(734) 667-5587
(734) 738-6593
info@apexhhc.com
Facebook-f
Linkedin-in
Google
Instagram
Quick Inquiry
Home
About
Services
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Therapy
Social Worker
Home Health Aide
Blog
Careers
Service Areas
Contact
Home
About
Services
Skilled Nursing Care
Physical Therapy
Occupational Therapy
Speech Therapy
Social Worker
Home Health Aide
Blog
Careers
Service Areas
Contact
Schedule Appointment
Application for Employment
Step
1
of
5
20%
Phone
This field is for validation purposes and should be left unchanged.
Personal information
Name
(Required)
Date
MM slash DD slash YYYY
Address
Phone
Email
Engagement Desired
Full-time
Part-time
Which days and hours are you able to work
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Hours
Language Skills
Are you employed now?
If so, may we contact your present employer?
Yes
No
Have you ever been convicted of a felony in the past 7 years?
Yes
No
Such a conviction may he relevant if related but it does not bar you from employment If yes -explain
Education
Currently Attending
Name and location Of School
# of years Completed
Did you Graduate?
Subjects Studied
Currently Attending
Name and location Of School
# of years Completed
Did you Graduate?
Subjects Studied
Do you Have any professional licenses or certifications
HHA
CNA
LPN
RR
Other
Summarize any special skills and qualifications you acquired through emplovment or other experiences that may qualify you to work with this company
Employment History
Name and Address of Employer
Phone
Job
Date Month and Year
Reason for Leaving
Name and Address of Employer
Phone
Job
Date Month and Year
Reason for Leaving
References: Give the names of 3 persons not related to you as professional references
List
Name
Address
Phone
Years Known
Add
Remove
In case of Emergency, notify
Phone
Relationship
Address
Conditions of Engagement - please read carefully (Initial)
Reporting to work with impaired abilities or the possession, consumption, or distribution of drugs or alcohol at worksites shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the employee to agree to physical examination and/or substance testing. Violations of our drug and alcohol policy will result in termination of employment. The employee handbook will be read carefully upon start of employment
It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or cancelation of employment.
I give Apex Home Healthcare the right to investigate all police, driving, and personal records and references if they are contract-related. I hereby release Apex Home Healthcare and its representatives from liability for seeking such information and all other people, corporations, or organizations for furnishing it. Pink Heart Home Healthcare Agency is an Equal Opportunity Employer and does not discern innate in employment or contract. No question on this application is used to limit or excuse any applicant's consideration for a contract on a basis prohibited by local, state, or federal law.
Ideally, I will give Apex Home Healthcare a written notice at least fifteen (15) days before voluntary separation. Pink Heart Home Healthcare Agency recognizes that you retain the option, as does Pink Heart Home Healthcare Agency, of ending your employment with Apex Home Healthcare at any time, with or without notice, and with or without cause. As such, your employment with Pink Heart Home Healthcare Agency is at will, and neither this letter nor any other oral or written representations may be considered a contract for any specific period.
The pay rate will be defined in the letter of employment offer. By Department of Labor rules, overtime payments are applicable for hours worked over forty per week at one and one-half times your regular pay rate. Additionally, as an employee, you are covered under Worker's Compensation Insurance
This application is current for 60 days. At the end of this time, if I have not heard from the company and still wish to be considered for employment, I will need to fill out a new application.
Signature
Date
MM slash DD slash YYYY
Background Check Consent & Sworn Statement Form
Print Name
Date of Birth
MM slash DD slash YYYY
SSN
I leave with no prior convictions of an offense described in 32. 1-1.62.9: 1 code or Virginia (Barrier C rinses), which could potentially bar employment.
I understand that, based on Virginia Department of Health regulations, the agency is required to conduct a criminal history check before entering into any agreement or providing an employment offer.
I, the undersigning, authorize Pink Heart Home Healthcare Agency to conduct and verify my criminal history by performing a criminal history check.
Signature
Date
MM slash DD slash YYYY
Provide personal care service to the client who needs physical assistance. Some examples of personal care are listed below:
• Follow the Caregiver Service Plan (CSP) to perform the agreed-upon tasks.
• Arbitration - physically assisting a patient who otherwise would be unable to move about independently
• Eating includes hand-feeding a patient who is incapable of self-feeding
• Personal hygiene - which includes bathing the patient
• Dressing - physically applying. patient's clothing to the patient's body
• Toileting assisting a patient in going to and from toileting facilities and in toileting activities.
• Provide competent, state-of-the-art care to its patients
• For security reasons, the caregiver should not disclose or knowingly permit the disclosure of any information in a client record except to appropriate provider staff, the client, the responsible party, the client's physician or other health care provider, the regulatory department, and other individuals authorized by the client in writing or by subpoena.
• In case of an emergency at a client's home, the caregiver must immediately contact the client's emergency contact name and notify the Pink Heart Home Healthcare Agency.
• Any request for leave should be submitted at least two weeks before the date of unavailability
The caregiver must notify the Pink Heart Home Healthcare Agency and the client's responsible party of any changes in the client's condition. The caregiver is encouraged to report to the office any changes that may improve the quality of care a patient is receiving.
I have read and understand the above and the job description, and I am ready to comply with this agreement.
Signature
Date
MM slash DD slash YYYY
File
Drop files here or
Select files
Max. file size: 512 MB.
CAPTCHA
Quick Inquiry
Instagram
This field is for validation purposes and should be left unchanged.
Name
(Required)
Phone
(Required)
Email
(Required)
Message Us:
CAPTCHA
Schedule Consultation
Name
This field is for validation purposes and should be left unchanged.
Name
(Required)
Phone
(Required)
Email
(Required)
Best Time to Call:
Morning
Afternoon
Evening
Message Us:
Automated page speed optimizations for fast site performance
