LPN Application Please provide the following information in the form: POSITION DESIRED * DATE AVAILABLE * TYPE OF EMPLOYMENT DESIREDSelectFull TimePart Time 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 HAVE A VALID DRIVER'S LICENSE?YesNo CLASS CDL?YesNo HAVE YOU EVER SERVED IN THE MILITARY?YesNo 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 Enter Reference Here Enter Reference Here Education and Skills LEVEL OF EDUCATION COMPLETEDHigh SchoolGEDCollege 0-3 YearsDegree: AssociationBachelorMasters SPECIFY MAJOR SOFTWARE APPLICATIONS TYPING WORDS PER MINUTE Experience List Last 5 Years of Work Experience 01 – Employment FROM TO 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 TO 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 TO 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 TO 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 TO 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  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 * DATE 12/23/2024 Please click to view and download the forms: Form I-9 Form W-4 Health Care Worker Background Check Form LPN Skills Checklist Name * Date of Hire 1 = Clinicals Only 2 = Some Experience 3 = Experienced 4 = Can Perform Task Independently Neurological System NEURO ASSESSMENT/NEURO VITALS *1234 HALO TRACTION *1234 SEIZURE PRECAUTIONS *1234 SPINAL CORD INJURY *1234 HEAD INJURY *1234 PRE / POST NEUROLOGICAL SURGERY *1234 REHABILITATION OF THE NEURO PATIENT *1234 CNS INFECTIONS *1234 PARKINSONS *1234 AUTONOMIC DYSREFLEXIA *1234 ALZHEIMERS *1234 CHRONIC C.V.A / T.I.A *1234 USING GLASCOW COMA SCALE *1234 Cardiovascular CAPILLARY REFILL *1234 EDEMA *1234 HEART TONES *1234 PULSES *1234 ANGINA (ACUTE AND CHRONIC) *1234 ASSESSING AND TREATING ORTHOSTATIC BP *1234 ASSESSING ABNORMAL HEART TONES *1234 ANTIEMBOLIC DEVICES *1234 Patients with Respiratory Problems Assessing the Respiratory System including: BREATH SOUNDS *1234 BREATHING PATTERN / EFFORT *1234 COUGH EFFORT *1234 SKIN AND NAIL BED COLOR *1234 SPUTUM (COLOR/CHARACTER) *1234 Care and Maintenance of: ACUTE AIRWAY *1234 NASOPHARYNGEAL AIRWAY *1234 OROPHARYNGEAL AIRWAY *1234 Administering and Monitoring O2 including: NASAL CANNULA *1234 MASK *1234 O2 SATS *1234 DEMONSTRATING PROPER USE OF AMBU BAG *1234 Care of Ventilator Dependent Patient: SUCTIONING: LENGTH OF TIME SUCTIONING *1234 HYPERVENTILATION *1234 VENTILATOR SETTINGS *1234 DOCUMENTATION *1234 Caring for a Patient with: RESPIRATORY FAILURE *1234 RESPIRATORY INFECTIONS *1234 STATUS ASTHMATICUS *1234 RESPIRATORY DISTRESS SYNDROME *1234 PULMONARY EDEMA *1234 PULMONARY EMBOLI *1234 TENSION PNEUMOTHORAX *1234 TRACHEOSTOMY *1234 USE OF INCENTIVE SPIROMETER *1234 Gastrointestinal ASSESSING BOWEL SOUNDS *1234 IDENTIFYING ABNORMALITIES *1234 CARING FOR PATIENT ON TOTAL PARENTERAL NUTRITION *1234 INSERTING /MAINTAINING FEEDING TUBES (NG) *1234 ADMINISTERING TUBE FEEDINGS *1234 ABDOMINAL WOUNDS OR INFECTIONS *1234 ILEOSTOMY/COLOSTOMY *1234 STOOL TESTS *1234 I&O: SHIFT VOLUMES AND TOTALS INCLUDING MARKING AND/ *1234 OR MEASURING AMOUNTS OF URINE, GASTRIC FLUID *1234 NG DRAINAGE, EMESIS, DIARRHEA *1234 Genitourinary / Renal INSERTING/MAINTAINING URINARY DRAINAGE TUBES: *1234 INSERTION OF FOLEY *1234 MANAGING UROSTOMY *1234 MANAGING SUPRAPUBIC CATHETER *1234 PLACING CONDOM CATHETER *1234 CARING FOR PATIENTS WITH CHRONIC RENAL FAILURE *1234 CARING FOR PATIENT RECEIVING DIALYSIS *1234 ASSESSING FLUID AND ELECTROLYTE PROBLEMS *1234 KNOWLEDGE OF UA VALUES *1234 COLLECTING SPECIMENS *1234 Endocrine Caring for the Diabetic Patient: CHECKING CAPILLARY BLOOD GLUCOSE *1234 DIABETIC TEACHING *1234 TREATING HYPO/HYPERGLYCEMIA *1234 INSULIN ADMINISTRATION *1234 HORMONE THERAPY *1234 Muscuskeletal TRACTION *1234 BRACES *1234 CASTS *1234 COLLARS *1234 SLINGS/SPLINTS *1234 SKELETAL AND SKIN TRACTION *1234 Beds: CLINITRON *1234 ROTO REST *1234 CRUTCH WALKING/WALKERS *1234 CIRCELECTRIC *1234 ARTHROSCOPY/ARTHROTOMY *1234 Caring for Patients with: JOINT/BONE DISORDERS *1234 TOTAL KNEE REPLACEMENT *1234 TOTAL HIP REPLACEMENT *1234 AMPUTATION *1234 Vital Signs and Weights Obtaining and Recording: BP, INCLUDING ORTHOSTATIC *1234 PULSE, RADIAL *1234 TEMPERATURE, ORAL *1234 TEMPERATURE, RECTAL *1234 RECOGNIZING CARDIAC ARREST *1234 CARDIOVERSION DEFIBILATION *1234 ACTIVATING CODE TERM *1234 BRINGING EMERGENCY EQUIPMENT TO ROOM *1234 DNR STATUS *1234 TEMPERATURE, AXILLARY *1234 TEMPERATURE, TYMPANIC *1234 RESPIRATIONS *1234 WEIGHT, POUNDS AND KILOGRAMS *1234 Use of Electronic VS equipment: APPLYING OXIMETER *1234 ELECTRONIC THERMOMETER *1234 AUTOMATIC BP MACHINE (DYNAMAP) *1234 Scale Use: STANDING *1234 CHAIR *1234 BED *1234 RECODING AND REPORTING INFORMATION *1234 Hygiene / Skin RISK FACTORS FOR SKIN BREAKDOWN *1234 OBSERVING, RECORDING AND REPORTING PRESSURE POINTS FOR REDNESS OF BREAKDOWN *1234 RECORDING AND REPORTING HYGIENE/SKIN//BREAKDOWN *1234 Bathing/Daily Hygiene: BATHING (SHOWER/TUB/ARJO) *1234 USE OF SHOWER CHAIR *1234 USE OF BATH/SHOWER BOAT *1234 ORAL CARE INCLUDING PATIENTS WHO ARE NPO, COMATOSE, WITH DENTURES *1234 PERI CARE *1234 FOOT CARE FOR PATIENTS WITH IMPAIRED CIRCULATION OF SENSATION *1234 INCONTINENCE CARE *1234 SHAVING AND PRECAUTIONS *1234 Use of Pressure and Friction Reduction Devices: SPECIAL BEDS/MATTRESSES *1234 HEELS AND ELBOW PROTECTION *1234 FOOT CRADLES *1234 Nutrition ESTIMATING INTAKE *1234 SETTING UP FOR MEALS *1234 ASPIRATION PRECAUTIONS *1234 NOURISHMENTS *1234 FEEDING PATIENTS *1234 COUNTING CALORIES *1234 FLUID RESTRICTION *1234 NPO *1234 RECORDING AND REPORTING NUTRITIONAL INFORMATION *1234 Care Routine New Admissions and Transfers: ROOM PREPARATION *1234 VS. HEIGHT AND WEIGHT *1234 INVENTORY AND DISPOSITION OF BELONGINGS *1234 ROOM ORIENTATION, CALL BELL *1234 BASIC COMFORT MEASURES *1234 PREPARING FOR AND EXPLAINING ROUTINES TO PATIENT *1234 POST MORTEM CARE *1234 Safety and Activity DETERMINING PATIENT ID *1234 IDENTIFYING/RESPONDING TO SAFETY HAZARDS *1234 DETERMINING NEED FOR ADDITIONAL HELP *1234 Recognizing Abuse: SUBSTANCE *1234 PHYSICAL *1234 EMOTIONAL *1234 MAINTAINING CLEAN , ORDERLY WORK AREA *1234 HANDLING HAZARDOUS MATERIALS *1234 PROPER BODY MECHANICS *1234 