Touched by Angels II Application Form

Application Form

We are an Equal Employment Opportunity Employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status. All new hires are required to pass a background check. I understand that my employment with TBAII is part-time and temporary by its very nature, and there is no commitment or guarantee of any number of hours of work, as clients and their needs may vary from moment to moment, as may the needs of TBAII. Job Description In-Home Aide III (CNA) Nurse Aide Services at this level are intended to provide substantial support to clients who require assistance with health/personal care tasks. Personnel who perform at this level must have a listing with the North Carolina Board of Nursing showing they have passed the required criteria for at least a Nurse Aide III (CNA) listing. Provision of these tasks involves extensive “hands on” care and potential assistance with a wide range of health-related conditions. Individuals to be serviced include those who are medically stable but need assistance with daily living activities resulting from a chronic condition or impairment. Clients under the care of a CNA Nurse Aide may have a need for help in the following categories: Personal Care (support of ADLs)-Assist or perform: bed or tub bath, shower oral care skin, nails, hair care dressing and undressing Body Mechanics Turn and position Transfers Use of lifts Assist with ambulation Assist with range of motion exercises Bed mobility Nutrition Meal preparation/set-up/clean up Feed clients Measure intake and output Encourage or restrict fluids Elimination Toileting bed pan, urinal Continent care Perineal and catheter care Medication reminders, assist with opening bottles; no medication administration by aide Vital signs-report and record Temperature (oral, rectal, axillary) Pulse, respirations, blood pressure, weight Provide respite care to a client in order to supply temporary relief to the family caregiver. Light housekeeping Linen and laundry Reading and writing Shopping and appointments Provide emotional and physical support to the client and their family. Support and companionship, encourage independence. The CNA may be required to lift patients in order to transfer. Exposure to blood borne pathogens is possible. The CNA may be in the presence of cigarette smoke and a client’s pets. Job Description In-Home Aide II (HHA) Services at this level will be provided by personnel who are capable by experience and observation to be able to provide support to individuals/families who require assistance with basic activities of daily living and home management tasks. Both home management and assistance with personal care tasks can be provided to the client when his capacities are diminishing or when the client is striving to maintain or improve his own functioning. Clients to be served include those who are medically stable and partially dependent in activities of daily living due to physical and/or mental impairment; or who have maintenance needs and/or rehabilitative potential. Clients under the care of an In-Home Aide II (HHA) may have a need for help in the following categories: Personal Care (support of ADLs)-Assist bed or tub bath, shower dressing and undressing Nutrition Meal preparation/set-up/clean up Medication reminders, assist with opening bottles; no medication administration by aide Provide respite care to a client in order to supply temporary relief to the family caregiver. Body Mechanics Assist with ambulation Bed mobility Transfers Elimination Toileting Urinal Continent needs Light housekeeping Linen and laundry Support and companionship Reading and writing Shopping and appointments The HHA may be required to assist patients in order to transfer. The HHA may be in the presence of a cigarette smoke and a client’s pets. Job Description Companion/Sitter Services at this level will be provided by personnel who are capable of providing companion, sitter or respite services. Service at this level means “non-hands-on care”, which does not require training or verification of skills by a registered nurse. Clients under the care of a Sitter may have a need for help in the following categories: Nutrition Meal preparation/set-up/clean up Medication reminders, assist with opening bottles; no medication administration by aide Provide respite care to a client in order to supply temporary relief to the family caregiver. Light housekeeping Linen and laundry Support and companionship Reading and writing Shopping and appointments The Sitter may be required to lift heavy items. The Sitter may be in the presence of a cigarette smoke and a client’s pets.

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Section 1 - General Information

I am applying for the position of: (Please refer to the position descriptions above) (required)

How did you hear about this job opportunity and who referred you?

Please give JOB NUMBER # and Description you are applying for?

Date Available? (required)

Have you worked for Touched by Angels II before and WHEN?

Job Type? (required)

Position Desired? (required)

Salary Desired?

Most of our positions require a valid driver's license, proof of auto insurance and reliable transportation.

Do you have reliable transportation? (required)

Yes No

If a contingent job offer is extended, can you provide documentation of a valid driver's license and proof of auto insurance? (required)

Yes No

Some of our clients require transportation by you, the Aide. Answering "YES" to the next question does not automatically disqualify you from employment with TBAII.

Have you had any driving violations in the last 12 months? (required)

Yes No

If yes, please explain.

The State of North Carolina blocks certain felonies and misdemeanors from employment in certain healthcare situations. Answering "YES" to the following question about conviction will NOT automatically disqualify you from employment with TBAII. (required)

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? TBAII runs background checks on all new hires. (required)

Yes No

If yes, please explain.

Do you have any animals? (required)

Yes No

Have you been a NC Resident for the last 5 years? (required)

Yes No

Are you willing to be fingerprinted if you have NOT been a NC Resident for the last 5 years?

Yes No

Section 2 - Certifications/licenses

Are you a CNA or RN? (required)

Let us verify your CNA by entering the last 4 digits of your Social Security Number

Other or First additional certification

Effective Date

Expiration Date

Second additional certification

Effective Date

Expiration Date

Note additional certifications

Section 3 - Availability

Approximate Hours Per Week

Days/Time you are available

Shift Desired?

