Thank you for your interest in Coastal Home Care! We are a licensed home care agency with over 30 years’ experience assisting individuals with the activities of daily living. If you are a caregiver, you’ve come to the right place! Coastal Home Care is hiring licensed RNs, LPNs and certified CNAs. If you are not licensed but have a minimum of two years’ caregiving experience, you can take the State of Georgia Personal Care Aide (PCA) exam at your closest Coastal Home Care branch office. You must pass the exam with an 80% or better score. Please note that in order to be a Coastal Caregiver, you must have a working phone, reliable transportation, a clean background, acceptable Motor Vehicle Report and provide two professional references. Coastal Caregivers work with the aged, blind and disabled. Experience working with individuals with developmental disabilities is a plus. Please complete the following application and deliver to your closest Coastal Home Care branch office. We have offices in Barnesville, Brunswick, Hinesville, Savannah and Statesboro, Georgia. You can find detailed information about offices on our Locations tab. We look forward to meeting you! 800.617.1126 www.CoastalHomeCare.us COASTAL HOME CARE STATEMENT OF NO ABUSE Employee Name: Date: I certify by my signature below that I have never abused, neglected, sexually assaulted, exploited, or deprived any person or subjected any person to serious injury as a result of intentional or grossly negligent misconduct. Signature Date ____________________________________ Witness ________________________ Date Macintosh HD:Users:preston:Desktop:Coastal Home Care:Statement of No Abuse.doc PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE NOTICE TO APPLICANT AND EMPLOYEES Screening tests for alcohol and illegal drug use may be required before hiring and/or during your employment. GENERAL INFORMATION – Please list any other names by which you may have been known, such as a maiden name. Name Address Last: First: MI: SS#: Street: City: State: Zip Code: How long at address listed above? years months Applying for what position? Phone Number:: Salary/Wage expected: Email Address: Alternate phone number: Preferred method of Contact: Applying for:  full time  part time st nd Are you willing to work any day(s), shift(s), including nights, or overtime as rd  1 shift  2 shift  3 shift assigned?  Yes  No Have you ever worked for Coastal Home Care or Altrus, Inc.?  Yes  No If yes, please indicate in the Employment History section Do you have relative and/or members of your household who are employed by Coastal Home Care or Altrus, Inc.?  Yes  No If yes, please explain. __________________________________________________________________________________________________________________ Have you ever worked with individuals who have mental retardation or developmental disabilities and/or the elderly?  Yes  No If yes, please explain. __________ _____________________________________________________________________ Are you age 18 or older?  Yes  No Referral  Advertisement  Web Posting  Agency If not, do you have a work permit?  Yes  No Source  School  Employee  Walk-‐in If hired, can you provide proof that you  Job Fair  Internal Employee are eligible to work in the United States?  Yes  No  Other Have you ever been convicted of a criminal offense?  Yes  No (Record of charges or convictions do not necessarily disqualify Have you ever been convicted of a felony? Misdemeanor?  Yes  No applicant from employment consideration. Criminal record Are there any charges pending against you?  Yes  No checks may be required as a condition of your employment) If yes to either question, provide details including nature of the crime, dates, and location: REFERENCES: List Name, Address, Contact Number of 3 BUSINESS OR PROFESSIONAL references or former supervisors) EDUCATION & TRAINING INFORMATION School/Location Degree Course/Major High School: College(s): Graduate School: Business/Vocation: Apprentice training or other courses: LICENSES, CERTIFICATES, OR PROFESSIONAL MEMBERSHIPS: (Do not include your driver’s license) EMPLOYMENT HISTORY (Please begin with your most recent employer. Attach additional sheets if necessary) 1. Employer: Hire Date: Termination Date: Address: Phone Number: ( ) Your job title: Supervisor: Starting Pay Rate: $ Final Pay Rate: $ May we contact your employer?  