* = Required Information
PERSONAL INFORMATION   Date
Name (Last Name First) *
 Social Security no. *
Present Address *
 City *
 State *
 Zip Code *
Permanent Address
City
State
Zip Code
Phone no. *
 Referred by
 
EMPLOYMENT DESIRED
Position
Date you can start
Salary Desired
Are you employed? YesNo If so, may we inquire of your present employer? YesNo
Ever applied to this company before?
YesNo		 Where?
When?
 
EDUCATION HISTORY
Name & Location of School Years Attended Did you graduate? Subjects studied
Grammar School
High School
College
Trade, Business or Correspndence School
 
GENERAL INFORMATION
Subjects of special study/research
Work or special training/skills
U.S Military or Naval service
Rank
 
FORMER EMPLOYERS (List below last four employers, starting with last one first)
Date
Month and Year		 Name & Address of Employer Salary Position Reason for leaving
From
To
From
To
From
To
From
To
 
REFERENCES   Give below the names of three persons not related to you, whom you have known at least one year.
Name Address Business Years known
 
JOB DESCRIPTION
Fundamental Purpose at the Job:
The HHA is an employee trained to provide personal care and related services in the home for the sick or disabled when no family member can assume this responsibility. He/She functions under the directions, instruction and supervision of RN's, Supervisor and RN Director of Agency.
Essential Functions:
      1. Assists patient with personal care (which includes lifting and transferring patients without assistance) to preserve good personal hygiene while maintaining a healthful safe environment.
      2. Performs simple procedures as an extension of therapy services such as ambulation, ROM and exercise.
      3. Reports changes in patient's condition and needs to Supervisor.
      4. Completes appropriate records as required by agency policy.
      5. Establishes and maintains a good working relationship with patient/family and co-workers of the agency.
      6. Participates in patient care conference to provide input requiring patient's status.
      7. Understands and conforms to agency policy and procedure.
      8. Improves patient care through participation in ongoing education and QA activities as assigned.
Other Job Functions:
The above list reflects the essential functions and other job functions considered necessary of the job identified, and shall not be construed as a detailed description of all work requirements that may be inherent in the job, or assigned by supervisory personnel.
 
 
AUTHORIZATION
* “ I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
        I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
        I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
        This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”