Are you willing to work overnight?

Yes No

Days and Time not available

Can you be called at the last minute in case of emergency?

Yes No

Will you work in a Smoking environment? (required)

Yes No

Are any animals in the home of concern to you? (required)

Section 4 - Employment Authorization Verification

Are you legally authorized to work in the U.S.? TBAII participates in I-9 and E-Verify for Employment Eligibility Verification. (required)

Section 5 - Physical Record

Have you read the essential job duties of an In-home Aide which are given at the top of this application? If not, please do so before answering the next question. (required)

Yes No

Can you perform all the essential job duties of an In-Home Aide? This may include heavy lifting. (required)

Yes No

If you answered "NO", please explain which duties may trouble you. There may be a reasonable accommodation available.

Can you present a negative TB test? (required)

Yes No

Section 6 - Education and Civics

Please state your highest level of education achieved. For example: High School, HS Diploma, GED, community college, Associate Degree, college, BS/BA, Etc. (required)

From High School on, list the Name of School(s), Course of study, degree (required)

List Professional Healthcare Organizations to which you belong.

List any Educational or Civic Honors or Citations

Section 7 - Your Past experience with the Elderly

Discuss any training or experience working with the elderly. How are you trained and/or experienced working with the elderly?

What do YOU do that shows and proves you are Reliable, Trustworthy and Honest?

What would you like least about working with the elderly?

Section 8 - Current Employment

Current Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

If we may NOT contact, why?

Section 9 - 1st prior Employment History

1st Previous Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

If we may NOT contact, why?

Section 10 - 2nd prior Employment History

2nd Previous Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

If we may NOT contact, why?

Section 11 - Reference 1, not a relative, known at least 1 year

We prefer your reference to be a Professional, business contact, educational, etc.

Name: (required)

What is your relationship with this individual? (required)

Phone:

E-mail address

How long have you known this individual, in years?

Section 12 - Reference 2, not a relative, known at least 1 year

We prefer your reference to be a Professional, business contact, educational, etc.

Name:

What is your relationship with this individual? (required)

Phone: (required)

E-mail address

How long have you known this individual, in years?

Section 13 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

Relationship: (required)

Section 14 - Skills

Please describe where you acquired these skills, such as education, on the job training, and for how long. (required)

Companion Care & Safety

Yes No

Alzheimer's

Yes No

Dementia

Yes No

Meal Prep/Clean Up

Yes No

Feeding

Yes No

Light House Keeping

Yes No

Laundry

Yes No

Medication Reminders

Yes No

Transportation

Yes No

Bathing (Reg, bed, sponge)

Yes No

Dressing/Grooming

Yes No

Incontinence

Yes No

Ambulation

Yes No

Transfer Assist

Yes No

Oral Care

Yes No

Shaving Assistance

Yes No

Assist with P.T. Exercises

Yes No

Assist with Prosthesis

Yes No

Hospice

Yes No

Willing to Work with Pets

Yes No

Speak fluent English

Yes No

Fluent in any other language?

Yes No

If Yes to question above, indicate other language(s)

Section 15 - Contribution to the team

Why do you feel you would be an excellent addition to our team? (required)

Section 16 - SIGNATURE

By signing, I am indicating that ALL my responses are true and accurate. Indicate your signature by SELECTING: (required)

I certify that information contained in this application is true and complete. I authorize investigation of all statements contained in this application. I understand that false, incomplete or omitted information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. Further, I understand and agree that my employment is for no definite period. I also understand that my employment with Touched by Angels II (TBAII) is part-time and temporary by its very nature, and there is no commitment or guarantee of any number of hours of work, as clients and their needs may vary from moment to moment, as may the needs of TBAII. We look forward to reviewing your application.

Signature

Touched by Angels II Application Form

We are an Equal Employment Opportunity Employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.All new hires are required to pass a background check.

I understand that my employment with TBAII is part-time and temporary by its very nature, and there is no commitment or guarantee of any number of hours of work, as clients and their needs may vary from moment to moment, as may the needs of TBAII.

Job Description In-Home Aide III (CNA)

Job Description In-Home Aide II (HHA)

Job Description Companion/Sitter

Personal Information

Section 1 - General Information

Section 2 - Certifications/licenses

Section 3 - Availability

Section 4 - Employment Authorization Verification

Section 5 - Physical Record

Section 6 - Education and Civics

Section 7 - Your Past experience with the Elderly

Section 8 - Current Employment

Section 9 - 1st prior Employment History

Section 10 - 2nd prior Employment History

Section 11 - Reference 1, not a relative, known at least 1 year

Section 12 - Reference 2, not a relative, known at least 1 year

Section 13 - Emergency Contact Information

Section 14 - Skills

Section 15 - Contribution to the team

Section 16 - SIGNATURE

We are an Equal Employment Opportunity Employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

All new hires are required to pass a background check.

I understand that my employment with TBAII is part-time and temporary by its very nature,
and there is no commitment or guarantee of any number of hours of work,
as clients and their needs may vary from moment to moment, as may the needs of TBAII.