Careers

STAFF NAME *

Date

APPLICATION INFORMATION

First Name

Middle Name

Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Email Address

DATE AVAILABLE

SOCIAL SECURITY NUMBER

DESIRED SALARY

POSITION APPLIED FOR

ARE YOU A CITIZEN OF THE UNITED STATES?

HAVE YOU EVER WORKED FOR THIS COMPANY?

HAVE YOU EVER BEEN CONVICTED OF FELONY?

EDUCATION

HIGH SCHOOL

HIGH SCHOOL COMPLETION

DID YOU GRADUATE?

DEGREE

Street Address

COLLEGE SCHOOL

COLLEGE SCHOOL COMPLETION

DID YOU GRADUATE?

DEGREE

Street Address

OTHER SCHOOL

OTHER SCHOOL COMPLETION

DID YOU GRADUATE?

DEGREE

Street Address

REFERENCES

First Name

Middle Name

Last Name

RELATIONSHIP

COMPANY

Phone

Street Address

First Name

Middle Name

Last Name

RELATIONSHIP

COMPANY

Phone

Street Address

First Name

Middle Name

Last Name

RELATIONSHIP

COMPANY

Phone

Street Address

PREVIOUS EMPLOYMENT

COMPANY

Street Address

Phone

JOB TITLE

RESPONSIBILITIES

SUPERVISOR

STARTING SALARY

ENDING SALARY

REASON FOR LEAVING

COMPANY

Street Address

Phone

JOB TITLE

SUPERVISOR

RESPONSIBILITIES

STARTING SALARY

ENDING SALARY

REASON FOR LEAVING

COMPANY

Street Address

Phone

JOB TITLE

SUPERVISOR

RESPONSIBILITIES

STARTING SALARY

ENDING SALARY

REASON FOR LEAVING

MILITARY SERVICE

BRANCH

FROM

RANK OF DISCHARGE

TYPE OF DISCHARGE

DISCLAIMER AND SIGNATURE

DISCLAIMER AND SIGNATURE *I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

NAME *

DATE

EMPLOYEE HEPATITIS B VACCINE RECORD/WAIVER

EMPLOYEE HEPATITIS B VACCINE RECORD/WAIVERI was vaccinated for Hepatitis B (HBV) in the past. Below are the dates of my vaccination:

1st Dose

2nd Dose

3rd Dose

APPLICANT NAME

DATE

HEPATITIS B VACCINE VERIFICATION DECLINATION

HEPATITIS B VACCINE VERIFICATION DECLINATIONt’s my choice to decline this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infections material and I choose to be vaccinated for Hepatitis B, I will receive the vaccine.

I have the option to wave Hepatitis B vaccine.

Date

REPRESENTATIVE NAME

Date

TUBERCULOSIS

NAME

Date

ADDRESS

CITY

STATE

ZIP CODE

MEDICAL INFORMATION

PHYSICIAN NAME

ALLERGIES

PPD TEST

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CHEST X-RAY

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NAME

Date

VERIFICATION OF PREVIOUS EMPLOYMENT

APPLICANT NAME

Date

POSITION APPLYING FOR

VERIFICATION OF PREVIOUS EMPLOYMENTI hereby authorize Divine Home Care LLC To verify my previous employment and my previous employer to supply the information requested. My Signature allows a photocopy of this authorization to be substituted as original.

APPLICANT NAME

Date

CHARACTER REFERENCE VERIFICATION

Name

First Name

Middle Name

Last Name

PERMANENT ADDRESS

CITY

STATE

ZIP CODE

DAYTIME PHONE

EVENING PHONE

CHARACTER REFERENCE

NAME

TELEPHONE NUMBER

ADDRESS

DATE CONTACTED

STAFF RESPONSIBILITIES

COMMENTS

CHARACTER REFERENCE

NAME

TELEPHONE NUMBER

ADDRESS

DATE CONTACTED

STAFF RESPONSIBILITIES

COMMENTS

CHARACTER REFERENCE

NAME

TELEPHONE NUMBER

ADDRESS

DATE CONTACTED

STAFF RESPONSIBILITIES

COMMENTS

SKILLS ASSESSMENT TEST

SKILLS ASSESSMENT TESTPlease check the appropriate box next to each question. Candidates must achieve a rating of 90% or better to qualify for employment.

