Kindly submit the following information in the form below POSITION DESIRED *DATE AVAILABLE *TYPE OF EMPLOYMENT DESIREDSelectFull TimePart TimePersonal InformationFirst Name *Middle NameLast Name *Street Address *Apartment, suite, etcCity *State *ZIP Code *PHONE NUMBER *ALTERNATIVE PHONE NUMBEREMAIL ADDRESS *DO YOU HAVE A VALID DRIVER'S LICENSE?YesNoCLASSCDL?YesNoHAVE YOU EVER SERVED IN THE MILITARY?YesNoDO YOU SPEAK ANY OTHER LANGUAGE(S)? SPECIFYDO YOU HAVE THE LEGAL RIGHT TO OBTAIN EMPLOYMENT IN THE UNITED STATES?YesNoCAN YOU PERFORM THE ESSENTIAL FUNCTIONS AND RESPONSIBILITIES OF THE POSITION FOR WHICH YOU ARE APPLYING?YesNoDO YOU REQUIRE ANY SPECIAL ACCOMMODATION TO PERFORM REQUIRED DUTIES?YesNoHAVE YOU EVER WORKED FOR KAFF HOMECARE, INC.?YesNoDO ANY OF YOUR RELATIVES WORK FOR KAFF HOMECARE, INC.?YesNoLIST ANY CURRENT LICENSES, CERTIFICATIONS, OR REGISTRATIONS REQUIRED FOR THE POSITION FOR WHICH YOU ARE APPLYING. INCLUDE DATE RECEIVED.LICENSE OR CERTIFICATION NUMBERDATE OF LICENSEEXPIRATION DATEMandatory: All Applicants with An Illinois License or Cna Certification Must Provide the License or Certification Number, Date of Such License or Certification.  CPR OR FIRST AID CERTIFICATIONTRAINING DATEMANTOUX TEST DATEHAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OR DRIVING OFFENSE(S) OTHER THAN A MINOR TRAFFIC VIOLATION?YesNoYou Must Provide at Least Three Current Reference Letters And/or the Name of Individuals with Whom a Reference Interview Can Be Conducted. Please Give the Full Name, Mailing Address, and Phone Number of Three References Who Have Knowledge of Your Background and Qualifications in The Field.Enter Reference Here *Enter Reference Here *Enter Reference Here *Education and SkillsLEVEL OF EDUCATION COMPLETEDHigh SchoolGEDCollege 0-3 YearsDegree: AssociationBachelorMastersSPECIFY MAJORSOFTWARE APPLICATIONSTYPING WORDS PER MINUTEExperienceList Last 5 Years of Work Experience01 – EmploymentFROMTOBEGINNING SALARYUSDENDING SALARYUSDNAME OF EMPLOYERMAY WE CONTACT?YesNoStreet AddressCityStateZIP CodeSUPERVISOR’S NAMEPHONE NUMBERTITLE AND DUTIES PERFORMEDREASON FOR LEAVING02 – EmploymentFROMTOBEGINNING SALARYUSDENDING SALARYUSDNAME OF EMPLOYERMAY WE CONTACT?YesNoSUPERVISOR’S NAMEPHONE NUMBERTITLE AND DUTIES PERFORMEDREASON FOR LEAVING03 – EmploymentFROMTOBEGINNING SALARYUSDENDING SALARYUSDNAME OF EMPLOYERMAY WE CONTACT?YesNoSUPERVISOR’S NAMEPHONE NUMBERTITLE AND DUTIES PERFORMEDREASON FOR LEAVING04 – EmploymentFROMTOBEGINNING SALARYUSDENDING SALARYUSDNAME OF EMPLOYERMAY WE CONTACT?YesNoSUPERVISOR’S NAMEPHONE NUMBERTITLE AND DUTIES PERFORMEDREASON FOR LEAVING05 – EmploymentFROMTOBEGINNING SALARYUSDENDING SALARYUSDNAME OF EMPLOYERMAY WE CONTACT?YesNoSUPERVISOR’S NAMEPHONE NUMBERTITLE AND DUTIES PERFORMEDREASON FOR LEAVING I agree to carry out the designated responsibilities to the best of my ability. I have read the position description. I am aware there is a conditional period of 3 months prior to permanent employment.I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. I authorized the investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed.NAME *DATE12/04/2024Certified Nursing Assistant Skills ChecklistPRINT NAME *DATE12/04/2024Directions Please select a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. Self Rating Key 0 No experience 1 Minimal experience or works with supervision 