Apply for CNA or CNA2 - 12 Hour Shifts - IntelliChoice Home Care

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Apply for CNA or CNA2 - 12 Hour Shifts

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:	CNA or CNA2 - 12 Hour Shifts
ID:	200280
Location:	Wilmington
Branch Office:	Wilmington
Service Category:	In Home Supports

Resume
Resume:	Supported formats: Word, PDF, RTF, Text, and HTML.

	- or Upload from:


Contact Information
* Title:	Ex. RN, LPN, CNA (not required)
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Cell Phone Carrier:
Attachments
Cover Letter:	You can type in a Cover Letter or Copy/Paste from an existing document.

Application for Employment

CNA Questionnaire

* Do you have a CNA/CNA2 certification in good standing?

	Yes
	No

* Are you 18 years or older?

	Yes
	No

* Do you have current CPR?

	Yes
	No

* Do you have valid driver's license and reliable transportation?

	Yes
	No

* What population do you have experience with?

	Adults
	Pediatrics

* What skills have you performed before?

* Have you lived in NC for the last 5 or more consecutive years?

	Yes
	No

* Have you ever been convicted of any crime?(Answering Yes may not exclude you from working with IntelliChoice and you are required to disclose all convictions prior to employment.)

	Yes
	No

* IntelliChoice Home Care engages candidates using text messages to the phone number you provided. Do you consent to receive text messages from IntelliChoice?

	Yes
	No

Emergency Contact Information

Please provide Emergency Contact Information.

* Name of Emergency Contact

* Phone Number of Contact

* Relationship of Contact

HIPAA

I understand that while performing my official duties I may have access to protected personal and health
information as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I also understand that:
• Protected health information (PHI) is individually identifiable health information that is created, maintained, or used within or by
IntelliChoice Home Care and/or its business clients.
• Protected health information is not available to the public.
• Special precautions are necessary to protect this type of information from unlawful or unauthorized access, use, modification, disclosure, or destruction.
• In order to help ensure the confidentiality and privacy of this information, I agree to:
• Access, use, or modify protected health information only as needed for the purposes of performing my official duties.
• Never access or use protected health information out of curiosity, or for personal interest or advantage, or in the presence of
an unauthorized third party.
• Never show, discuss, or disclose protected health information to or with anyone who does not have the legal authority.
• Never retaliate, coerce, threaten, intimidate or discriminate against or take other retaliatory actions against individuals or others who file
complaints or participate in investigations or compliance reviews.
• Neverremove protected health information from the work area without proper written authorization.
• Never share passwords with anyone or store passwords in a location accessible to unauthorized persons.
• Always store protected health information in a place physically secure from access by unauthorized persons and out of plain view.
• Dispose of protected health information by utilizing an approved method of destruction (i.e.shredding). I will not dispose of such
information in wastebaskets or recycle bins.
I understand that penalties for violating one of the above limitations may include disciplinary action including possible termination, civil or criminal prosecution.
By signing this document, I certify that I have read, understand, and agree to comply with all statements above:

* Signature:

* Date:

First Name:

Last Name:

Questions to help find you a great assignment

Please answer these questions to help find you a great assignment

* What Shifts are you willing to work?

	All Shifts
	Days
	Nights
	Weekends

* What type of work are you willing to do?

	Full Time
	Part time
	Full or Part Time

* How far are you willing to travel?

	0-15 minute drive
	0-30 minute drive
	0-45 minute drive
	Over an hour drive

* Please describe your ideal working schedule.

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

Submit

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	Tube Feeding
	Urinary Catheter
	Oral Suctioning
	Bowel Programs
	Oxygen
	N/A

	American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
	Black or African American (Not Hispanic or Latino) A person having origins in any of the Black racial groups of Africa
	Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
	Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
	White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
	Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
	Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above races
	I Choose Not to Respond

	Individual with a Disability An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
	Vietnam Era Veteran A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
	Disabled Veteran 1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
	War/Campaign/Expedition Veteran A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
	Armed Forces Service Medal Veteran A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
	Recently Separated Veteran Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
	I Choose Not to Respond

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