PRN HOME CARE SERVICES, LLC

PO Box 2745                                                                                                                                                                                                                                                    (office use only)  DOH:___________ Murrells Inlet, SC 29576                                                                      PPD DATE:___________ Telephone: 843-655-4612                                                                                 ROP:___________              www.prncares.org

 

INDEPENDENT CONTRACTOR APPLICATION

        ___RN       ___LPN       ___CNA           ___IN HOME AIDE

                                                              (Circle or Check Position)

 

NAME: _______________________________________________            SS#______/______/________

ADDRESS: __________________________________________      CITY: ________________________

STATE: _______________    ZIP CODE: ______________     DATE OF BIRTH: __________________

HOME#_________________________________   CELL#_____________________________________

ARE YOU AT LEAST 18 YEARS OF AGE?    ______YES _____NO

ARE YOU A U.S. CITIZEN?    _____YES ______NO

DRIVERS LICENSE #________________   STATE OF ISSUE: ________ EXP. DATE: ____________

PROFESSIONAL INFORMATION:

STATE(S) WHERE LICENSED (IF RN/LPN): ________________ LICENSE# _____________

STATE WHERE CERTIFIED AS A CNA (IF APPLICABLE): ________ EXPIRATION: _______

CPR PROVIDER? ____YES ____NO         EXPIRATION DATE: _________________

ACLS/PALS?        ____YES ____NO         EXPIRATION DATE: _________________

IV CERTIFIED?   ____YES ____NO       INFUSION THERAPY TRAINING? ___YES ___NO

OTHER MEDICAL CERTIFICATION: _____________________________________________ ______________________________________________________________________________

AVAILABILITY:

SHIFT PREFERENCE:    DAYS      EVENINGS    NIGHTS     WEEKENDS

IS THERE A DAY OR DAYS YOU ARE NOT AVAILABLE TO WORK?

PLEASE LIST: ________________________________________________________________

ARE YOU WILL TO WORK OVERTIME/HOLIDAYS?   ____YES ___NO

DATE AVAILABLE TO START WORK? ____________________________

EXPECTED RATE OF PAY: _______________________________________

EDUCATION:

HIGH SCHOOL: _________________________________ DIPLOMA/GED: ____YES ___NO

UNIVERSITY/TECHNICAL COLLEGE: ___________________________________________

DATE DEGREE/DIPLOMA/CERTIFICATE RECEIVED: _____________________________

MAJOR OR COURSE OF STUDY: ________________________________________________

PLEASE LIST ALL VOCATIONAL/TRADE TRAINING OR SPECIALIZED TRAINING YOU POSSESS:________________________________________________________________

 

_______________________________________________________________________ (PLEASE ATTACH COPIES OF ALL DEGREES/DIPLOMAS/CERTIFICATIONS)

 

 

PERSONAL INFORMATION:

HAVE YOU EVER BEEN CONVICTED OF ANYTHING OTHER THAN A MINOR TRAFFIC VIOLATION? ________YES _________NO

IF YES PLEASE EXPLAIN: _____________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

 

ARE YOU WILLING TO GIVE AUTHORIZATION FOR A CRIMINAL BACKGROUND CHECK?   ____YES ____NO

ARE YOU WILLING TO TAKE A DRUG TEST?      ____YES ____NO

DO YOU HAVE RELIABLE TRANSPORTATION?  ____YES ____NO

DO YOU HAVE RELIABLE CHILD CARE?              ____YES ____NO ____NA

AVAILABLE START DATE:  ____________________________________________________

 

 

 

 

 

EMPLOYMENT HISTORY: (PLEASE FILL OUT COMPLETELY)

Dates Employed From: _______________ To: _______________

Company Name: ___________________________ Phone # __________________

Job Title: _____________________   Supervisor: __________________________

Beginning Pay: ____________            Ending Pay _______________

Reason for Leaving: _________________________________________________

May We Contact Employer:  _____YES _____NO

 

Dates Employed From: _______________ To: _______________

Company Name: ___________________________ Phone # __________________

Job Title: _____________________   Supervisor: __________________________

Beginning Pay: ____________            Ending Pay _______________

Reason for Leaving: _________________________________________________

May We Contact Employer:  _____YES _____NO

 

