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Employment Application

PERSONAL INFORMATION:

Date(Required)

MM slash DD slash YYYY

Position(Required)

LPN

CNA

Caregiver

Job Status

Full Time

Part Time

Temporary

Referral Source(Required)

N/A if not Applicable

Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

SSN(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Upload Image of SSN Card(Required)

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Upload Image of Drivers License or State ID - BACK(Required)

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Email(Required)

Are you legally qualified to work in the United States? To be employed by Awa Medical Staffing LLC, you must meet certain state and federal employment eligibility requirements. These include (but are not limited to) United States citizenship or authorization to work in this country, and no felony convictions (for some jobs). Please answer the following questions.(Required)

Yes

If no, please explain details in full:

EDUCATION:

List(Required)

Schools/College Attended

# Years

Year Grad

Degree

EMPLOYMENT/WORK EXPERIENCE:

Start with your present or most recent position. Include military service assignments and volunteer activities. Exclude organization names that indicate race, color, religion, sex or national origin.

Previous Employer:(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Job Title:(Required)

Supervisor Name(Required)

Phone(Required)

Describe Duties(Required)

Reason for Leaving:(Required)

Dates of Employment (Month/Year): From(Required)

Dates of Employment (Month/Year): To(Required)

Job Title:

Supervisor

Address

Street Address City State ZIP Code

Phone

Describe Duties

Reason for Leaving:

Dates of Employment (Month/Year): From

Dates of Employment (Month/Year): To

MILITARY SERVICE

(A copy of a report of separation from the Armed Services may be required)

Are you a veteran?(Required)

Yes

If yes, list type of discharge:

Dates of service (From/To)

Are you a surviving spouse of a veteran who has not remarried?

Yes

Are you a surviving orphan of a veteran?

Yes

If yes, dates of service for veteran:

LANGUAGE SKILLS:

Check any which apply to you.

Multilingual (Specify languages)

Sign Language

Specify languages

SPECIAL SKILLS:(Required)

Describe any special skills or qualifications for this work:

I AUTHORIZE any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they may have, personal or otherwise, with regard to any of the subjects covered by this application, and I release such parties from all liability from any damages which may result from furnishing such information to you. I CERTIFY that the above answers are true and complete to the best of my knowledge. I authorize Awa Medical Staffing LLC, to investigate any statement contained in this application, and to obtain a credit report on me (and my company if this application is for reselling by a company) as necessary to determine my qualifications. I understand that this application is not and is not intended to be any kind of contract or agreement. In the event of employment, I understand that any false or misleading information given in my application, correspondence, discussions or interview may result in refusal to hire or immediate termination if hired. I understand also, that I am required to abide by all rules, regulations and policies of Awa Medical Staffing LLC. AWA Medical Staffing LLC(AMS) employees who represent the company(AMS) are not eligible to join facilities that are contracted by AWA medical staffing LLC within one year of employment. Employees who violate this agreement will be fined ($5,000-$10,000). By signing this agreement, you acknowledge that you have read and understood the terms and agree that if you branch any of the terms in this agreement, you will subject our fines and penalties. Signature(Required)

Signature Box

Upload TB Sreening(Required)

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Upload Pysical(Required)

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Upload Covid Vaccine Card

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Employment Eligibility Verification

Employee Information and Attestation

Last Name (Family Name)(Required)

First Name (Given Name)(Required)

Middle Initial

Other Last Names Used (if any)

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

U.S. Social Security Number(Required)

Employee's E-mail Address(Required)

Employee's Telephone Number(Required)

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes)(Required)

A citizen of the United States

A noncitizen national of the United States (See instructions)

A Lawfull permanent resident (Alien Registration Number/USCIS Number)

An Alien authorized to work

(Alien Registration Number/USCIS Number)

(expiration date, if applicable, mm/dd/yyyy). Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

Alien Registration Number/USCIS Number (OR)

Form I-94 Admission Number (OR)

(a) Foreign Passport Number

(b) Country of Issuance

Signature(Required)

Preparer and/or Translator Certification (check one)(Required)

I did not use a preparer or translator.

