CNA Application 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 INSPIRED GRACE HEALTHCARE, INC.?YesNoDO ANY OF YOUR RELATIVES WORK FOR INSPIRED GRACE HEALTHCARE, 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 HereEnter Reference HereEnter Reference HereEducation 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 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 *DATE12/23/2024Please click to view and download the forms: Form I-9 Form W-4 Health Care Worker Background Check Form Certified Nursing Assistant Skills ChecklistPRINT NAME *DATE12/23/2024Directions 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:  AmbulationCRUTCHES1234WALKER1234CANE1234GAIL BELT1234Personal Care1.BATHA.BED1234B.TUB1234C.SHOWER12342.SKIN CAREA.BACK RUB1234B.DECUBITUS PREVENTION OR CARE12343.DRESSA.ASSIST AS NEEDED1234B.USE OF ASSISTIVE DEVICES1234B.USE OF ASSISTIVE DEVICES12345.NAIL CARE (FINGERS AND TOES)A.CLEAN OR FILE OR TRIM WITH CLIPPERS12346.ORAL HYGIENEA.MOUTH CARE1234B.BRUSH TEETH1234C.DENTURE CARE12347.SHAVING: SAFETY RAZOR OR ELECTRIC RAZOR1234Nutrition or Hydration1.FEEDING TECHNIQUES12342.ASSIST WITH EATING12343.USE OF FEEDING ASSISTIVE DEVICES12344.MEASURE AND RECORD INTAKE12345.ENCOURAGE FLUIDS1234Assisting or Care of Patient with Bowel and Bladder Elimination1.BEDPAN OR URINAL12342.BEDSIDE COMMODE12343.CARE OF INCONTINENT PATIENT12344.STOMA CARE12345.BOWEL OR BLADDER TRAINING12346.MEASURE AND RECORD OUTPUT1234Urinary Catheter Care1.PERINEAL HYGIENE12342.FOLEY CATHETER12343.SUPRA PUBLIC CATHETER1234Transfer Techniques1.USE OF TRANSFER GAIT BELT12342.WEIGHT BEARING12343.NON-WEIGHT BEARING12344.MECHANICAL LIFT12345.WHEELCHAIR1234Turning / Position Patient1. SUPINE12342. SIDE-LYING12343. IN CHAIR12344. IN BED12345. USE OF LIFT SHEET1234Communication1. VERBAL12342. NON-VERBAL WITH COGNITIVELY IMPAIRED PATIENTS1234Range of Motion Excersices1. ACTIVE12342. PASSIVE12343. COMBINATION1234Take & Record Vital Signs1. TEMPERATUREA. ORAL1234B. RECTAL1234C. EAR CANAL12342. PULSEA. APICAL1234B. RADIAL1234C. PEDAL12343. RESPIRATIONS12344. BLOOD PRESSURE12345. HEIGHT12346. WEIGHTB. BED SCALE1234A. STANDING1234C. CHAIR SCALE1234Safety Devices1. VEST RESTRAINT12342. (SOFT) WRIST / ANKLE RESTRAINT)12343. PADDED SIDE RAIL12344. SIDE RAILS1234Mental Health & Social Services Needs1. DEMONSTRATES PRINCIPLES OF BEHAVIOR MANAGEMENT12342. PROVIDES EMOTIONAL SUPPORT TO PATIENT12343. ECOURAGES FAMILY SUPPORT12344. ECOURAGES PATIENTS TO MAKE PERSONAL CHOICES12345. REPECTS PATIENT'S RIGHTS AND DIGNITY, INCLUDING PRIVACY & CONFIDENTIALITY12346. ENCOURAGES SELF-CARE AS ABILITY ALLOWS12348. KNOWLEDGE OF DOMESTIC VIOLENCE AND VIOLENT INJURY REPORTING STATUES12347. KNOWLEDGE OF ADULT, CHILD AND ELDER ABUSE REPORTING STATUTES1234Safety / Emergencies1. RECOGNIZES & REPORTS SAFETY HAZARDS12342. RECOGNIZES & REPORTS EMERGENCIES AND RESPONDS APPROPRIATELY12343. HANDLES O2 SAFELY12344. OBSERVES, REPORTS & DOCUMENTS CHANGES IN BODY FUNCTIONS, BEHAVIOR1234Care of Prosthetic Devices1. LIMBS12342. EYE GLASSES12343. HEARING AIDS1234Specimen Collection1. URINE12342. STOOL12343. SPUTUM1234Understand and Can Perform1. BINDERS AND BANDAGESA. ACE BANDAGES1234B. SUPPORT STOCKINGS12342. CARE OF THE DECEASED1234ASSIST THE CARE OF PATIENT WITH1. DIABETES12342. CANCER12343. HEART DISEASE12344. O2 THERAPY12345. RESPIRATORY DISEASE12346. TERMINAL12347. INFECTIOUS DISEASE1234Additional DocumentsUpload fileDrag and Drop (or) Choose FilesYou can attach up-to 3 additional documents. Maximum of 9MB. Note that if you’re having trouble uploading one of the enabled filetypes, that filetype may be restricted by our security.To the best of my knowledge, 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 *DATE12/23/2024 Submit
