CNA New Hire Checklist__________________________________________________________

Attached Documents:  Employment Application  Signed Job Description  Professional Reference (2)  HIPAA Training Module  OSHA Standards Post Test  2011 National Patient Safety Goals  Back Care Education and Brace Acceptance  Annual Mandated Topics Acknowledgement Form  Payment Options  I9  W4  Auto Insurance Attestation  Physical Exam (included: PPD/Chest X-Ray and MMR/ Titers)  Hepatitis B Vaccination Acknowledgement What we need from you:  Resume  Drivers License/State ID  Social Security Card/Passport  Professional Certification  CPR card (If applicable)

PearlCare is an equal opportunity employer

Employment Application____________________________________________________________________________ Personal Data_____________________________________________________________________________________ __________________________________________________________________________________________________ Last Name First Name Middle Name Social Security Number __________________________________________________________________________________________________ Home Phone Number Cell Phone Number Pager Number Email Address __________________________________________________________________________________________________ Best Days to Call/Best Time to Call Date of Birth __________________________________________________________________________________________________ Street Address City County State Zip Country __________________________________________________________________________________________________ Previous Street Address City County State Zip Country __________________________________________________________________________________________________ Name of Emergency Contact Relation Phone Number

Job Information____________________________________________________________________________________ Title (check one) □ RN

□ LPN

□ CNA

□ Other____________________________

Work Experience/Specialty Skills (Please list the number of years you have experience in each area and are willing to work) — — — — — — —

Burn L&D Post Partum Mother/Baby Nursery Pediatrics Rehab

— — — — — — —

CCU ENT MICU NICU PACU PICU SICU

— — — — — — —

— — — — — —

Detox/Drug Rehab

Dialysis Geriatric Med/Surge Oncology Orthopedics Stepdown

ER Neurology Open Heart OR Recovery Room Telemetry

Other Specialty______________________________________________________________________________________ Type of Work Desired (Check all that apply) □ Hospital □ Long-Term Care □ Clinic (Specify _____________ Languages Spoken other than English □ Spanish □ French □ Portuguese □ Italian

□ Rehab

□ German

□ Other____________

□ Other___________________

Check the type of assignment(s) you are interested in (check all that apply) □ Full-Time □ Part-Time □ Per Diem □ Permanent □ Travel Check the Day(s) of the week you are interested in working (check all that apply) □ Sunday □ Monday □ Tuesday □ Wednesday □ Thursday

□ Friday

Check the shift(s) you are interested in working (check all that apply) □ 7am-3pm □ 3pm-11pm □ 11pm-7am □ 7am-7pm □ 7pm-7am

□ Other___________________

□ Saturday

Based on your experience, work ethic, and devotion to PearlCare Medical Staffing, tell us what you think you deserve for compensation______________$/hour. -1-

PearlCare is an equal opportunity employer

__________________________________________________________________________________________________ Education and Training_____________________________________________________________________________ __________________________________________________________________________________________________ High School Name City State Zip Country Did you receive H.S Diploma? __________________________________________________________________________________________________ College/Vocational School City State Zip Country Highest Grade Completed __________________________________________________________________________________________________ Major in College Type of Degree (i.e. B.S./B.A./etc…) __________________________________________________________________________________________________ Graduate School City State Zip Country Did you receive Diploma? __________________________________________________________________________________________________ Major in Graduate School Type of Degree (i.e. Masters/P.H.D/etc…) __________________________________________________________________________________________________ License/Certification_______________________________________________________________________________ __________________________________________________________________________________________________ License Type License/Certification Number State Expiration Date __________________________________________________________________________________________________ License Type License/Certification Number State Expiration Date __________________________________________________________________________________________________ License Type License/Certification Number State Expiration Date Has your professional License/Certification ever been suspended, revoked or gone under investigation? □ Yes □ No If yes, please explain why___________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Additional Information_____________________________________________________________________________ Are you legally authorized to work in the United States? □ Yes □ No If no, are you interested in being sponsored to work in the United States? □ Yes (If yes, you must commit to at least 3 years) □ No Enter the approximate date you are available to immigrate to the United States________________________________ (Should you become an employee of PearlCare Medical Staffing, you will be required to provide the documentation proving your eligibility to work in the United States). Have you ever been convicted of a felony or misdemeanor crime? □ Yes □ No If yes, please explain each violation____________________________________________________________________ __________________________________________________________________________________________________ -2-

