ER Home Health Employment Application

Answering YES to these questions does not constitute an automatic rejection for employment. Date of offense, seriousness and nature of violation, rehabilitation and position applied for will be considered.

Education History

Previous Employment — Begin with the most recent

Skills Checklist

Directions: Please carefully assess your strengths and select the appropriate experience level for each skill. This information will be utilized by Essential Response Home Health for appropriate placement. 1= Proficient (Expert) 2= Experienced (Performs independently) 3=Familiar (May require assistance) 4=Unfamiliar (No experience)

Vital Signs

Personal Care

Elimination

Nursing Notes, Charting, Documentation

Housekeeping Duties

Meal Preparation

Care Experience

Client Transportation

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”