LPN Application

Please provide the following information in the form:

POSITION DESIRED *

DATE AVAILABLE *

TYPE OF EMPLOYMENT DESIRED

Personal Information

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

PHONE NUMBER *

ALTERNATIVE PHONE NUMBER

EMAIL ADDRESS *

DO YOU SPEAK ANY OTHER LANGUAGE(S)? SPECIFY

DO YOU HAVE THE LEGAL RIGHT TO OBTAIN EMPLOYMENT IN THE UNITED STATES?YesNo

CAN YOU PERFORM THE ESSENTIAL FUNCTIONS AND RESPONSIBILITIES OF THE POSITION FOR WHICH YOU ARE APPLYING?YesNo

DO YOU REQUIRE ANY SPECIAL ACCOMMODATION TO PERFORM REQUIRED DUTIES?YesNo

HAVE YOU EVER WORKED FOR INSPIRED GRACE HEALTHCARE, INC.?YesNo

DO ANY OF YOUR RELATIVES WORK FOR INSPIRED GRACE HEALTHCARE, INC.?YesNo

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 with An Illinois License or Cna Certification Must Provide the License or Certification Number, Date of Such License or Certification.

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?YesNo

You 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

Education and Skills

SPECIFY MAJOR

SOFTWARE APPLICATIONS

TYPING WORDS PER MINUTE

Experience

List Last 5 Years of Work Experience

01 – Employment

FROM

BEGINNING SALARY

USD

ENDING SALARY

USD

NAME OF EMPLOYER

MAY WE CONTACT?YesNo

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?YesNo

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?YesNo

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?YesNo

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?YesNo

SUPERVISOR’S NAME

PHONE NUMBER

TITLE AND DUTIES PERFORMED

REASON FOR LEAVING

NAME *

DATE

04/22/2025

Please click to view and download the forms:

LPN Skills Checklist

Name *

Date of Hire

1 = Clinicals Only

2 = Some Experience

3 = Experienced

4 = Can Perform Task Independently

Neurological System

USING GLASCOW COMA SCALE *1234

Cardiovascular

Patients with Respiratory Problems

Assessing the Respiratory System including:

SPUTUM (COLOR/CHARACTER) *1234

Care and Maintenance of:

Administering and Monitoring O2 including:

Care of Ventilator Dependent Patient:

Caring for a Patient with:

USE OF INCENTIVE SPIROMETER *1234

Gastrointestinal

Genitourinary / Renal

Endocrine

Caring for the Diabetic Patient:

HORMONE THERAPY *1234

Muscuskeletal

Beds:

ARTHROSCOPY/ARTHROTOMY *1234

Caring for Patients with:

Vital Signs and Weights

Obtaining and Recording:

WEIGHT, POUNDS AND KILOGRAMS *1234

Use of Electronic VS equipment:

Scale Use:

Hygiene / Skin

Bathing/Daily Hygiene:

Use of Pressure and Friction Reduction Devices:

Nutrition

RECORDING AND REPORTING NUTRITIONAL INFORMATION *1234

Care Routine

New Admissions and Transfers:

Safety and Activity

Recognizing Abuse:

APPLICATION AND DOCUMENTATION OF RESTRAINTS: BELT, INCLUDING SEAT BELT WRIST/ANKLE VEST USE OF SEIZURE PADS *1234

Infection Control

Medication and Administration

Proper Use of Specific Barrier Methods:

DISPOSAL OF SHARPE *1234

Line Skills

IV Therapy Including:

SET UP AND MONITORING FOR TPN *1234

Suppositories:

Other Skills

Communication

Communicating to Charge RN:

Unit Activity

Miscellaneous

Knowledge of Serum Lab Values Including:

Additional Documents

Use this section to attach the following: TB test, Covid Card, Social Security Card, CPR, Nursing License, & Physical

Upload file(s)

Attach up-to 6 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.

Confirmation

Full Name *

DATE

04/22/2025

LPN Application

Personal Information

Education and Skills

Experience

List Last 5 Years of Work Experience

LPN Skills Checklist

Neurological System

Cardiovascular

Patients with Respiratory Problems

Gastrointestinal

Genitourinary / Renal

Endocrine

Muscuskeletal

Vital Signs and Weights

Hygiene / Skin

Nutrition

Care Routine

Safety and Activity

Infection Control

Medication and Administration

Line Skills

Other Skills

Communication

Unit Activity

Miscellaneous

Additional Documents

Use this section to attach the following: TB test, Covid Card, Social Security Card, CPR, Nursing License, & Physical

Confirmation

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Contact Details

Phone: 224-484-0596

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