INDEPENDENT CONTRACTOR APPLICATION

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1 INDEPENDENT CONTRACTOR APPLICATION Programs, services, and employment are available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for application or interview. Applicant Data Name LAST FIRST MIDDLE Date Social Security Number Address STREET CITY STATE ZIP Permanent Address STREET CITY STATE ZIP Phone ( ) Mobile In Case Of Emergency: Contact Name Contact Phone ( ) Contact Address (1) Are you 18 years or older? YES NO (2) Are you a United States citizen/alien authorized to work in the US? YES NO (3) Have you ever pleaded guilty no contest or been charged of a crime? YES NO If yes, give dates and details: Have you ever worked for Compassionate Healthcare Nursing Services before? YES NO If yes, where? And when? How did you find out about this agency? 1

2 EDUCATION NAME AND LOCATION # OF YEARS ATTENDED Grammar School YEAR OF GRADUATION SUBJECTS STUDIED High School College Nursing School Summarize your special skills or qualifications: Are you licensed in any other states besides Maryland? YES NO If yes, please list Please list any languages you speak besides English US Military or Naval Service Present member of National Guard or Reserves? YES NO 2

3 Former Employers (LIST BELOW LAST FOUR (4) EMPLOYERS STARTING WITH MOST RECENT) DATE (MO/YR) NAME & ADDRESS OF EMPLOYER POPULATION (CIRCLE) DUTIES (Circle) LPN RN CNA From: To: Peds (0-12yrs) Adol (12-18yrs) Adults Geriatrics Other From: To: Peds (0-12yrs) Adol (12-18yrs) Adults Geriatrics Other (Circle) LPN RN CNA From: To: Peds (0-12yrs) Adol (12-18yrs) Adults Geriatrics Other (Circle) LPN RN CNA From: To: Peds (0-12yrs) Adol (12-18yrs) Adults Geriatrics Other (Circle) LPN RN CNA References: Give the names of three persons not related to you, whom you have known at least one year. REF #1 REF #2 REF #3 Name Address/ Phone # Work Years Acquainted 3

4 I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENT ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE. Date: Signature: DO NOT WRITE BELOW THIS LINE INTERVIEWED BY DATE REMARKS NEATNESS ABILITY HIRED yes no POSITION DEPT. SALARY/WAGE DATE REPORTING TO WORK APPROVED EMPLOYMENT MANAGER DEPT. HEAD GENERAL MANAGER 4

5 CONSENT/DECLINE FORM FOR HEPATITIS B VACCINATION CHNS, Inc., the agency I contract with, has provided me education about the Hepatitis B vaccine. I understand the effectiveness of the vaccine, the risk of contracting Hepatitis B due to exposure to blood and other potential infectious materials while working at the various sites that CHNS, Inc. are currently under contract to service with staffing needs and the importance of taking active steps to reduce the risk. I currently choose of my own free will, to hereby DECLINE/CONSENT being given the Hepatitis B vaccine. I do understand that if I decline the vaccination in the future I may receive it. Employee Name =[I 7 Date Employee Signature Date Employee Address Witness Date NOTE: Maintain this record for duration of employment plus 30 years. 5

6 INDEPENDENT CONTRACTOR AGREEMENT The undersigned consultant acknowledges attainment for one or several of the following contractual services for the Compassionate Healthcare Nursing Services, Inc. agency: Nursing Care Provider Nursing Assessment Consultant Nursing Trainer It is further acknowledged that: 1. The undersigned shall be deemed an independent contractor and is not bound for any length of time with CHNS, Inc. for employment, partnership, joint venture, or other agency associations. 2. The relationship between the undersigned independent contractor and CHNS, Inc. is based on the independent contractor s decision to work at his/her own discretion with regards to self-scheduling on the available cases/positions. 3. Consistent with the foregoing, CHNS, Inc. will not be responsible or held liable for the following: FICA, Medicare, Federal, State, and any other required tax deductions. The undersigned independent contractor acknowledges his/her responsibility to pay all of the above mentioned tax liabilities. 4. The undersigned independent contractor further acknowledges that he/she is not entitled to any benefits bestowed on an employee of CHNS, Inc.: pension, profit sharing, unemployment insurance, professional liability, overtime, pay bonuses, sick leave, vacation leave, family leave, tuition reimbursement, and travel reimbursement. 5. The undersigned independent contractor accepts the above mentioned terms for referral of services by CHNS, Inc. and payment strictly for hours worked at the rate of $ per hour. Signed on this (date) day of (month) of 201. Consultant Signature CHNS Inc. Representative Signature Consultant Printed Name CHNS Inc. Representative Printed Name Office: (410) Fax: (410)