1) PERSONAL CARE IS PROVIDING HANDS-ON ASSISTANCE TO SOMEONE WHO IS NOT ABLE TO PERFORM HIS OR HER DAILY ROUTINES BECAUSE OF A PHYSICAL DISABILITY OR HANDICAP.TrueFalse

3)PERSONAL CARE OR ATTENDANT CARE SERVICES ALSO INCLUDE THE PERFORMANCE OF DELEGATED NURSING DUTIES.TrueFalse

2) BATHING IS INCLUDED IN ACTIVITIES OF DAILY LIVING.TrueFalse

4) TOILETING RELATES TO BLADDER AND BOWEL REQUIREMENTS, BEDPAN ROUTINES, MOVEMENT TO AND FROM BATHROOM.TrueFalse

5) CAREGIVERS ARE NOT REQUIRED TO REPORT CASES OF SUSPECTED ABUSE.TrueFalse

6) DRESSING AND CHANGING CLOTHES ARE CONSIDERED DAILY LIVING ACTIVITIES.TrueFalse

7) ALL CERTIFIED NURSING ASSISTANCE (CNA) ARE PERMITTED TO ADMINISTER MEDICATIONS.TrueFalse

8) A CNA IS NOT ALLOWED TO PROVIDE CATHETER CARE.TrueFalse

9) MOBILITY - TRANSFERRING FROM A BED, CHAIR, OR OTHER STRUCTURE AND MOVING ABOUT INDOORS AND OUTDOORS.TrueFalse

10) MOVING - TURNING AND POSITIONING THE BODY WHILE IN BED OR IN A WHEELCHAIR.TrueFalse

REQUEST TO WAIVE PERSONAL ASSISTANCE QUALIFICATIONS FOR AGENCY EMPLOYEE PROVIDERS

REQUEST TO WAIVE PERSONAL ASSISTANCE QUALIFICATIONS FOR AGENCY EMPLOYEE PROVIDERSDivine Home Care LLC may choose to waive, upon the request of a participant certain provider's qualifications/requirements otherwise outlined in the Mayland Code of Regulations (COMAR 10.07.05)

DIVINE HOME CARE LLC WORKER/CAREGIVER

Name *

CLIENT NAME *

MEDICAL ASSISTANCE NUMBER *

DELEGATING NURSE NAME *

Date

CLIENT REPRESENTATIVE NAME *

Date

CERTIFICATION (CHECK ALL THAT APPLY)

All of the above

LPN

GNA/CNA

CMT

Other

OTHER

Please attach photocopies of the following:

DRIVERS LICENSE

No file chosen

COPY OF SOCIAL SECURITY CARD

No file chosen

EMPLOYMENT AUTHORIZATION/ELIGIBILITY

No file chosen

CPR CERTIFICATIONS (IF ANY)

No file chosen

PROFESSIONAL LICENSE (IF ANY)

No file chosen

FIRST AID CERTIFICATE(IF ANY)

No file chosen

BLS UNRESTRICTED PROFESSIONAL LIC (IF ANY)

No file chosen

CRIMINAL BACKGROUND CHECK USING CJIS

No file chosen

PHYSICAL EXAMININATION AND TUBERCULOSIS

No file chosen

HEPATITIS B

No file chosen

MESSAGE

Join our compassionate and dedicated team. Please fill out the needed information below.

APPLICATION INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

DISCLAIMER AND SIGNATURE

EMPLOYEE HEPATITIS B VACCINE RECORD/WAIVER

HEPATITIS B VACCINE VERIFICATION DECLINATION

TUBERCULOSIS

MEDICAL INFORMATION

VERIFICATION OF PREVIOUS EMPLOYMENT

CHARACTER REFERENCE VERIFICATION

CHARACTER REFERENCE

CHARACTER REFERENCE

CHARACTER REFERENCE

SKILLS ASSESSMENT TEST

REQUEST TO WAIVE PERSONAL ASSISTANCE QUALIFICATIONS FOR AGENCY EMPLOYEE PROVIDERS

DIVINE HOME CARE LLC WORKER/CAREGIVER

CERTIFICATION (CHECK ALL THAT APPLY)

Please attach photocopies of the following: