Home Health Care Jobs | Just Like Family Home Health

Personal Information

Your Name*

First Last

Your Email Address*

Enter Email Confirm Email

Your Home Address*

Street Address Unit / Suite Number City State Zip Code

Maiden Name

Date of Birth (Optional)

Cell Phone*

Home Phone

Referred By

Application Date*

Questionnaire

How did you hear about Just Like Family?*

Do you have a high school diploma or G.E.D.?*

Have you ever been convicted of a felony or misdemeanor, or do you have any pending charges against you?*

If yes, what were the charges?*

Have you ever worked for an agency?*

If yes, where?

What type of work are you expecting from Just Like Family?*

If other, please describe.

We require everyone to work at least two weekends per month. Is this acceptable to you?*

Traveling to and from clients' homes is required. Do you have reliable transportation?*

Car/Insurance
Bus
Rides

How far are you willing to travel?*

There are times when you will be required to run errands or take clients to appointments. Will you be able to do this?*

Do you have a home phone/answering machine?*

Are you willing to work at a lower skill level if work is not presently available at your level?*

RN as LPN
RN as CNA
RN as PCA
LPN as CNA
LPN as PCA
I am applying for a PCA position

We sometimes offer shifts on short notice. Will that be a problem?*

Sometimes we must transfer heavy clients. How do you feel about that?*

Would you be willing to get a flu shot, as required by some facilities?*

Many of our clients have animals in their home. Do you have any issues working in a home where animals are present?*

If yes, please specify.

Employment Information

Nursing Title*

Where did you receive your license or certification?

Date of receiving license or certification.

License or certification number

State

Expiration Date

Private Duty Nursing

Nursing Home

Charge Nurse

Supervisor

List any special qualifications and/or certifications.

Do you have a valid driver's license?*

License #

PA resident since*

Year and make of your auto.

Who is your auto insurance carrier?

Inspection Expiration Date

Have you ever been convicted of a felony or misdemeanor?*

If yes, please provide details.

Why do you want to work for Just Like Family Home Health Care Services?*

Work Availability

Date I Can Start*

Hours You Are Available for Work*

Please enter what hours you are available for work each day of the week. (ex. 8am-4:30pm)

If other than above, please specify.

How many total hours per week are you available?

Are you punctional?*

Do you work well with others?*

Did you ever work or apply here before?*

Qualifications and Experience

High School Name*

Number of Years*

Diploma or G.E.D.?*

Name of College

Number of Years

Diploma or Certificate?*

Nursing School Name

Number of Years

Diploma or Certificate?*

Technical Training

Number of Years

Diploma or Certificate?

Briefly describe your experience in the health care field.*

Employment History

(List most recent first.)

Employer*

Phone*

Position

Start Date

End Date

Supervisor

Address

Salary

May we contact employer?

Reason for leaving

Add Another Employer

Yes

Employer*

Phone*

Position

Start date

End date

Supervisor

Address

Salary

May we contact employer?

Reason for leaving

Add Third Employer

Yes

Employer

Phone

Position

Start date

End date

Supervisor

Address

Salary

May we contact employer?

Reason for leaving

References

Name of Reference 1*

Phone*

Title

Relationship*

Years known*

Name of Reference 2

Phone

Title

Relationship

Years known

Emergency Contact

Name of Emergency Contact*

Phone*

Work Phone

Address*

Relationship*

Upload Your Resume

Accepted file types: pdf, doc, docx, Max. file size: 24 MB.

Upload your resume in .pdf, .doc or .docx format.

Certification

“I certify that all of the information provided in this application is correct. I have not misrepresented any facts, nor have I failed to provide you with any information that is necessary in evaluating my possible employment with Just Like Family. I 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 listed above to give you any and all information they may have, personal and otherwise, and release all liability for damages that may result from furnishing same to you.”

Acceptance*

I agree to the certification statement above.

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Phone

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Employment Application

Personal Information

Questionnaire

Employment Information

Work Availability

Qualifications and Experience

Employment History

References

Emergency Contact

Certification

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