RN Application Please provide the following information in the form: 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 *DATE12/23/2024HTMLPlease click to view and download the forms: Form I-9 Form W-4 Health Care Worker Background Check Form RN Checklist Please indicate experience level as 1, 2, 3, or 4 in the boxes below using the following rankings: 1 = Clinicals Only 2 = Some Experience 3 = Experienced 4 = Can Perform Task Independently NEUROLOGICAL SYSTEMNEURO ASSESSMENT/NEURO VITALS *1234HALO TRACTION *1234SEIZURE PRECAUTIONS *1234Caring for Patient with:SPINAL CORD INJURY *1234HEAD INJURY *1234REHABILITATION OF THE NEURO PATIENT *1234CNS INFECTIONS *1234Pre / Post Neurological SurgeryPARKINSONS *1234ALZHEIMERS *1234AUTONOMIC DYSREFLEXIA *1234CHRONIC C.V.A / T.I.A *1234USING GLASCOW COMA SCALE *1234CARDIOVASCULARAssessment:Capillary Refill *1234Edema *1234Heart Tones Antiembolic Devices *1234Pulses *1234Angina (Acute and Chronic) *1234Assessing and Treating Orthostatic BP *1234Assessing Abnormal Heart Tones *1234Antiembolic Devices *1234PATIENTS WITH RESPIRATORY PROBLEMSAssessing the Respiratory System including:Breathing Pattern / Effort *1234Breath Sounds *1234Cough Effort *1234Skin and Nail Bed Color *1234Sputum (Color/Character) *1234Care and Maintenance of:Acute Airway *1234Nasopharyngeal Airway *1234Oropharyngeal Airway *1234Administering and Monitoring O2 including:Nasal Cannula *1234Mask *1234O2 Sats *1234Demonstrating proper use of Ambu Bag *1234Administering and Monitoring O2 including:Suctioning: Length of time suctioning *1234Hyperventilation *1234Ventilator Settings *1234Documentation *1234Caring for a Patient with:Respiratory Failure *1234Respiratory Infections *1234Status Asthmaticus *1234Respiratory Distress Syndrome *1234Pulmonary Edema *1234Pulmonary Emboli *1234Tension Pneumothorax *1234Tracheostomy *1234Use of Incentive Spirometer *1234GASTROINTESTINALAssessing Bowel Sounds *1234Identifying Abnormalities *1234Caring for Patient on Total Parenteral Nutrition *1234Inserting /Maintaining Feeding Tubes (NG) *1234Administering Tube Feedings *1234Abdominal Wounds or Infections *1234Ileostomy/Colostomy *1234Stool Tests *1234I&O: Shift volumes and totals including marking and/ *1234Or measuring amounts of urine, gastric fluid *1234NG drainage, emesis, diarrhea *1234GENITOURINARY/RENALInserting/Maintaining Urinary Drainage Tubes:Insertion of Foley *1234Managing Urostomy *1234Managing Suprapubic Catheter *1234Placing Condom Catheter *1234Caring for Patients with Chronic Renal Failure *1234Caring for Patient receiving Dialysis *1234Assessing Fluid and Electrolyte Problems *1234Knowledge of UA values *1234Collecting Specimens *1234ENDOCRINECaring for the Diabetic Patient:Checking Capillary Blood Glucose *1234Diabetic Teaching *1234Treating Hypo/Hyperglycemia *1234Insulin Administration *1234Hormone Therapy *1234MUSCULOSKELETALTraction *1234Braces *1234Casts *1234Collars *1234Slings/Splints *1234Skeletal and Skin Traction *1234Beds:Clinitron *1234Roto Rest *1234Circelectric *1234Crutch Walking/Walkers *1234Arthroscopy/Arthrotomy *1234Caring for Patients with:Joint/Bone Disorders *1234Total Knee Replacement *1234Total Hip Replacement *1234Amputation *1234VITAL SIGNS AND WEIGHTSObtaining and Recording:BP, Including Orthostatic *1234Pulse, Radial *1234Temperature, Oral *1234Temperature, Rectal *1234Temperature, Axillary *1234Temperature, Tympanic *1234Respirations *1234Weight, Pounds and Kilograms *1234Use of Electronic VS equipment:Automatic BP Machine (Dynamap) *1234Electronic Thermometer *1234Recognizing Cardiac Arrest *1234Cardioversion Defibilation *1234Activating Code Term *1234Bringing Emergency Equipment to Room *1234DNR Status *1234Applying Oximeter *1234Scale Use:Standing *1234Chair *1234Bed *1234Bed *1234HYGIENE/SKINRisk Factors For Skin Breakdown *1234Observing, recording and reporting pressure points for redness of breakdown *1234Recording and Reporting Hygiene/Skin//Breakdown *1234Bathing/Daily Hygiene:>Bathing (shower/tub/arjo) *1234Use of Shower Chair *1234Use of Bath/Shower Boat *1234Oral care including patients who are NPO, Comatose, with dentures *1234Peri Care *1234Foot care for Patients with Impaired Circulation of Sensation *1234Incontinence care *1234Shaving and Precautions *1234Use of Pressure and Friction Reduction Devices:Special Beds/Mattresses *1234Heels and Elbow Protection *1234Foot Cradles *1234NUTRITIONEstimating Intak *1234Setting up for Meals *1234Aspiration