PERSONAL INFORMATION 

First Name                                   Middle Name                               Last Name   

Alternate Last Name(s), if applicable,  in which degrees, licenses, credentials, etc. would be listed

 Social Security #        Date Available            E-mail Address                    Work Visa # (if applicable)
          

 Current Address

 City                                                                                  ST               Zip
     

The address above is _____.  Permanent    Temporary
 Day Phone                        Eve Phone                        Cell Phone                  
      

The best time to reach you is -- 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 A.M. P.M. Anytime . 
By which number(s) should we attempt to contact you? Day Eve Cell Pager

  Please Select Way In Which You Found Out About CWC             Please List Name of Source
----- School (via faculty recommendation or flyer) Medical Facility (via superior or flyer) Newspaper Ad Trade Magazine (i.e. Advance) National or State Respiratory Board National or State Respiratory Association Link from another Web Site Friend or Colleague  

I am interested in the following:

Per Diem Work (day by day assignment in a specific area)    
Travel or Local Assignment (i.e. committment for 6/13/26 weeks/ time)
Permanent Placement (on staff w/ one or just a few families in my area or new area)
Are you available for 24-hour assignments? (With family round the clock for 1-6 days at a time) 

Please list locations in which you have interest in working

Do you have reliable transportation for daily work commute?  Yes  No
Will you be bringing a vehicle to a travel assignment?              Yes  No

Work Preferences (select as many as you wish)
Days  Eves  Nights  4-hr  8-hr  12-hr  16 (doubles okay) 24s (sleep at family's home) 

Most facilities (vs. home environment) prefer to provide a shared housing environment for travelers, with a one or two roommate situation. If travel is one of your interests, are you amenable to a roommate situation if placed with a facility?  Yes  No  Will not need subsidized housing (provide own)

LICENSURE / CREDENTIALS - We are an unlicensed state for caregiving in the home.  If you have licenses from other States, please list here, as well as certifications.

Do you/have you held additional licenses other than listed above? Yes  No

Please answer the following with regard to any State license issued to you:
     Has a complaint ever been filed against you/your license?   Yes   No
     Has your license ever been investigated, suspended or revoked?   Yes   No
     Have you ever been named in a malpractice or negligence suit?   Yes   No

     Have you ever been convicted, found or pleaded guilty, or pleaded no
          contest to a felony?   Yes   No

If you answered yes to any of the preceding, please explain the details regarding the item(s).  List the States or Provinces in which they occurred, dates, circumstances, and current status or outcome.  Please be sure to include any information about stipulated orders.  And, please be as detailed as possible.
    

Credentials:   CNA other

Please list the expiration dates (mm/dd/yy) for any of the following credential you have obtained
BCLS   First-Aid
Please list the names and expiration dates for any other credentials/licenses you hold not listed above

Which of the following have you completed?  To complete your application, we must have proof of the following (please bring with to interview):

    Yes    No    Recent TB (Negative TB Test or Chest x-ray within past year)

    Yes    No    MMR (Measle, Mumps, Rubella Vaccination)

    Yes    No    Varicella (Chicken Pox Vaccine)

    Yes    No    HepB (Hepatitis B)

Do you have your own transportation?  If so, would you be willing to transport clients for errands and appointments?  If so, we will need proof of current Automobile Insurances.  Can you provide this at the time of your interview?     Yes    No

Please be sure to bring the following items, in addition to the above, to meet State and Federal requirements: Legal Photo ID (driver's license, military card, or passport); and, Social Security or Work Visa

CLINICAL SKILLS

In an effort to match your unique strengths with the needs of the requesting client/family/party, please rank yourself on the items in this section using the following key. If you are unsure as to the meaning of an area of expertise or what it entails, please leave it blank.

1 =  Highly Experienced (2-5+ years).  You have a strong amount of experience in this area, are proficient and will feel comfortable working alone or with minimal supervision, and can even teach others.

2 =  Experienced (1-2 years).  You have a growing amount of experience in this area and are fairly proficient.  You are confident to take an assignment using these skills if you are asked to.

3 = Some Experience.  You have been introduced to the skill in school, clinicals, or assisting others, but you don't have the direct responsibility or experience, or comfort level to be alone on your own in all required areas. 

4 = No Experience.  You have never been introduced to this skill or task.  You may not feel comfortable with direct responsibility for this, but you would be willing to learn and use this skill.

5 = Unwilling to perform this task.

Please list any other areas you are comfortable with, as well as any situations you are not comfortable with.  Please be sure to also list any allergies which may affect placement (i.e. dogs or cats, nuts, etc.)

Charting Methods Familiar With: Written   Computerized  Both

List computerized charting programs you are experienced with

EDUCATION
(List Name, Address and Phone for each in the appropriate scroll box)

Grade School - Degree Earned? Yes  No

High School - Degree Earned? Yes  No

College - Degree Earned? Yes  No


Caregiving or Nursing School - Degree Earned? Yes  No


Other - Degree Earned? Yes  No

EMPLOYMENT HISTORY 

List most recent first.  When listing a period of time through which you worked through an agency, list the agency and it's related contact information first.  Then, list all travel assignments in separate rows underneath the main agency listing, making sure to list that agency just before the facility name in the scrolling text box, to ensure we understand you worked at that facility as agency personnel.  If you worked at several facilities as per diem through an agency, no need to list those facilities on a separate line.  But, rather, add them in parentheses in the same box as the agency's information immediately following the agency's supervisor's and areas worked.

Thank you for completing this application and for your interest in becoming part of the phenomenal CWC team!  Please press the 'Submit' button below when you are finished filling this out, or fax this form with complete information to (602) 266-6542.  We will contact you shortly.  Again, thank you.  We look forward to being a part of your career path!