Dates Employed From: _______________ To: _______________

Company Name: ___________________________ Phone # __________________

Job Title: _____________________   Supervisor: __________________________

Beginning Pay: ____________            Ending Pay _______________

Reason for Leaving: _________________________________________________

May We Contact Employer:  _____YES _____NO

 

Dates Employed From: _______________ To: _______________

Company Name: ___________________________ Phone # __________________

Job Title: _____________________   Supervisor: __________________________

Beginning Pay: ____________            Ending Pay _______________

Reason for Leaving: _________________________________________________

May We Contact Employer:  _____YES _____NO

 

 

 

REFERENCES: (PLEASE LIST REFERENCE WHO ARE NOT FAMILY MEMBERS)

NAME: _____________________________ PHONE: ________________________

YEARS KNOWN: __________   PROFESSIONAL ______   PERSONAL ______

 

NAME: _____________________________ PHONE: ________________________

YEARS KNOWN: __________   PROFESSIONAL ______   PERSONAL ______

 

NAME: _____________________________ PHONE: ________________________

YEARS KNOWN: __________   PROFESSIONAL ______   PERSONAL ______

 

NAME: _____________________________ PHONE: ________________________

YEARS KNOWN: __________   PROFESSIONAL ______   PERSONAL ______

 

 

I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS ACCURATE AND SUBJECT TO VERIFICATION.  I UNDERSTAND THAT ANY MISLEADING OR FALSE STATEMENTS MAY RENDER THIS APPLICATION VOID.

 

SIGNATURE: _________________________________________ DATE: ________________

 

DIRECTOR SIGNATURE: ______________________________DATE: ________________

 

BY SIGNING THIS APPLICATION, I UNDERSTAND THAT I WILL BE CONSIDERED AND INDEPENDENT CONTACTOR OF PRN HOME CARE SERVICES, LLC. I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ALL FEDERAL AND STATE WITHHOLDINGS.  I HEREBY RELEASE PRN HOME CARE SERVICES, LLC FROM ANY LIABILITY REGARDING WITHHOLDINGS.  I UNDERSTAND THAT PRN HOME CARE SERVICES, LLC CARRIES PROFESSIONAL AND GENERAL LIABILITY INSURANCE ONLY.  I ALSO UNDERSTAND THAT I MAY BE RESPONSIBLE FOR COST INCURRED DURING THE HIRING PROCESS, INCLUDING, BUT NOT LIMITED TO, DRUG SCREENINGS AND CRIMINAL BACKGROUND CHECKS.

 

 

 

PRN HOME CARE SERVICES, LLC

CRIMINAL BACKGROUND CHECK ACKNOWLEDGMENT

 

I understand that I am responsible for providing PRN HOME CARE SERVICES, LLC with a current criminal background history pertaining to me including, but not limited to, outstanding warrants, charges, and dispositions of any felony or misdemeanor charges which may be found in the files of any state or local law enforcement agency or court.

 

 

 

 

Applicant’s Signature: _______________________________________

 

Full Printed Name: __________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRN HOME CARE SERVICES, LLC

DRUG SCREEN ACKNOWLEDGMENT

 

 

I, ______________________________, AM AWARE THAT PRE-ASSIGNMENT DRUG SCREENING IS REQUIRED AT MY OWN EXPENSE.  I UNDERSTAND THAT I MUST PROVIDE A COPY OF A CURRENT DRUG SCREEN PRIOR TO ASSIGNMENT.  I ALSO UNDERSTAND THAT I MAY BE REQUIRED TO PROVIDE A RANDOM DRUG SCREEN UPON REQUEST.  I UNDERSTAND THAT FAILURE TO PROVIDE THE RANDOM DRUG SCREEN RESULTS MAY FORFEIT ANY SCHEDULED SHIFTS. 

 

SIGNATURE: ________________________________________________________________

 

PRINT NAME: ___________________________________________ DATE: _____________

 

 

 

 

                                                               DISCLAIMER

 

In the signing of this document, I acknowledge and agree that I am contracted by PRN HOME CARE SERVICES, LLC.  I also understand that I am not an employee of PRN HOME CARE SERVICES, LLC and I have no legal rights to any benefits provided by PRN HOME CARE SERVICES, LLC.

