Live Free Home Health Care, LLC. - Bristol, New Hampshire

Contact Information

First Name*:

Phone*:

Address*:

State*:

Last Name*:

Email*:

City*:

Zip Code*:

Are you authorized to work in the US?*

Are you 18 years of age or older?*

Date of Birth*:

What position are you applying for?

Yes   No

Yes   No

If you are hired, when can you start?

Desired rate of pay her hour?

Certifications (Check one or more)

RN   LPN   LNA

Education

High School
Name of school:

Number of years attended:

Date of graduation:

Location:

Did you graduate?
Yes   No

College
Name of school:

Number of years attended:

Date of graduation:

Location:

Did you graduate?
Yes   No

What degree did you earn?

Other School
Name of school:

Number of years attended:

Date of graduation:

Location:

Did you graduate?
Yes   No

What degree did you earn?

Employment History

Beginning with your most recent employment and working back in time, please give the following information:

Employer 1
Employer:

Address:

Phone Number:

Job Title:

Salary/Hourly Rate:

Duties:

Dates of Employment:

Supervisor:

Reason for Leaving:

Employer 2
Employer:

Address:

Phone Number:

Job Title:

Salary/Hourly Rate:

Duties:

Dates of Employment:

Supervisor:

Reason for Leaving:

Employer 3
Employer:

Address:

Phone Number:

Job Title:

Salary/Hourly Rate:

Duties:

Dates of Employment:

Supervisor:

Reason for Leaving:

Personal References

Please provide the names of two references who have not employed you and are not related to you.

Reference 1
Name:

Address:

Phone Number:

Relationship:

Reference 2
Name:

Address:

Phone Number

Relationship:

Preferences

Will you travel 30 minutes?
Yes   No

Will you work every other weekend?
Yes   No

Will you work short shifts?
Yes   No

Will you work long shifts?
Yes   No

Will you work Private duty cases?
Yes   No

Will you work with children?
Yes   No

How many hours per week are you willing to work?

Please indicate your availability:

Skills

The following information will help us place you where your skills, knowledge of nursing and preferences will be best suited.

Can you do vital signs?
Yes   No

Can you chart Nurses’ Notes?
Yes   No

Can you do catheter care?
Yes   No

Can you insert catheters?
Yes   No

Can you start IV’s?
Yes   No

Can you give IV Medications?
Yes   No

Are you IV certified?
Yes   No

Can you draw blood?
Yes   No

Can you suction patients?
Yes   No

Can you set up oxygen for patients?
Yes   No

Can you do neurological assessments?
Yes   No

Can you assess patients for admission?
Yes   No

Can you discharge patients?
Yes   No

Are you Currently CPR certified?
Yes   No

Do you have Intensive Care Unit experience?
Yes   No

Can you do gravity and pump G-tube feedings?
Yes   No

Can you design Nursing Care Plans?
Yes   No

Can you perform ROM?
Yes   No

Do you have ventilator experience?
Yes   No

Do you have any Nursing Supervisor/teaching skills?
Yes   No

In which of the following areas have you had experience?

Additional Qualifications

Please tell us about any other special training in nursing, education, skills or achievements that you feel should be considered.

Job Description

Attached to this application is a complete job description. Please review it carefully. In the space provided below, please explain generally your ability to perform the listed duties. If you are called for a job interview, please be prepared to discuss this more fully at that time.

Have you ever been convicted of abuse, neglect, or exploitation? Yes   No

Agreement and Submission

I certify that this information is correct and acknowledge that its accuracy is subject to verification by Live Free Home Health Care, LLC. I understand that furnishing incorrect information will render this application void and will be just cause for termination.

Applicant's Signature*:

Date*:

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