Precautions *1234Nourishments *1234Feeding Patients *1234Counting Calories *1234Fluid Restriction *1234NPO *1234Recording and Reporting Nutritional Information *1234CARE ROUTINENew Admissions and Transfers:Room Preparation *1234VS. Height and Weight *1234Basic Comfort Measures *1234Inventory and Disposition of Belongings *1234Room Orientation, Call Bell *1234Preparing for and Explaining Routines to Patient *1234Post Mortem Care *1234SAFETY AND ACTIVITYDetermining Patient ID *1234Identifying/Responding to Safety Hazards *1234Determining Need for Additional Help *1234Recognizing Abuse:Substance *1234Physical *1234Emotional *1234Maintaining Clean , Orderly work area *1234Handling Hazardous Materials *1234Proper Body Mechanics *1234ROM Exercises *1234Transfer to Bed, WC, Commode with or without device *1234Turning and Positioning *1234Ambulating with or without Device *1234Patient Safety Module *1234Reporting Broken Equipment *1234Use of Hoyer Lift (Dextra/Maxi) *1234Bed Operation *1234Use of Wheel Locks *1234Use of Alarms (Bed, Patient, Unit) *1234Use of Call Light *1234Application and Documentation of Restraints: Belt, Including Seat Belt Wrist/Ankle, Vest, Use of Seizure Pads *1234INFECTION CONTROLProper Use of Specific Barrier Methods:Gloves *1234Gown *1234Mask/Goggles *1234Protective/Reverse Isolation *1234Brody Substance Isolation *1234TB Precautions *1234MRSA Precautions *1234Hand Washing *1234Infectious/Hazardous Waste Disposal *1234Supply/Equipment Disposal *1234Use of Disposable Thermometer *1234Use of CPR Mask/Bag *1234Disposal of Sharpe *1234LINES SKILLSVenipuncture for Specimen *1234IV Therapy Including:Starting IV *1234Changing IV Sites *1234Changing IV Dressings *1234Changing IV Tubing *1234Administering Fluids on Continuous IV Pumps *1234Setting Up and Monitoring PCA *1234Obtaining Central Venous/Peripheral Venous Blood *1234Using PICC, Hickman, Triple Lumen Caths *1234Set up and Monitoring for TPN *1234MEDICATION AND ADMINISTRATIONCimetidine (Tagamet) *1234Diazepam (Valium) *1234Digoxin (Lanoxin) *1234Duramorph *1234Furosemide (Lasix) *1234Heparin *1234Insulin *1234Terbutaline *1234Theophylline *1234Verapamil (Calan) *1234Oral Medications *1234Lorazepam (Ativan) *1234Morphine *1234Naloxone (Narcan) *1234Nitroglycerine *1234Pentobarbital *1234Phenytoin (Dilantin) *1234Potassium Chloride *1234Topical Medications *1234Suppositories:Vaginal *1234Rectal *1234Ordering Meds *1234OTHER SKILLSObtaining Cultures for Septic Work-up (Blood, Sputum, Urine, Catheter Tips) *1234Caring for Patient Using Jehovah Witness Protocol *1234Overbed Frame Safety *1234Specialty Beds (i.e. Kinair) *1234Hospital Transport *1234Providing Education to Patient Family Related to Medical Condition, Self Care and Health Care Habits *1234Communicating Discharge Needs and Arrangements for Support through Appropriate Documentation *1234Coordinating Multidisciplinary Plan of care and Initiating Interdisciplinary Referral for Patient Needs *1234Preparing Patient for Surgery *1234Clearly Communicating the Plan of care, Patient Responses and Outcomes in the Patient Record According to Standards *1234Assigning or Delegating Tasks to Another for which that Person is Prepared and Qualified to Perform, i.e. CNA’s *1234Using Computerized Tools Effectively *1234COMMUNICATIONUsing Appropriate Abbreviations *1234Identifying Need for Alternate Communicating Mechanisms *1234Communicating to Charge RN:Changes in Patient Condition *1234Patient Needs, Complaints and Concerns *1234Unusual Incidents *1234Reinforcing RN Teaching with Patient *1234Selecting and Using Forms Appropriately *1234Using Alternate Communication Tools/Devices *1234UNIT ACTIVITYIdentifying Unusual Incidents on the Unit that Require reporting *1234Locating and Using Appropriate Reference Materials *1234Charging for Patient Care items *1234Completing Risk Management Reports as Needed *1234Obtaining Needed Supplies and Equipment *1234Using Telephone System *1234MISCELLANEOUSCommunicating to Charge RN:Chem 7, Chem 10 *1234CBC *1234Serum drug levels *1234Caring for Drains/Tubes (i.e. Hemovac, Penrose) *1234Monitoring and Assessing I & O *1234Performing Complex Dressing Changes *1234Alert Charting *1234ADDITIONAL DOCUMENTUse this section to attach the following: TB test, Covid Card, Social Security Card, CPR, Nursing License, Identity Card (ID Card) & Physical.Upload file(s)Drag and Drop (or) Choose FilesAttach up-to 7 documents. 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