Yes  No Describe work performed: Reason for leaving: 2. Employer: Hire Date: Address: Phone Number: ( ) Your job title: Supervisor: Starting Pay Rate: $ Final Pay Rate: $ May we contact your employer?  Yes  No Describe work performed: Reason for leaving: 3. Employer: Hire Date: Address: Phone Number: ( ) Your job title: Supervisor: Starting Pay Rate: $ Final Pay Rate: $ May we contact your employer?  Yes  No Describe work performed: Reason for leaving: Termination Date: Termination Date: MILITARY INFORMATION Service branch: Final Rank: Specialty: Current obligations: CERTIFICATION & AGREEMENT I certify that I have never abused, neglected, sexually assaulted, exploited, or deprived any person nor I have I subjected any person to serious injury as a result of intentional or grossly negligent misconduct. I authorize the release to Coastal Home Care, Inc. (and/or any of its licensed agents) of information held by any parties regarding my previous employment, criminal history record and/or record of convictions in state and local files for violations of any federal, state, local statutes or ordinances, military records, credit history, driving record and scholastic records and hereby release said persons, schools, companies, government agencies, court and law enforcement authorities from any damage whatsoever for releasing this information. I certify that all the information I have provided on this application is true and accurate. I understand that misstatements, omissions, or false or misleading statements which I have provided on this application, on my resume and/or in interview(s) shall constitute grounds for refusal to hire or immediate termination from employment. I understand that the terms and conditions of employment may be changed at any time without notice by the company. In consideration of employment with CHC, I agree to comply with all the policies, procedures and requirements of CHC. I understand this application and/or any CHC policy, manual, handbook or other written document describing such items do not constitute a written contract at this time or in the future. I understand my employment would be at-‐will and that my employment could be terminated at any time by either party, with or without cause and with or without notice. Any modification of the at-‐will employment relationship, oral or written, can only be accomplished by a written document signed by Coastal Home Care’s Chairman/President, CEO, or Board of Directors. I have read and understand the above. _______ Applicant’s Signature Date This employment application is current for sixty (60) days. If you have not heard from us and still wish to be considered for employment, it will be necessary for you to fill out a new application. APPLICANT SHOULD NOT WRITE BELOW THIS LINE Interviewed by: Date: Recommended action: Interviewed by: Date: Recommended action: Revised 01/2012 X:\ADMINISTRATION\Human Resources\Hiring Process-‐ Caregivers\Caregiver Application -‐ Part 1 Coastal Home Care Applicant Information Sheet Applicant Name:____________________________________________ Please put a check mark next to the areas you are able and willing to work: ________ Savannah/Chatham County: Downtown, Islands, Southside, Westside, Pooler, Bloomingdale, Garden City, Port Wentworth ________ Effingham County: Rincon, Springfield ________ Bryan County: Richmond Hill, Pembroke ________ McIntosh County: Darien ________ Liberty County: Hinesville, Midway, Walthourville ________ Glynn County/Golden Isles: Brunswick, St. Simons, Jekyll Island ________ Camden: St. Marys, Kingsland, Woodbine ________ Charlton County: Folkston ________ Ware County/Waycross ________ Long County/Ludowici ________ Wayne County/Jesup ________ Barnesville and surrounding counties (Butts, Henry, Lamar, Monroe, Pike, Upson, Spalding) Which days and hours are you able and willing to work? Hours available for CHC Not available to work for CHC Monday Tuesday Wednesday Thursday Friday Saturday Sunday Are you a PCA (Personal Care Assistant) or CNA? ____ How many years of experience do you currently have? _____ Do you have Hoyer Lift Experience? _____ Yes _____ No If no, would you like additional training? ______ Do you have any pet restrictions? ______Yes _____ No If yes, please list the pet/s ______________________________ Do you have a preference working with male/female clients? _____ Yes Preference ____ No Preference If you check yes, please list which client you would prefer to work with __________________________ Would you be comfortable working in a home where the client or family members smoke? ___ Yes ___ No My signature on this form indicates that I agree to work the above following shifts/days. I understand that I can stay as busy as I would like to stay as long as my work ethic complies with Company policy. In the event that I accept a case/s and I do not show up, I will be immediately terminated and will not be eligible for re-hire with any other Coastal Home Care Services Agency. I also agree to give a two week notice before resigning and I understand that if I do not give proper notice and work the schedule that I agreed to, I will not be eligible for re-hire and I will be terminated. No exceptions. I understand that one of the requirements for this position, will be to work at least two shifts, two weekends per month. Signature: _____________________________________ Date: ____________________ Contact Info: Home _________________ Cell___________________ Email address: ____________________________________________________ What area do you currently live in including the zip-code? _______________________________________ NURSING ASSISTANT SKILLS ASSESSMENT Please check if you have performed and can adequately demonstrate the following: VITAL SIGNS ___ORAL TEMPERATURE ___RECTAL TEMPERATURE ___PULSE ___RESPIRATION ___BLOOD PRESSURE PERSONAL HYGIENE ___BED BATH ___SPONGE BATH ___TUB BATH ___SHOWER SKIN CARE ___BACK RUB ___SIMPLE DRESSING CHANGES ___POSITIONING TO RELIEVE PRESSURE AREAS ___WASH WITH SOAP/WATER MOUTH CARE ___BRUSH TEETH ___BRUSH DENTURES ___MOUTH CARE FOR UNCONSCIOUS PATIENT HAIR CARE ___SHAMPOO/COMB ___USE OF SHAMPOO TRAY NUTRITION ___SIMPLE MEAL PREPARATION ___OFFERING FLUIDS TO PATIENTS ___MEASURING INTAKE /OUTPUT ___FEEDING PATIENTS W/CHEWING & SWALLOWING PROBLEMS ___ G-‐TUBE FEEDINGS SHAVING ___WITH ELECTRIC RAZOR ___WITH SAFETY RAZOR NAIL CARE ___SOAK & FILE TOENAILS ___CLEAN & FILE FINGERNAILS ASSIST WITH CLOTHING ___BEDBOUND PATIENT ___WHEELCHAIR PATIENT BODY MECHANICS ___USE OF TRANSFER BELT ___RANGE OF MOTION EXERCISE ___“STAND BY” AMBULATION ___ASSISTING W/CANES ___ASSISTING W/ WALKERS ___ASSISTING W/CRUTCHES BED POSITIONING ___SIDE LYING ___PRONE (BACK LYING) ___USE OF TROCHANTER ROLLS USE OF DRAWSHEEET BEDMAKING ___UNOCCUPIED ___OCCUPIED HOUSECLEANING ___LAUNDRY ___ HOME CLEANING ___GROCERY SHOPPING URINARY ___USE OF REGULAR BED PAN ___USE OF FRACTURE BED PAN ___USE OF URINAL/MALE CATHETER ___FOLEY CATHETER-‐EMPTY BAG ___CLEANING PERINEUM AT CATHETER INSERTION POINT ___CARE/CHANGING OF OVERNIGHT DRAINAGE BAG ___CONDOM CATH-‐EMPTY BAG CARE/CHANGING OF LEG BAG ___APPLICATION OF CONDOM CATHETER BOWEL ___COLOSTOMY CARE-‐EMPTY BAG ___SOAPSUDS ENEMA ___TAPWATER ENEMA ___FLEETS ENEMA ___USE OF PORTABLE COMMODE ___BOWEL PROGRAM FOR QUADRIPLEGIC TRANSFERS ___TO/FROM BATH BENCH ___TO/FROM WHEELCHAIR ___TRANSFER BOARD ___HOYER LIFT MISCELLANEOUS ___BASIC COMMUNICATION ___ACTIVE LISTENING ___ASSIST W/OXYGEN NASAL PRONGS ___UNIVERSAL PRECAUTIONS ___CPR ___FIRST AID AGE SPAN AND SPECIALTIES ___PRENATAL ___POSTPARTUM ___NEWBORN/INFANCY ___CHILDREN ___ADULTS ___GERIATRICS ___DEVELOPMENTALLY DISABLED ___BRAIN INJURED ___QUADRIPLEGIA/PARAPLEGIA APPLICANT REFERENCE CHECK Source of reference:  Written Applicant Name: LAST FIRST  Telephone Social Security: MI Business Name/Location: ________________________________________________________________________________ Supervisor Name/Title: _______________________________________________Phone #(s): __________________________ Address:__________________________________________________________ Fax/e-mail:__________________________ Applicant Title:________________________ Brief Description of Job:_____________________________________________ Employment Dates: to Earnings: $ hourly/biweekly (circle one) I authorize the release to Coastal Home Care (and/or any of its licensed