I further agree that I will not make any claims against PRN HOME CARE SERVICES, LLC for any wages or benefits including Worker’s Compensation Claims.  I understand and agree that in order to file a claim as an Independent Contractor, I am self-employed and must carry my own Worker’s Compensation Insurance.

 

 

Signature: ____________________________________________________________________

 

Print Name: __________________________________________ Date: ___________________

 

 

PRN HOME CARE SERVICES, LLC

INDEPENDENT CONTRACTOR AGREEMENT

 

 

I, __________________________________, agree that upon acceptance of my contactor application, PRN HOME CARE SERVICES, LLC will act as my agent to broker assignments.

 

As a contracted caregiver (RN, LPN, CNA, In- Home Aid, or Office Personnel) I agree to read, understand and be responsible and to follow the guidelines of PRN HOME CARE SERVICES, LLC.

 

I acknowledge the fact that failure to read and follow these guidelines could result in the termination of our agreement at any time.

 

 

 

 

SIGNATURE: _________________________________________________________________

 

PRINT NAME: ______________________________________  DATE: ___________________

 

 

 

 

 

 

 

 

 

 

 

 

PRN HOME CARE SERVICES, LLC

RULES OF CONDUCT

 

1.      CONFIDENTIALITY:   As an IHA, CNA, LPN, RN you cannot reveal confidential information about your client(s) to ANYONE not listed on the Medical Information Release Form.  This list should include family members and friends.  If their names are not on the list, you cannot give out information.  Please remember that confidentiality includes your family members and friends.  Under no circumstances are you allowed to discuss any client information with your family or friends.  This includes, but is not limited to, your spouse, children, significant other, neighbors, or friends.  This includes any gossip that you may hear from family or friends.  Do not participate in this type of conversation.

 

2.      Conduct:  Professional conduct is expected at all times.  Any insubordination to management and/or any misconduct with a client will not be tolerated.  Such actions could result in IMMEDIATE TERMINATION.

 

3.      Any dispute with a client or other staff member should be reported to the office and/or the Director of Nursing immediately.  Mediation will be scheduled to assess the situation and resolve any issues.

 

4.      All staff members are expected to report to their client’s home free of drugs or alcohol.  At NO time should any IHA, CNA, LPN, or RN to go to a client’s home under the influence of drugs or alcohol.  This is cause for immediate termination and possible involvement of local law enforcement.  DRUGS AND ALCOHOL WILL NOT BE TOLERATED IN THE CLIENT’S HOME.

 

5.      Exercising undo influence on any client, including but not limited to, promotion of the sale of service, goods, or drugs in such a manner as to exploit the client for you or any family members’ financial gain is strictly prohibited.

 

6.      Any conduct that shows moral unfitness to perform your job is strictly prohibited.

 

7.      Time sheets are to be filled out accurately and turned in to the office on time.  Only include the exact time that was worked at the client’s home on your time sheet.  Any missed time or absences must be reported to the office.  Including hours that were not worked on your time sheet is prohibited and could result in disciplinary actions and/or termination.  If there is an emergency and you must leave your client’s home you must contact the office immediately.

 

8.      If a personal emergency situation arises, contact the office immediately prior to leaving your client’s home.  Do not abandon a client that requires constant care, such as a trach or vent client.  A replacement staff member will be sent to relieve you as soon as possible or the family will be notified of the schedule change.

 

9.      Abusing a client by any single or repeated act of force, violence or harassment, deprivation, neglect or mental pressure, which could reasonably cause physical pain or injury or mental anguish or fear is strictly prohibited. THE RESULT OF THIS ACTION IS IMMEDIATE TERMINATION AND NOTIFICATION TO LOCAL LAW ENFORCEMENT OF THE INCIDENT.

 

10.  Taking or selling ANY drugs from a client’s home is strictly prohibited. THE RESULT OF THIS ACTION IS IMMEDIATE TERMINATION AND NOTIFICATION TO LOCAL LAW ENFORCEMENT OF THE INCIDENT.

