LPN / RN Application

Personal Information

Position Desired *

Date Available *

Type of Employment Desired

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc.

City *

State *

ZIP Code *

Phone Number *

Social Security Number

Email Address *

Do you have a valid driver's license?

Yes No

Class

CDL?

Yes No

Have you ever served in the military?

Yes No

Do you speak any other language(s)? Specify

Do you have the legal right to obtain employment in the United States?

Yes No

Can you perform the essential functions and responsibilities of the position for which you are applying?

Yes No

Do you require any special accommodation to perform required duties?

Yes No

Have you ever worked for Kaff Homecare, Inc.?

Yes No

Do any of your relatives work for Kaff Homecare, Inc.?

Yes No

List any current licenses, certifications, or registrations required for the position for which you are applying. Include date received.

License or Certification Number

Date of License

Expiration Date

Mandatory: All applicants must provide their Illinois LPN or RN license number and the date of the license.

CPR or First Aid Certification — Training Date

Mantoux Test Date

Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation?

Yes No

You must provide at least three current reference letters and/or the names 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.

Reference 1 *

Reference 2 *

Reference 3 *

Education and Skills

Level of Education Completed

High School GED College 0-3 Years Degree: Associate Bachelor Masters

Specify Major

Software Applications

Typing Words Per Minute

Experience

List your last 5 years of work experience.

01 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

02 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

03 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

04 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

05 — Employment

From

Beginning Salary (USD)

Ending Salary (USD)

Name of Employer

May we contact?

Yes No

Street Address

City

State

ZIP Code

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

Applicant Certification

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 authorize 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 *

Date *

LPN / RN Skills Checklist

Print Name *

Date

Directions: Please select a value for each skill to give us and interested facilities an assessment of your clinical experience. Each skill below requires a rating.

Rating key: 1 = No experience · 2 = Minimal experience / works with supervision · 3 = Independent / works without supervision in most cases · 4 = Senior / works at a supervisory or teaching level

Has knowledge of and can provide care and assist patients with the following tasks:

Ambulation

1234

AMBULATION – CRUTCHES

AMBULATION – WALKER

AMBULATION – CANE

AMBULATION – GAIT BELT

Personal Care

1234

BATH – BED

BATH – TUB

BATH – SHOWER

SKIN CARE – BACK RUB

SKIN CARE – DECUBITUS (PRESSURE ULCER) PREVENTION OR CARE

DRESSING – ASSIST AS NEEDED

DRESSING – USE OF ASSISTIVE DEVICES

HAIR CARE – SHAMPOO, COMB OR BRUSH

NAIL CARE (FINGERS AND TOES) – CLEAN, FILE OR TRIM WITH CLIPPERS

ORAL HYGIENE – MOUTH CARE

ORAL HYGIENE – BRUSH TEETH

ORAL HYGIENE – DENTURE CARE

SHAVING – SAFETY RAZOR OR ELECTRIC RAZOR

Nutrition or Hydration

1234

NUTRITION – FEEDING TECHNIQUES

NUTRITION – ASSIST WITH EATING

NUTRITION – USE OF FEEDING ASSISTIVE DEVICES

NUTRITION – MEASURE AND RECORD INTAKE

NUTRITION – ENCOURAGE FLUIDS

Assisting or Care of Patient with Bowel and Bladder Elimination

1234

ELIMINATION – BEDPAN OR URINAL

ELIMINATION – BEDSIDE COMMODE

ELIMINATION – CARE OF INCONTINENT PATIENT

ELIMINATION – STOMA CARE

ELIMINATION – BOWEL OR BLADDER TRAINING

ELIMINATION – MEASURE AND RECORD OUTPUT

Urinary Catheter Care

1234

CATHETER CARE – PERINEAL HYGIENE

CATHETER CARE – FOLEY CATHETER

CATHETER CARE – SUPRAPUBIC CATHETER

Transfer Techniques

1234

TRANSFER – USE OF TRANSFER GAIT BELT

TRANSFER – WEIGHT BEARING

TRANSFER – NON-WEIGHT BEARING

TRANSFER – MECHANICAL LIFT

TRANSFER – WHEELCHAIR

Turning / Position Patient

1234

POSITIONING – SUPINE

POSITIONING – SIDE-LYING

POSITIONING – IN CHAIR

POSITIONING – IN BED

POSITIONING – USE OF LIFT SHEET

Communication

1234

COMMUNICATION – VERBAL

COMMUNICATION – NON-VERBAL WITH COGNITIVELY IMPAIRED PATIENTS

Range of Motion Exercises

1234

RANGE OF MOTION – ACTIVE

RANGE OF MOTION – PASSIVE

RANGE OF MOTION – COMBINATION

Take & Record Vital Signs

1234

TEMPERATURE – ORAL

TEMPERATURE – RECTAL

TEMPERATURE – EAR CANAL

PULSE – APICAL

PULSE – RADIAL

PULSE – PEDAL

RESPIRATIONS

BLOOD PRESSURE

HEIGHT

WEIGHT – STANDING

WEIGHT – BED SCALE

WEIGHT – CHAIR SCALE

Safety Devices

1234

SAFETY DEVICES – VEST RESTRAINT

SAFETY DEVICES – SOFT WRIST / ANKLE RESTRAINT

SAFETY DEVICES – PADDED SIDE RAIL

SAFETY DEVICES – SIDE RAILS

Mental Health & Social Services Needs

1234

DEMONSTRATES PRINCIPLES OF BEHAVIOR MANAGEMENT

PROVIDES EMOTIONAL SUPPORT TO PATIENT

ENCOURAGES FAMILY SUPPORT

ENCOURAGES PATIENTS TO MAKE PERSONAL CHOICES

RESPECTS PATIENT'S RIGHTS AND DIGNITY, INCLUDING PRIVACY & CONFIDENTIALITY

ENCOURAGES SELF-CARE AS ABILITY ALLOWS

KNOWLEDGE OF ADULT, CHILD AND ELDER ABUSE REPORTING STATUTES

KNOWLEDGE OF DOMESTIC VIOLENCE AND VIOLENT INJURY REPORTING STATUTES

Safety / Emergencies

1234

RECOGNIZES & REPORTS SAFETY HAZARDS

RECOGNIZES & REPORTS EMERGENCIES AND RESPONDS APPROPRIATELY

HANDLES O2 SAFELY

OBSERVES, REPORTS & DOCUMENTS CHANGES IN BODY FUNCTIONS AND BEHAVIOR

Care of Prosthetic Devices

1234

PROSTHETIC DEVICES – LIMBS

PROSTHETIC DEVICES – EYE GLASSES

PROSTHETIC DEVICES – HEARING AIDS

Specimen Collection

1234

SPECIMEN COLLECTION – URINE

SPECIMEN COLLECTION – STOOL

SPECIMEN COLLECTION – SPUTUM

Understand and Can Perform

1234

BINDERS AND BANDAGES – ACE BANDAGES

BINDERS AND BANDAGES – SUPPORT STOCKINGS

CARE OF THE DECEASED

ASSIST WITH CARE OF PATIENT WITH DIABETES

ASSIST WITH CARE OF PATIENT WITH CANCER

ASSIST WITH CARE OF PATIENT WITH HEART DISEASE

ASSIST WITH CARE OF PATIENT WITH O2 THERAPY

ASSIST WITH CARE OF PATIENT WITH RESPIRATORY DISEASE

ASSIST WITH CARE OF TERMINALLY ILL PATIENT

ASSIST WITH CARE OF PATIENT WITH INFECTIOUS DISEASE

Certification

To the best of my knowledge, the information I have provided on this skills checklist and application is true and correct. *

Name *

Date

Please complete all required fields and skill ratings (*) before submitting.

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LPN / RN Application

Personal Information

Education and Skills

Experience

Applicant Certification

LPN / RN Skills Checklist

Ambulation

Personal Care

Nutrition or Hydration

Assisting or Care of Patient with Bowel and Bladder Elimination

Urinary Catheter Care

Transfer Techniques

Turning / Position Patient

Communication

Range of Motion Exercises

Take & Record Vital Signs

Safety Devices

Mental Health & Social Services Needs

Safety / Emergencies

Care of Prosthetic Devices

Specimen Collection

Understand and Can Perform

Certification