A preparer(s) and/or translator(s) assisted the employee in completing Section

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of myknowledge the information is true and correct.

Signature of Preparer or Translator

Today's Date

MM slash DD slash YYYY

Last Name (Family Name)(Required)

First Name (Given Name)(Required)

Address(Required)

Street Address City State ZIP Code

Health Care Worker Background Check

Illinois Department of Public Health Health Care Worker Registry, 525 W. Jefferson St., Springfield, IL 62761 Phone: (217) 785-5133 Health Care Worker Background Check Disclosure and Authorization for Criminal History Records Check I hereby authorize the Illinois Department of Public Health (IDPH), IDPH’s designee that train or test health care workers, staffing agency, or the health care employer to request a criminal history records check and I further authorize the Illinois State Police (ISP) to release information relative to the existence or non existence of any criminal record which it might have concerning me to the requestor solely to determine my suitability for employment or continued employment. I further authorize any agency which maintains records relating to me to provide same on request to the ISP or IDPH. I certify that the ISP and any agency, including IDPH, their employees or officers who furnish this information shall be held harmless from any and all liability which may be incurred as a result of releasing such information. I further acknowledge that a health care employer shall not be liable for the failure to hire or to retain an applicant or employee who has been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25)

I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment or, if discovered after employment begins, could result in discipline up to and including my termination of employment.

I understand that the information requested below regarding sex, race, height, eye color, and date of birth is for the sole purpose of identification and the gathering of the above-mentioned information about me accurately, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my social security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.

Name(Required)

First Middle Last

Mailing Address(Required)

Street Address City State ZIP Code

Physical Address (if different)

Street Address City State ZIP Code

Other Names Used

Telephone(Required)

States Where You Have Lived?

Gender(Required)

Male

Female

Prefer not to answer

Date of Birth(Required)

MM slash DD slash YYYY

Height

Eye Color

Social Securtiy Number(Required)

Race(Required)

Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander.

Black or African American (Not Hispanic or Latino)

Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin)

American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition.

Of undeterminable race. Of Untold mixture.

W Caucasian (not Hispanic or Latino)

Have you ever had an administrative finding of Abuse, Neglect, or Theft?(Required)

Yes

If “Yes”, give full details and state.

Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated delinquent)?(Required)

Yes

If “Yes”, give full details of each offense and the state in which convicted.

I certify that the above is true and correct and give my consent for my name to appear on IDPH’s Health Care Worker Registry as a result of this criminal history records check:

Signature(Required)

Date(Required)

MM slash DD slash YYYY

As the parent or guardian of the above named individual, who is under the age of seventeen, I give my consent for this named individual to have a criminal history records check.

(Signature of Parent or Guardian when applicable)

Date

MM slash DD slash YYYY

The following sections will be an assessment of your experience in certain clinical areas...

Please select one below.(Required)

CNA

LPN/RN

CNA Skills Checklist

This assessment is for determining your experience in the below outlined clinical areas. This checklist will not be used as a determining factor in accepting your application to become an employee of Awa Medical Staffing.

PROFICIENCY SCALE

No Experience
Need Training
Able to perform with supervision
Able to perform independently

Are you a certified CNA?(Required)

Yes

N/A

Documentation

Clinical Note; on a scale of 1 to 4(Required)

Patient charting; on a scale of 1 to 4(Required)

Personal Care

Total Bed Bath; on a scale of 1 to 4(Required)

Tub Bath; on a scale of 1 to 4(Required)

Patient charting; on a scale of 1 to 4(Required)

Shower; on a scale of 1 to 4(Required)

Sponge Bath; on a scale of 1 to 4(Required)

Sitz Bath; on a scale of 1 to 4(Required)

Hair Care; on a scale of 1 to 4(Required)