 

11.   Universal precautions are to be used with all clients.

 

12.  Staff members are prohibited from taking any family members or friends to a client’s home.  This includes, but is not limited to, your spouse, children, or any other immediate family member, as well as friends or friends of the family. 

 

13.  Client transportation is not allowed unless approved by the office.  Contact the office with any questions regarding client transportation.

 

14.   Sexual contact, exposure or other sexual behavior with or in the presence of a client is strictly prohibited. THE RESULT OF THIS ACTION IS IMMEDIATE TERMINATION AND NOTIFICATION TO LOCAL LAW ENFORCEMENT OF THE INCIDENT.

 

15.   Do not remove anything from the client’s home without specific permission from the client and prior authorization from the office.  THE RESULT OF THIS ACTION IS IMMEDIATE TERMINATION AND NOTIFICATION TO LOCAL LAW ENFORCEMENT OF THE INCIDENT.

 

16.  Staff members are not allowed to accept gifts or monetary compensation from any client.  This could result in disciplinary actions and/or termination.

 

 

 

Signature:        ____________________________________________________________

 

Date:               ____________________________________________________________

 

 

 

 

 

 

 

 

PRN HOME CARE SERVICES, LLC

GUIDELINES FOR HOURS

 

I understand and agree to accept the shifts of my choice through PRN Home Care Services or directly from the individual facility.  I understand that I will not have a set schedule with PRN or the facility and my hours will vary according to my own personal availability. 

 

I understand that in accepting shifts for facilities, either through PRN or directly with said facility, I am considered an Independent Contractor and that PRN acts only as my agent to broker assignments.  I understand that I am responsible for the shifts that I accept, whether it’s through PRN or directly from the facility.  I also understand that there is no guarantee that the facilities will have any needs and shifts are based on facility availability only.  

 

I understand that I must record my time worked on an approved time sheet.  I also understand that my time sheet must include a signature from a facility nurse to be complete.  I understand that I am required to take a 30 minute lunch break for each 8 or 12 hour shift worked and deduct this time from the total hours worked. 

 

By signing below, I agree that I have read and understand these Guidelines of PRN Home Care Services. 

                                                                                                                        

 

 

 

Signature:        __________________________________________________________________

 

Date:               __________________________________________________________________

 

 

 

 

 

PRN HOME CARE SERVICES, LLC

HEPATITIS B CONSENT/DECLINATION FORM

 

 

Please select Consent or Declination

 

_____Consent:  As a healthcare professional having occupational exposure to blood or other potentially infectious materials, which include risk of acquiring Hepatitis B virus (HBV) infection.  I have been informed about and offered the Hepatitis B vaccine.  I understand that I must have 3 doses of vaccine to develop immunity.  However, as with any medical treatment, there is no guarantee that I will become immune or that I will not experience any adverse side effects from the vaccine.  I accept the offer at this time.  I consent to the offer at this time.

 

_____Declination:  I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection.  I have been given the opportunity to be vaccinated with Hepatitis B vaccine.  However, I decline Hepatitis B vaccination at this time.  I know this continues to put me at risk, but if in the future, while actively working for the Company, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine. 

 

 

 

Signature:  _______________________________________  Date:  ____________

 

 

 

 

 

 

 

PRN HOME CARE SERVICES, LLC

STAFF HEALTH RECORD

This form is to be completed by staff prior to assignment.

Name:_________________________________       Position:__________________________________

Address:____________________________________________________________________________

Date of Birth:__________________________         SSN:_________________________________

Please indicate with an (x) if you have or have had the following:

__ Severe Headache                                           __High Blood Pressure

__Vision Impairment                        __Low Blood Pressure

__Speech Impairment                                        __Back Problems

__Fainting/Dizzy Spells                                      __Arthritis/Bone Problems

__Allergy/Wheezing/Asthma                            __Stomach Ulcer

__Frequent Colds                                                __Bowel Problems/Hernia

__TB/Any Communicable Disease                 __ Menstrual Difficulties

__Chest Pain/Pressure                                        __Venereal Disease

__Varicose Veins                                                 __Diabetes

__Hepatitis                                                           __Kidney Problems/Disease

__Heart Problems                                               __Skin Allergies/Disease

__Alcoholism/Drug Addiction                          __Nervous Breakdown

1.      Are you under the care of a physician?                                   ___Yes     ___NO

2.      Are you taking any medication?                                              ___Yes     ___NO

3.      Have you had surgery/been hospitalized?                               ___Yes     ___NO

4.      Have you had any serious accidents?                                      ___Yes     ___NO

5.      Have you had a positive PPD?                                                 ___Yes    ___NO

6.      Can you up to __5lbs___35lbs?                                               ___Yes    ___NO

7.      Have you ever filed a Worker’s Compensation Claim?           ___Yes    ___NO

If you answered YES to any of the above Please explain.  If you answered NO to number 6 Please explain. __________________________________________________________________________________________

__________________________________________________________________________________________

       If required in your position, would you be willing to have a screening test for drug/alcohol alone on your blood or urine as a condition of       employment?      ___YES   ___NO

If  NO, please explain___________________________________________________________________________

_____________________________________________________________________________________________

 

I herby give permission to release the results of any test and/or information regarding my health status to PRN Home Care Service LLC. I understand that I must have a biennial PPD to retain active employment with PRN Home Care Services LLC.

Signature_____________________________    Date:______________

PRN HOME CARE SERVICES, LLC

FIRST AIDE 2.0 CEU TEST

1.     What is first aid?

a.     Initial help given to a person who is sick or injured.

b.     Assistance given to a person after injury has last for a couple of days.

c.      Help given to someone who has no injury.

d.     All of the above.

 

2.     The first step in first aid is evaluating the situation?  ____True ____False

 

3.     What do you use to clean wounds and abrasions with?

a.     Wound Cleanser

b.     Tap Water

c.      Sugar Water

d.     All of the above

 

4.     You always move the patient to make giving treatment more comfortable for you?     _____True _____False

 

5.     You always attempt to put a fire out by yourself.   ____True ____False

 

 

6.     Is profuse sweating a symptom of a heart attack?   ____True ____False

 

 

7.     Pain can cause elevated blood pressure?    ____True ____False

 

 

 

 

 

Signature:_______________________      Date:_____________

 

 

 

 

PRN HOME CARE SERVICES, LLC.

HANDWASHING CEU TEST

 

1.     You should wash your hands before, during and after food preparation.                                    _____ Yes    _____ NO

2.     You should always wash your hands after using the restroom.                                                ______Yes   _______NO

3.     You never wash your hands before and after treating a cut.                                                   ______True   ______False

4.     There’s no need to wash your hands after handling garbage.                                                 ______True   _____False

5.     You always apply soap to your hands when washing them.                                                                                                 _____True   ____False

6.     Always scrub your hands for at least 20 seconds.                                                           _____True ____False

7.     Always dry your hands with a clean paper towel.                 

_____True   _____False

8.     When available use hand sanitizer instead of soap and running water to clean hands. 

 ____True   ____False

9.     Washing hands with soap and warm water does not reduce microbes.                                 ____True   _____False

10.                        Handwashing is the number one defense against spreading infections.                                                                                                                 ____True   ____False

 

 

 

 

Signature:_________________________    Date:____________

 

 

 

 

 

Direct Deposit Authorization

Fill out completely and return to PRN Home Care Services.

This document must be signed by the contractor requesting automatic deposit of paychecks and retained on file by PRN Home Care Services. 

Account 1 Type

o   Checking

o   Savings

Bank Routing Number (ABA Number): __________________________________

Account Number:  ___________________________________________________

Percentage or Dollar Amount to be deposited to this account: _________________

 

Account 2 Type 

o   Checking

o   Savings

Bank Routing Number (ABA Number): __________________________________

Account Number:  ___________________________________________________

Percentage or Dollar Amount to be deposited to this account: _________________

 

Authorization

This authorizes PRN Home Care Services (PRN) to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my accounts indicated above and to other accounts I identify in the future.  This authorizes the financial institution holding the Account to post all such entries.  I agree that the ACH transactions authorized herein shall comply with all applicable US Law.  This authorization will be in effect until PRN receives a written termination notice from myself and has a reasonable opportunity to act on it. 

 

Authorized Signature:  ________________________________________________

Printed Name:  _______________________________________  Date: _________

Social Security Number: ______________________________________________