CNA - Compassionate Home Health Care, Inc

GET PAID TO TAKE CARE OF A FAMILY MEMBER

(724) 965-8355 info@mychhcare.com

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CNA

Position Applied For

PERSONAL INFORMATION

First Name

Middle Initial

Last Name

Address

Home Phone

Cell Phone

Email

Are you at least 18?

Yes

No

Are you a US Citizen?

Yes

No

Legally Eligible to work in USA?

Yes

No

Convicted of a Felony

Yes

No

If yes, what was the charge?

Lived outside Ohio in past 5 years?

Yes

No

If yes, where?

List any previous last names

"Month" you were born

"Day" of the month you were born

Social Security Number (secure)

Next

JOB SPECIFIC INFORMATION

Reliable Vehicle?

Yes

No

Current Vehicle Insurance

Yes

No

Preferred Shift (1st)

Preferred Shift (2nd)

Days Available to Work

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Start Time

End Time

Hours Requested per Week

Where did you hear about us?

HWH employees you may know

Own a Smartphone or Tablet?

Yes

No

Is it an android of I-phone model?

Android

iPhone

Other

Available Start Date

Areas willing to travel to

Tell us something NICE about yourself

Is there anything else we need to know?

Next

EMPLOYER 1

Company Name

Address

Phone Number

Start Date

End Date

Position Held

Hourly Wage

Supervisor's Name

Reason for Leaving

Did you give a 2 week notice?

Yes

No

May we contact?

Yes

No

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Next

EMPLOYER 2

Company Name

Address

Phone Number

Start Date

End Date

Position Held

Hourly Wage

Supervisor's Name

Reason for Leaving

Did you give a 2 week notice?

Yes

No

May we contact?

Yes

No

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EMPLOYER 3

Company Name

Address

Phone Number

Start Date

End Date

Position Held

Hourly Wage

Supervisor's Name

Reason for Leaving

Did you give a 2 week notice?

Yes

No

May we contact?

Yes

No

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Next

MANDATORY REQUIREMENTS

High School

City

State

Certification Number

Certification Issue Date

Certification Expiration Date

CPR Issue Date

CPR Expiration Date

First Aid Issue Date

First Aid Expiration Date

Driver's License Number

Driver's License Issue Date

Driver's License Expiration Date

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Next

SKILL COMFORT LEVEL

Point of Care Software

Tablet Use

Telephony

Electronic Visit Verification System (EVVS)

Positioning and Turning Client

Stand, Pivot, Transfer Client from Bed to Wheel Chair

Assist Client with ROM Exercises

Ambulation

Operating Hoyer Lift and Assistive Devices

Hand Washing & Universal Precautions

Personal Protective Equipment

Temperature - Measuring & Recording

Pulse - Measuring & Recording

Respirations - Measuring & Recording

Blood Pressure - Measuring & Recording

Making an Occupied Bed

Incontinence & Perineal Care

Assist with Bedpan, Urinal, & Bedside Commode

Emptying Urinary Drainage Bag & Leg Bag

Familiarity with O2 Equipment

Bathing and Shower Safety

Oral Hygiene & Denture Cleaning

Hair Care, Nail Care, Shaving & Dressing Client

Applying Elastic Stockings

Laundry

Housekeeping & Cleaning

Meal Preparation and Grocery Shopping

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Attach Resume

Compassionate Home Health Care, Inc

2305 Wilmington Rd., Suite #3
New Castle, PA 16105

Phone



Email

info@mychhcare.com

Service Areas

Allegheny
Beaver
Butler
Crawford
Lawrence
Mercer
Venango

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