Name
*
First Name
Last Name
Please list total years of experience in the healthcare field (from starting year to ending year) including any types of agencies or facilities you've worked in (Skilled Nursing, Home Health, Board and Care, Home Care Agency)
Please list any licenses you've held (CNA, HHA, LVN, LPN, RN, MA, EMT, etc.) or special training, classes or certifications completed (1ST AIDE, CPR, direct care training classes by topic)
Please list all types of care delivered to patients (past or present): meal planning and preparation, feeding assist, tube feeding, dysphasia diets, medication monitoring, personal care, incontinent care, catheter care, colostomy care, bathing and grooming, oral care, therapy and exercises, range of motion and positioning, total bedside care, wound care, transfer and ambulating assistance, medical devices used (Hoyer Lift, Sit-To-Stand, tube feeding, respiration devices, C-PAP, BI-PAP), protective care and observation, household chores, shopping and errands, planned activities
Please list the types of patients served (stroke, head injury, heart attack, Parkinson's, Multiple Sclerosis, Lou Gehrig's Disease, Congestive Heart Disease, Pulmonary disease, cancer, Hospice/terminal, developmental disability, etc.)
Please list any/all services you would be uncomfortable, unable or unwilling to perform and why (lack of training, physical limitations, lack of desire)
Please confirm your current availability (even if you are presently assigned to a client on your available days/times): days (Mon-Sun), hours (daytime, evenings and/or overnights from what time to what time) and geographical locations (Northern - Trinidad, McKinleyville, Arcata, Blue Lake; Central - Eureka, Kings Salmon, Samoa, Humboldt Hill; Southern - Loleta, Ferndale, Fortuna, Hydesville, Rio Dell)