Shampoo; on a scale of 1 to 4(Required)

Nail and Foot Care; on a scale of 1 to 4(Required)

Skin Care; on a scale of 1 to 4(Required)

Perineal Care; on a scale of 1 to 4(Required)

Oral Care; on a scale of 1 to 4(Required)

Denture Care; on a scale of 1 to 4(Required)

Shaving; on a scale of 1 to 4(Required)

Applying Elastic Stocking; on a scale of 1 to 4(Required)

Compression: Cold/warm; on a scale of 1 to 4(Required)

Dietary restrictions; on a scale of 1 to 4(Required)

Patient charting; on a scale of 1 to 4(Required)

CPR; on a scale of 1 to 4(Required)

Elimination

Monitor Bowel Movements; on a scale of 1 to 4(Required)

Measure Output; on a scale of 1 to 4(Required)

Bedpan; on a scale of 1 to 4(Required)

Bedside Commode; on a scale of 1 to 4(Required)

Assist to Bathroom; on a scale of 1 to 4(Required)

Assist with Bowel Program; on a scale of 1 to 4(Required)

Assist with Ostomy Change; on a scale of 1 to 4(Required)

Empty Foley Catheter bag; on a scale of 1 to 4(Required)

Empty Drainage Bag; on a scale of 1 to 4(Required)

Other (List)

Activity

Repositioning; on a scale of 1 to 4(Required)

Walk with Assistance; on a scale of 1 to 4(Required)

Walk with Supervision; on a scale of 1 to 4(Required)

Dangle; on a scale of 1 to 4(Required)

Walker; on a scale of 1 to 4(Required)

Passive Range of Motion; on a scale of 1 to 4(Required)

Active Range of Motion; on a scale of 1 to 4(Required)

Transfer; on a scale of 1 to 4(Required)

Hoyer Lift; on a scale of 1 to 4(Required)

Assist with Exercise Program; on a scale of 1 to 4(Required)

Dangling; on a scale of 1 to 4(Required)

Observation

Temperature; on a scale of 1 to 4(Required)

Oral; on a scale of 1 to 4(Required)

Axillary; on a scale of 1 to 4(Required)

Tympanic; on a scale of 1 to 4(Required)

Respiration; on a scale of 1 to 4(Required)

Sitter(Required)

Companion; on a scale of 1 to 4(Required)

Infection Control; on a scale of 1 to 4(Required)

Standerd Universal Control; on a scale of 1 to 4(Required)

Reverse Isolation; on a scale of 1 to 4(Required)

TB/Aieborne Precautions; on a scale of 1 to 4(Required)

MRSA/ VRE precautions; on a scale of 1 to 4(Required)

Reporting Change in patient condition; on a scale of 1 to 4(Required)

Height and weight measurement; on a scale of 1 to 4(Required)

Age Specific Competency

Newborn (birth- 30 days); on a scale of 1 to 4(Required)

Infant (30 days- 1 years); on a scale of 1 to 4(Required)

Toddler (1-3years); on a scale of 1 to 4(Required)

Preschooler (3-5 years); on a scale of 1 to 4(Required)

School Age (5-12 years); on a scale of 1 to 4(Required)

Adolescents (12-18 years); on a scale of 1 to 4(Required)

Young Adults (18-39 years); on a scale of 1 to 4(Required)

Middle Adults (39-64 years); on a scale of 1 to 4(Required)

Older Adults (64+ Years); on a scale of 1 to 4(Required)

The information represented above is true and correct to the best of my knowledge. I also authorize Awa Medical Staffing to share the above skills checklist with its contracting facility if need.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

NURSE SKILLS COMPETENCY CHECKLIST

Upload an image of your LPN/RN State License(Required)

Accepted file types: jpg, gif, png, pdf, Max. file size: 200 MB.