2 Independent or works without supervision in most cases 3 Senior or works at a supervisory or teaching level Has knowledge of and can provide care and assist patients with the following tasks:  AmbulationCRUTCHES *1234WALKER *1234CANE *1234GAIL BELT *1234Personal Care1.BATHA.BED *1234B.TUB *1234C.SHOWER *12342.SKIN CAREA.BACK RUB *1234B.DECUBITUS PREVENTION OR CARE *12343.DRESSA.ASSIST AS NEEDED *1234B.USE OF ASSISTIVE DEVICES *1234B.USE OF ASSISTIVE DEVICES *12345.NAIL CARE (FINGERS AND TOES)A.CLEAN OR FILE OR TRIM WITH CLIPPERS *12346.ORAL HYGIENEA.MOUTH CARE *1234B.BRUSH TEETH *1234C.DENTURE CARE *12347.SHAVING: SAFETY RAZOR OR ELECTRIC RAZOR *1234Nutrition or Hydration1.FEEDING TECHNIQUES *12342.ASSIST WITH EATING *12343.USE OF FEEDING ASSISTIVE DEVICES *12344.MEASURE AND RECORD INTAKE *12345.ENCOURAGE FLUIDS *1234Assisting or Care of Patient with Bowel and Bladder Elimination1.BEDPAN OR URINAL *12342.BEDSIDE COMMODE *12343.CARE OF INCONTINENT PATIENT *12344.STOMA CARE *12345.BOWEL OR BLADDER TRAINING *12346.MEASURE AND RECORD OUTPUT *1234Urinary Catheter Care1.PERINEAL HYGIENE *12342.FOLEY CATHETER *12343.SUPRA PUBLIC CATHETER *1234Transfer Techniques1.USE OF TRANSFER GAIT BELT *12342.WEIGHT BEARING *12343.NON-WEIGHT BEARING *12344.MECHANICAL LIFT *12345.WHEELCHAIR *1234Turning / Position Patient1. SUPINE *12342. SIDE-LYING *12343. IN CHAIR *12344. IN BED *12345. USE OF LIFT SHEET *1234Communication1. VERBAL *12342. NON-VERBAL WITH COGNITIVELY IMPAIRED PATIENTS *1234Range of Motion Excersices1. ACTIVE *12342. PASSIVE *12343. COMBINATION *1234Take & Record Vital Signs1. TEMPERATUREA. ORAL *1234B. RECTAL *1234C. EAR CANAL *12342. PULSEA. APICAL *1234B. RADIAL *1234C. PEDAL *12343. RESPIRATIONS *12344. BLOOD PRESSURE *12345. HEIGHT *12346. WEIGHTB. BED SCALE *1234A. STANDING *1234C. CHAIR SCALE *1234Safety Devices1. VEST RESTRAINT *12342. (SOFT) WRIST / ANKLE RESTRAINT) *12343. PADDED SIDE RAIL *12344. SIDE RAILS *1234Mental Health & Social Services Needs1. DEMONSTRATES PRINCIPLES OF BEHAVIOR MANAGEMENT *12342. PROVIDES EMOTIONAL SUPPORT TO PATIENT *12343. ECOURAGES FAMILY SUPPORT *12344. ECOURAGES PATIENTS TO MAKE PERSONAL CHOICES *12345. REPECTS PATIENT'S RIGHTS AND DIGNITY, INCLUDING PRIVACY & CONFIDENTIALITY *12346. ENCOURAGES SELF-CARE AS ABILITY ALLOWS *12348. KNOWLEDGE OF DOMESTIC VIOLENCE AND VIOLENT INJURY REPORTING STATUES *12347. KNOWLEDGE OF ADULT, CHILD AND ELDER ABUSE REPORTING STATUTES *1234Safety / Emergencies1. RECOGNIZES & REPORTS SAFETY HAZARDS *12342. RECOGNIZES & REPORTS EMERGENCIES AND RESPONDS APPROPRIATELY *12343. HANDLES O2 SAFELY *12344. OBSERVES, REPORTS & DOCUMENTS CHANGES IN BODY FUNCTIONS, BEHAVIOR *1234Care of Prosthetic Devices1. LIMBS *12342. EYE GLASSES *12343. HEARING AIDS *1234Specimen Collection1. URINE *12342. STOOL *12343. SPUTUM *1234Understand and Can Perform1. BINDERS AND BANDAGESA. ACE BANDAGES *1234B. SUPPORT STOCKINGS *12342. CARE OF THE DECEASED *1234ASSIST THE CARE OF PATIENT WITH1. DIABETES *12342. CANCER *12343. HEART DISEASE *12344. O2 THERAPY *12345. RESPIRATORY DISEASE *12346. TERMINAL *12347. INFECTIOUS DISEASE *1234To the best of my knowledge, the information provided on this CNA Skills Checklist is true and accurate. My signature indicates that I have read this document in its entirety and understand its contents.NAME *DATE12/04/2024 Submit