ROM EXERCISES *1234 TRANSFER TO BED, WC, COMMODE WITH OR WITHOUT DEVICE *1234 TURNING AND POSITIONING *1234 REPORTING BROKEN EQUIPMENT *1234 AMBULATING WITH OR WITHOUT DEVICE *1234 PATIENT SAFETY MODULE *1234 USE OF HOYER LIFT (DEXTRA/MAXI) *1234 BED OPERATION *1234 USE OF WHEEL LOCKS *1234 USE OF ALARMS (BED, PATIENT, UNIT) *1234 USE OF ALARMS (BED, PATIENT, UNIT) *1234 USE OF CALL LIGHT *1234 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: GLOVES *1234 GOWN *1234 MASK/GOGGLES *1234 PROTECTIVE/REVERSE ISOLATION *1234 BRODY SUBSTANCE ISOLATION *1234 TB PRECAUTIONS *1234 MRSA PRECAUTIONS *1234 HAND WASHING *1234 INFECTIOUS/HAZARDOUS WASTE DISPOSAL *1234 SUPPLY/EQUIPMENT DISPOSAL *1234 USE OF DISPOSABLE THERMOMETER *1234 USE OF CPR MASK/BAG *1234 DISPOSAL OF SHARPE *1234 Line Skills VENIPUNCTURE FOR SPECIMEN *1234 ADMINISTERING BLOOD AND BLOOD PRODUCTS *1234 IV Therapy Including: STARTING IV *1234 CHANGING IV SITES *1234 CHANGING IV DRESSINGS *1234 CHANGING IV TUBING *1234 ADMINISTERING FLUIDS ON CONTINUOUS IV PUMPS *1234 SETTING UP AND MONITORING PCA *1234 OBTAINING CENTRAL VENOUS/PERIPHERAL VENOUS BLOOD *1234 USING PICC, HICKMAN, TRIPLE LUMEN CATHS *1234 SET UP AND MONITORING FOR TPN *1234 CIMETIDINE (TAGAMET) *1234 DIAZEPAM (VALIUM) *1234 DIAZEPAM (VALIUM) *1234 DURAMORPH *1234 FUROSEMIDE (LASIX) *1234 HEPARIN *1234 INSULIN *1234 TERBUTALINE *1234 THEOPHYLLINE *1234 VERAPAMIL (CALAN) *1234 ORAL MEDICATIONS *1234 LORAZEPAM (ATIVAN) *1234 MORPHINE *1234 NALOXONE (NARCAN) *1234 NITROGLYCERINE *1234 PENTOBARBITAL *1234 PHENYTOIN (DILANTIN) *1234 POTASSIUM CHLORIDE *1234 TOPICAL MEDICATIONS *1234 Suppositories: VAGINAL *1234 RECTAL *1234 ORDERING MEDS *1234 Other Skills PROVIDING EDUCATION TO PATIENT FAMILY RELATED TO MEDICAL CONDITION, SELF CARE AND HEALTH CARE HABITS *1234 USING COMPUTERIZED TOOLS EFFECTIVELY *1234 Communication USING APPROPRIATE ABBREVIATIONS *1234 IDENTIFYING NEED FOR ALTERNATE COMMUNICATING MECHANISMS *1234 Communicating to Charge RN: CHANGES IN PATIENT CONDITION *1234 PATIENT NEEDS, COMPLAINTS AND CONCERNS *1234 UNUSUAL INCIDENTS *1234 REINFORCING RN TEACHING WITH PATIENT *1234 SELECTING AND USING FORMS APPROPRIATELY *1234 USING ALTERNATE COMMUNICATION TOOLS/DEVICES *1234 Unit Activity IDENTIFYING UNUSUAL INCIDENTS ON THE UNIT THAT REQUIRE REPORTING *1234 LOCATING AND USING APPROPRIATE REFERENCE MATERIALS *1234 COMPLETING RISK MANAGEMENT REPORTS AS NEEDED *1234 CHARGING FOR PATIENT CARE ITEMS *1234 OBTAINING NEEDED SUPPLIES AND EQUIPMENT *1234 USING TELEPHONE SYSTEM *1234 Miscellaneous Knowledge of Serum Lab Values Including: CHEM 7, CHEM 10 *1234 CBC *1234 SERUM DRUG LEVELS *1234 PAIN MANAGEMENT *1234 CARING FOR DRAINS/TUBES (I.E. HEMOVAC, PENROSE) *1234 MONITORING AND ASSESSING I & O *1234 PERFORMING COMPLEX DRESSING CHANGES *1234 ALERT CHARTING *1234 Additional Documents Use this section to attach the following: TB test, Covid Card, Social Security Card, CPR, Nursing License, & Physical Upload file(s) Drag and Drop (or) Choose Files 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 12/23/2024 Submit