Please enter your nursing License Number(Required)

Total years of Nursing Experience:(Required)

Please rate your Skill Level by checking the appropriate box using the key below:

PROFICIENCY SCALE

0 - No experience
1 - Limited competency; requires supervision
2 - Experienced (Performs independently)
3 - Proficient/Expert/Highly skilled

Skills

Documentation/Notes; on a scale of 0 to 3(Required)

Vital Signs – BP, TPR, Height, Weight; on a scale of 0 to 3(Required)

Intake & Output monitoring; on a scale of 0 to 3(Required)

Activities of Daily Living (ADLs); on a scale of 0 to 3(Required)

Admission of Client; on a scale of 0 to 3(Required)

Medications: Oral, IM, SQ, PR, Topical; on a scale of 0 to 3(Required)

Bathing assistance; on a scale of 0 to 3(Required)

Body Systems Review (Head to Toe Assessment); on a scale of 0 to 3(Required)

Oral Hygiene; Denture Care; on a scale of 0 to 3(Required)

Nail and Skin Care; on a scale of 0 to 3(Required)

Backrubs/back care; on a scale of 0 to 3(Required)

Use of Bedpan/Urinal; on a scale of 0 to 3(Required)

Bowel Regimen; on a scale of 0 to 3(Required)

Client Care Plans (Revise & Update); on a scale of 0 to 3(Required)

Client Safety Standards/Precautions; on a scale of 0 to 3(Required)

Infection Control Precautions; on a scale of 0 to 3(Required)

Handwashing; on a scale of 0 to 3(Required)

Compresses: warm/cold; on a scale of 0 to 3(Required)

CPR; on a scale of 0 to 3(Required)

Applying/Removing TEDS stockings; on a scale of 0 to 3(Required)

Prosthetic/Assistive Devices; on a scale of 0 to 3(Required)

Restraints – Apply/Monitor; on a scale of 0 to 3(Required)

Reporting changes in client’s condition; on a scale of 0 to 3(Required)

Intravenous therapy; on a scale of 0 to 3

Wound Care; on a scale of 0 to 3(Required)

Colostomy Care & Irrigation; on a scale of 0 to 3(Required)

Discharge of Client; on a scale of 0 to 3(Required)

Pain Assessment; on a scale of 0 to 3(Required)

Traction; on a scale of 0 to 3(Required)

Supervision of CNA; on a scale of 0 to 3(Required)

Reporting concerns to team/supervisor; on a scale of 0 to 3(Required)

Repositioning/Transferring; on a scale of 0 to 3(Required)

Use of Hoyer Lift; on a scale of 0 to 3(Required)

Use of Walker/Canes; on a scale of 0 to 3(Required)

Crutch walking; on a scale of 0 to 3(Required)

Use of manual wheelchair; on a scale of 0 to 3(Required)

Use of electric wheelchair; on a scale of 0 to 3

Special Diet Restrictions (Diabetic, Low Salt, Fluid Restriction, etc.); on a scale of 0 to 3(Required)

Making occupied bed; on a scale of 0 to 3(Required)

Basic Medical Asepsis; on a scale of 0 to 3(Required)

Oxygen (cannula, mask, etc); on a scale of 0 to 3(Required)

Pulse Oximetry; on a scale of 0 to 3(Required)

Range of Motion Exercises; on a scale of 0 to 3(Required)

Assist with Ambulation; on a scale of 0 to 3(Required)

Dressing changes; on a scale of 0 to 3(Required)

Advance Directives; on a scale of 0 to 3(Required)

Postmortem Care; on a scale of 0 to 3(Required)

Cast Care; on a scale of 0 to 3(Required)

GT/NG tubes; on a scale of 0 to 3(Required)

Ostomy Care; on a scale of 0 to 3(Required)

Catheterization – straight/foley; on a scale of 0 to 3(Required)

Incentive Spirometry; on a scale of 0 to 3(Required)

Specimen Collection; on a scale of 0 to 3(Required)

