(s):
*
Days
Evenings
Overnights
Weekends
Training & Certifications
Please check all that apply:
*
I have completed a 30-Hour Home Health Aide Course
I currently hold a CNA certificate
I currently hold an STNA certificate
I currently hold a Medical Assistant (MA) certificate
I need Home Health Aide training
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School or Training Program:
*
Write N/A if not applicable
Certification Number (if applicable):
*
Write N/A if not applicable
Expiration Date (if applicable):
*
Write N/A if not applicable
Caregiver Experience Requirement
Applicants for the Home Health Aide position must have at least one (1) year of supervised caregiver experience.
Please list your TWO MOST RECENT employers below.
Employer #1
Company Name:
*
Position Held:
*
Supervisor Name & Phone:
*
Dates Worked:
*
Main Duties Performed:
*
Reason for Leaving:
*
Employer #2
Company Name:
*
Position Held:
*
Supervisor Name & Phone:
*
Dates Worked:
*
Main Duties Performed:
*
Reason for Leaving:
*
Skills & Preferences
Please check any duties you have experience performing:
Duties
*
Bathing
Grooming
Meal Preparation
Light Housekeeping
Transfers
Ambulation
Toileting
Medication Reminders
Laundry
Transportation
Shopping
Companionship
Are you willing to work with clients who smoke?
*
YES
NO
Are you willing to work around pets?
*
YES
NO
Do you speak any languages other than English?
*
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Background & Ohio Attestation
Have you ever been convicted of a felony or misdemeanor offense?
*
YES
NO
If yes, please explain:
*
Write N/A if not applicable
Please list all states you have lived in during the last 5 years:
*
DISQUALIFYING OFFENSE ATTESTATION
I understand that Nattingham Home Care conducts criminal background checks in accordance with Ohio law. I attest that I have not been convicted of, pleaded guilty to, or been found eligible for intervention in lieu of conviction for offenses that would disqualify me from employment in a direct care role under Ohio law, including offenses involving abuse, neglect, theft, fraud, violence, drug trafficking, exploitation, or patient harm.
I understand that failure to disclose disqualifying offenses or falsification of information may result in denial of employment or termination.
Applicant Initials:
*
Applicant Certification & Authorization
I certify that the information provided in this application is true and complete to the best of my knowledge.
I authorize Nattingham Home Care to verify previous employment, certifications, references, and conduct background screenings as permitted by law.
I understand that submission of this application does not guarantee employment and that employment, if offered, is at-will.
Applicant Signature:
*
Printed Name:
*
Date:
*
-
Month
-
Day
Year
Date
Nattingham Home Care is an Equal Opportunity Employer.
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