agents) of information held by any parties regarding my previous employment and hereby release said persons, schools, companies, government agencies, court and law enforcement authorities from any damage whatsoever for releasing this information. Applicant signature: Date: REFERENCE TO COMPLETE BELOW THIS LINE The individual above has applied for the position of with Coastal Home Care. So as to comply with good employment practices, we ask that you furnish the information requested below. Any and all information will be held in the strictest confidence and not divulged to the applicant. Your reply is greatly appreciated. Coastal Home Care Representative: Date: ___________________________ Please check the boxes that best describe applicant's performance Excellent Good Satisfactory Unsatisfactory Unable to evaluate Quality of work Attendance record Dependability Working relationship with other employees Working relationship with clients Skills related to the job ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ Are the above employment dates correct? ¨ Yes ¨ No If no, please provide correct dates: to Reason for separation: Are the above stated earnings correct? ¨ Yes ¨ No If not, correct amount is $ . Would you rehire this individual? ¨ Yes ¨ No If no, why not? Do you recommend this applicant for employment? ¨ Yes ¨ No Are you aware of any incident for which this individual was convicted of having abused, neglected or mistreated an individual? If yes, please provide date(s) and circumstance(s) on an attachment. Additional comments: Signature Title Date PERSONAL CARE ASSISTANT Job Description Job Summary: The Personal Care Assistant (PCA) is responsible for the client’s personal care needs and surroundings and may supply temporary relief (respite) for the client’s primary caregiver. The PCA provides care in the home, in a hospital, or in a nursing home. The PCA is also referred to as a nursing assistant, respite care worker, or personal support aide. ALL EMPLOYEES MUST never have been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by this written statement to this effect Qualifications: The Personal Care Assistant must have one of the following: • • • • Certification as a CNA on the Georgia State Registry. Credentials indicating successful completion of a health care or personal care credentialing program. Successful completion of a 40-hour training program provided by a private home care provider. Successful completion of a competency exam. Performance Requirements: The Personal Care Assistant must be able to: • • • • Lift and/or transfer clients without restrictions. Must be able to lift at least 30 lbs. Show patience and respect in dealing with sick, elderly, or disabled clients. Work under close supervision of agency staff and cooperate with the client’s family and staff from other agencies involved in the client’s care. Maintain CPR and First Aid certification and annual TB screening. Essential Job Functions: The PCA follows the care plan established for the individual client. This care plan may include any or all or the following: • • • • • • Activities of Daily Living assistance including personal care needs, meal preparation, and assistance with eating. Personal Care needs may include giving or assisting with bath or shower, dressing, grooming, toileting, ambulating, and transferring from bed to chair or other locations. Routine housekeeping chores including: laundry, changing bed linens, dusting, washing dishes, vacuuming, and other light household duties. Errands as necessary and directed by supervisor. Serve as companion to client and/or provide temporary relief to caregiver. Provision of specialized client care as instructed by the supervisor and as evidenced by documentation of training. Communicate to CHC the client’s needs and any changes in the client’s status through written documentation and verbal communication. I have read this job description, and I can meet the position’s qualifications, performance requirements, and essential job functions. Signature _________________________________________________________ Date ___________________ X:\ADMINISTRATIVE ITEMS\Human Resources\Hiring Process-Caregivers\Caregiver Application - Part 1\PCA Job Description.docx