Phlebotomy; on a scale of 0 to 3

Urine Dipstick; on a scale of 0 to 3(Required)

Blood Glucose Monitoring; on a scale of 0 to 3(Required)

Suctioning; on a scale of 0 to 3(Required)

Tracheostomy Care; on a scale of 0 to 3(Required)

Transfer/Transport Clients; on a scale of 0 to 3(Required)

Assessing Educational Needs; on a scale of 0 to 3(Required)

Teaching Client, Staff, Family, Caregivers; on a scale of 0 to 3(Required)

Coordinating Care with Team; on a scale of 0 to 3(Required)

Communicating with Physician/Provider; on a scale of 0 to 3(Required)

Documenting Orders Appropriately; on a scale of 0 to 3(Required)

Drug Calculations; on a scale of 0 to 3(Required)

Handling Emergent Situations; on a scale of 0 to 3(Required)

Care of Client with:

Alzheimer’s/Dementia; on a scale of 0 to 3(Required)

Stroke; on a scale of 0 to 3(Required)

Asthma/COPD/Respiratory Illness; on a scale of 0 to 3(Required)

Head Injuries; on a scale of 0 to 3(Required)

Amputation; on a scale of 0 to 3(Required)

Diabetes; on a scale of 0 to 3(Required)

Pacemaker; on a scale of 0 to 3

Spinal Cord Injury; on a scale of 0 to 3(Required)

Wounds/Drains(Required)

Tracheostomy; on a scale of 0 to 3(Required)

CHF/Cardiac Diseases; on a scale of 0 to 3(Required)

Renal Diseases; on a scale of 0 to 3(Required)

Hip/Knee Replacements; on a scale of 0 to 3(Required)

AIDS/Immunosuppression; on a scale of 0 to 3(Required)

Cancer; on a scale of 0 to 3(Required)

Burns; on a scale of 0 to 3(Required)

Recent Surgery; on a scale of 0 to 3(Required)

Mental Illness; on a scale of 0 to 3(Required)

Multiple Trauma; on a scale of 0 to 3(Required)

Terminal Illness; on a scale of 0 to 3(Required)

Age-Appropriate Care of:

Newborn (birth – 30 days); on a scale of 0 to 3(Required)

Infant (31 days – 1 year); on a scale of 0 to 3(Required)

Toddler (1 – 3 years); on a scale of 0 to 3(Required)

Preschooler (3 – 5 years); on a scale of 0 to 3(Required)

School Age (5 – 12 years); on a scale of 0 to 3(Required)

Adolescents (12 – 18 years); on a scale of 0 to 3(Required)

Middle Adults (39 – 64 years); on a scale of 0 to 3(Required)

Young Adults (18-39 years); on a scale of 0 to 3(Required)

Older Adults (64+ years); on a scale of 0 to 3(Required)

Do you speak any other language(s) besides English? If YES, please list other language(s):

Do you have any other skills not listed here that are pertinent to the position?

File

Max. file size: 512 MB.

Upload any additional items (CPR, Covid Card, TB Test, etc.)

Accepted file types: jpg, gif, png, pdf, Max. file size: 200 MB.

I hereby certify that all information I have provided to MAS Home Care of New Hampshire on this skills checklist is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate dismissal.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Section Break

File

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Phone

This field is for validation purposes and should be left unchanged.

Enroll

Employment Application

PERSONAL INFORMATION:

EDUCATION:

EMPLOYMENT/WORK EXPERIENCE:

MILITARY SERVICE

LANGUAGE SKILLS:

Employment Eligibility Verification

Employee Information and Attestation

Health Care Worker Background Check

The following sections will be an assessment of your experience in certain clinical areas...

CNA Skills Checklist

Documentation

Personal Care

Elimination

Activity

Observation

Age Specific Competency

NURSE SKILLS COMPETENCY CHECKLIST

Skills

Care of Client with:

Age-Appropriate Care of:

Section Break

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