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I understand before I can be considered for a position with Home Companions Senior Care
I must have met the following requirements:
Digital Finger Printing (within the last two years)
Current CPR Card (within the last two years)
Valid Florida Drivers License
Valid Florida Auto Insurance
Valid Auto Tag/Registration
Proof of Alzheimer's and Related Dementia training (within the last two years)
Proof of Assistance with Self-Administered Medication (within the last two years)
Proof of HIV/Aids training (within the last two years)
Proof of C.N.A. Training
Valid Florida C.N.A. License
Proof of Home Health Training
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I am applying for a position of:
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Certified Nursing Assistant/HHA
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Application Date:
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Applicant Name:
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Social Security #
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Applicant Email Address:
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Applicant Cell Number:
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Applicant Telephone:
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Applicant Physical Address:
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include: city, state, zip code
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Applicant Mailing Address:
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include: city, state, zip code
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Background Checks
Home Companions of Lake County Inc, conducts a thorough background investigation and employment
screening process on all applicants being considered for employment, including, but not limited to,
employment and personal references, FDLE, MVR, education, certifications, licenses and court records. We
reserve the right to utilize this information in any way deemed necessary to make a final determination of
employment.
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Yes
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No
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Have you ever been arrested?
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Have you been convicted of a felony?
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No
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Yes
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Are you a citizen of the United States?
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No
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Yes
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Are you an alien with legal work status?
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Yes
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No
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Education and Skills related to position you're applying for:
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Technical School Name and Location Year (s) Attended Certificate/ Degree Florida License#
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Activities of Daily Living Skills:
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Bathing Dressing Eating Toileting Continence Ambulation
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Instrumental Activities of Daily Living Skills:
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Cook/Serve a Meal Doing Laundry Grocery/Household Shopping Vacuuming Dusting Driving Set Appts
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Grooming and Hygiene Skills:
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Mouth Care Brushing Teeth Soak/Clean Dentures Shampoo Hair File Nails Foot Bath Moisturize Skin
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Functional and Cognitive Impairment Skills:
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Diversion Techniques Distraction Technique Social and Recreation Activity Skills
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Essential Clinical Skills:
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Blood Pressure Pulse: Apical Radial Temperature: Oral Axillary Respirations Range of Motion
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Adaptive Aids and Mobility Equipment
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Crutches, Cane, Quad Cane, Walker, Wheelchair, Power Chair, Hearing Aids, Leg Prosthesis, Hoyer Lift
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Driving and Transportation is a task that may be required to drive a client in their car or your car to
a medical appointment or other essential errands such as: shopping, to the bank or post office.
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Do you agree to this requirement?
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Yes
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No
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Do you have a reliable vehicle?
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No
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Yes
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Employment History last position held related to the position applying for:
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Name of Employer:
Direct Supervisor:
Date Employment Stated:
Position Held:
Responsibilities:
Date Employment Ended:
Reason for Leaving:
May we contact for reference:
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No
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Yes
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Using the simple 'click' box, click the box next to the
week day; select the time you would like to work.
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Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
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Comments:
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