7 EMPLOYMENT VERIFICATION AND REFERENCE REQUEST Employer: Phone #: Address: State, ZIP: RELEASE OF INFORMATION I,, hereby authorize the release of any information concerning my APPLICANT NAME previous employment to Compassionate Health Care Nursing Services. SIGNATURE OF APPLICANT DATE OF SIGNATURE I. Verification of Employment (1) Title and position of applicant during employment with your company: (2) Approximate hours/week applicant worked: (3) Date Hired: Date Left: (4) Would you rehire? YES NO (5) Did this applicant work with pediatric patients? YES NO (6) Have they used the ventilator with your company? YES NO SIGNATURE OF PERSON COMPLETING EMPLOYMENT VERIFICATION II. Reference Check Applicant s Work Performance (Please check each item below) Item Excellent Good Fair Poor N/A Quality of work performed Quantity of work produced Relationships with customers and coworkers Punctuality Attendance Professional conduct Comments: SIGNATURE OF INDIVIDUAL COMPLETING FORM DATE OF SIGNATURE 7

8 EMPLOYMENT VERIFICATION AND REFERENCE REQUEST Employer: Phone #: Address: State, ZIP: RELEASE OF INFORMATION I,, hereby authorize the release of any information concerning my APPLICANT NAME previous employment to Compassionate Health Care Nursing Services. SIGNATURE OF APPLICANT DATE OF SIGNATURE I. Verification of Employment (1) Title and position of applicant during employment with your company: (2) Approximate hours/week applicant worked: (3) Date Hired: Date Left: (4) Would you rehire? YES NO (5) Did this applicant work with pediatric patients? YES NO (6) Have they used the ventilator with your company? YES NO SIGNATURE OF PERSON COMPLETING EMPLOYMENT VERIFICATION II. Reference Check Applicant s Work Performance (Please check each item below) Item Excellent Good Fair Poor N/A Quality of work performed Quantity of work produced Relationships with customers and coworkers Punctuality Attendance Professional conduct Comments: SIGNATURE OF INDIVIDUAL COMPLETING FORM DATE OF SIGNATURE 8

9 I,, hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment. PRINT NAME SIGNATURE DATE 9

10 NURSING SKILLS CHECKLIST NAME: LPN RN SPECIFIC CARE Assessment Neurological Respiratory - Identify breath sounds - Identify abnormal breath sounds Identify Respiratory Distress Cardiovascular Skeletal Integumentary Gastro-Intestinal Tube Feeding Bolus Feed Use of feeding pump Medication via GT/NGT Providing GT/JT Care Checking for GT/NGT Placement and Patercy G Tube/NGT insertion Administering O2 Therapy With humidity Via mask Nasal canula Trach collar Determining O2 amt O2 concentrator Equipment Pulse oximetry Apnea monitor Feeding pump Nebulizer machine Chest vest Compressor Urinary Care Foley catheter care Insertion of Foley catheter Straight catheterization RN SUPERVISOR VALIDATION Yes No Satisfactory Unsatisfactory Supervisor Initial Date Observed 10

11 SPECIFIC CARE Urinary Care (cont.) Giving vaginal medication Performing a douche Giving an enema Suctioning Oral Nasopharyngeal Tracheal Deep Suctioning Tracheostomy Care Performing tracheal care Cleaning the inner canula Inserting the trach Changing trach ties Replacing the trach collar Care of Client on Ventilator LTV TBird Legacy LP 10 Vital Signs Oral temp Rectal temp Axillary temp Ear Pulse brachial Pulse radial Pulse apical Respirations Blood pressure Activities Applying brace Applying splints Applying passive ROM Applying active ROM Using crib Using stroller Using wheelchair Hoyer lift RN SUPERVISOR VALIDATION Yes No Satisfactory Unsatisfactory Supervisor Initial Date Observed 11

12 SPECIFIC CARE Ostomy Care Caring for a colostomy Caring for a ileostomy Irrigating the colostomy Irrigating the ileostomy Care of the stoma Applying an ostomy bag Teaching clients/family about ostomies Activities of Daily Living Bathing the client Changing the diaper Performance of mouth care Dressing the client Wound Care Assessing a wound Performing wet-to-dry dressing Irrigating a wound Performing wound measurement Applying a transparent wound dressing Packing a wound Applying a bandage Medication Administration Administering medication by mouth Administering IM medication Administering Sub Q medication Documenting medications Performing narcotic counts Administering narcotics Writing Nurse Notes Documenting of 2-hour Head-to-toe assessment Documenting family teaching RN SUPERVISOR VALIDATION Yes No Satisfactory Unsatisfactory Supervisor Initial Date Observed NURSE SIGNATURE DATE RN SUPV. SIGNATURE DATE 12

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