EMPLOYMENT APPLICATION

Acclaim Home Care Services, LLC

www.AcclaimHomeCareServices.com | Equal Opportunity Employer

1
Personal Information
2
Education & License
3
Clinical Skills & Experience
4
References & Compliance
5
Availability & Final Submission

Personal Information

Position Applied For
Personal Information
To help the hotelier to welcome you

Education & License

Education Qualification
Professional Licenses & Certifications
Clinical Skills & Areas of Expertise

Check all that apply and indicate proficiency: E = Expert, P = Proficient, F = Familiar, N = No Experience

EPFN
Head-to-Toe Assessment
Neurological Assessment
Cardiovascular Assessment
Respiratory Assessment
Wound / Skin Assessment
Pain Assessment
Nutritional Assessment
OASIS Assessment, Start of Care
OASIS Re-Assessment / ROC
OASIS Discharge Assessment
Fall Risk Assessment
Functional Assessment
EPFN
Simple Wound Care / Dressing Changes
Complex Wound Care
Debridement
Negative Pressure Wound Therapy (NPWT/VAC)
Compression Therapy
Ostomy Care
Pressure Injury Prevention & Treatment
Surgical Wound Care
Burns Management
EPFN
Peripheral IV Insertion
IV Push Medications
IV Piggyback Administration
Central Line Care / PICC Line
Port-A-Cath Access
TPN / Lipid Administration
Antibiotic Infusion
Chemotherapy Infusion (Chemo Certified)
IV Pain Management
EPFN
Oxygen Monitoring
Nebulizer Treatments
Tracheostomy Care
Trach Tube Care
Ventilator Management
Chest Physiotherapy
Tube Care & Maintenance
BiPAP / CPAP Maintenance
EPFN
Cardiac Monitoring
12 Lead ECG
Telemetry Care
Defibrillator Use
Antiarrhythmia Agent
CHF Management
Arrhythmia Monitoring
EPFN
Medication Reconciliation
Oral / Sublingual Medications
Injection Medications (IM/SC)
Insulin Administration & Sliding Scale
Insulin Pump Management
Controlled Substance Management
Patient / Caregiver Medication Education
EPFN
Diabetes / Insulin Management
Hospice / Palliative Care
Pediatric / Newborn Health
Adult Care / Geriatric Care
Oncology Nursing
Orthopedic / Post-Surgical Rehab
Neurological / Stroke Rehab
Renal / Dialysis
Dementia / Alzheimer's Care
Pain Management
EPFN
Physical Therapy Assessment
Occupational Therapy Assessment
Speech-Language Pathology
Home Exercise Work
Patient / Nutritional Counseling
Home Health Aide Supervision
EPFN
Electronic Health Records (EHR)
OASIS / HCHB Software
Epic
Homecare Homebase (HCHB)
Access
WellSky / Kinnser
MatrixCare
CPR & Safety Certifications

Clinical Skills & Experience

Employment History

List most recent employer first. Home health / clinical experience should be listed separately if applicable.

Employer #1
Home Health & Skilled Nursing Experience

Tell us about your home health and clinical nursing experience.

Home Health Software Experience

References & Compliance

Professional References

List three (3) professional references. Do not list family members. At least one reference must be a direct supervisor or clinical colleague.

Reference #1
Reference #2
Reference #3
Compliance, Background & Health Screening

Please answer each compliance question carefully.

Health Screening Information

Availability & Final Submission

Availability

Select all shifts you are available for each day of the week.

DaysEveningsNightsOn-CallNot Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Additional Information

Help us learn more about you and how you found us.

Languages Spoken (other than English)

Applicant Certification & Authorization

I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that false or misleading information or omissions may disqualify me from further consideration for employment and may result in immediate termination if discovered after hire.

I authorize Acclaim Home Care Services, LLC to verify all information provided herein, including contacting former employers, educational institutions, licensing boards, and references. I consent to a background investigation and drug screening as required. I understand that employment with Acclaim Home Care Services is at-will and may be terminated by either party at any time.

I acknowledge receipt of and agree to abide by Acclaim Home Care Services policies, including HIPAA privacy policies, infection control standards, and all applicable federal and state home health regulations.

Electronic Signature

PDF, DOC, DOCX, JPG, or PNG (max 10MB)