PearlCare is an equal opportunity employer

How did you hear about PearlCare Medical Staffing? □ Mail

□ Advertisement

□ Other______________________

□ Website

□ PearlCare Medical Staffing Employee Name___________________________

Please explain any other work-related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, honors, etc…________________________________________ __________________________________________________________________________________________________

Work Experience (Skip if resume is attached, otherwise list last two most recent places of employment and information)_____ __________________________________________________________________________________________________ Facility/Employer Name Dates Employed (From-To) __________________________________________________________________________________________________ Facility/Employer Address Title __________________________________________________________________________________________________ City State Zip Country Department __________________________________________________________________________________________________ Number of Beds in Facility Name/Title of Supervisor __________________________________________________________________________________________________ Describe Duties and Specialty Areas Supervisory Experience (yes/no) __________________________________________________________________________________________________ Telephone Number Was this a travel assignment? __________________________________________________________________________________________________ Pay rate/Salary ($/hour or $/year) Reason for leaving __________________________________________________________________________________________________ Facility/Employer Name Dates Employed (From-To) __________________________________________________________________________________________________ Facility/Employer Address Title __________________________________________________________________________________________________ City State Zip Country Department __________________________________________________________________________________________________ Number of Beds in Facility Name/Title of Supervisor __________________________________________________________________________________________________ Describe Duties and Specialty Areas Supervisory Experience (yes/no) __________________________________________________________________________________________________ Telephone Number Was this a travel assignment? __________________________________________________________________________________________________ Pay rate/Salary ($/hour or $/year) Reason for leaving -3-

PearlCare is an equal opportunity employer

Applicant Acknowledgement________________________________________________________________________ I certify that the information in this application is accurate, current and complete. I understand that mis-statements or omissions may result in disqualification from further consideration or termination of employment. I authorize PearlCare Medical Staffing to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision. I authorize PearlCare Medical Staffing to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize PearlCare Medical Staffing to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release PearlCare Medical Staffing and any individual or entity providing information to PearlCare Medical Staffing from all liability for any damages from the disclosure of this information. PearlCare Medical Staffing, LLC, is contracted by many organizations to provide temporary, contract and per diem personnel to said organizations. It is our policy of PearlCare Medical Staffing, LLC, not to allow its employees to pursue employment directly with a PearlCare client for a period of Three-Hundred sixty (360) days from the last date of work by the PearlCare employee with said client through PearlCare Medical Staffing. Therefore, by signing this agreement, the PearlCare employee may not pursue employment directly with a PearlCare client they have worked for through PearlCare for a minimum of Three-Hundred sixty (360) days from the last date they were scheduled through PearlCare with said client. If the PearlCare employee does work directly for a PearlCare client that they have worked for through PearlCare, or any of its agents or contractors, prior to the end of the Three Hundred sixty (360) day period referenced above, the said employee will be responsible for payment of a placement fee to PearlCare in the amount of twenty-five percent (25%) of the individuals annualized full time salary. The facility will abide to the contract signed by facility in regards to any employee buyout situation. I also understand and agree that: Passing a medical examination and/or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired, employment may be terminated. Subject to applicable state laws, the Company reserves the right to conduct drug screening and testing for reasonable suspicion at any time during employment and as a pre-employment requirement. Any violation of this policy shall result in an applicant not being hired or an adverse employment action up to and including immediate termination. PearlCare Medical Staffing has the right to change this policy at any time as it requires with proper notification to employees/applicants. I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between PearlCare Medical Staffing and me for either employment of for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable ‘at will’, that I will have the right to terminate my employment at any time, and that PearlCare Medical Staffing will retain a similar right to terminate my employment at any time. I hereby acknowledge that I have received a copy of the Employee Handbook of PearlCare Medical Staffing, LLC. I will familiarize myself with the information in this handbook. I agree to observe all of the policies in the handbook. I understand that PearlCare Medical Staffing may revise its policies or practices at any time. It is part of my job to inquire about a new and updated volume to keep up with the latest industry policies and standards. I have received and agree to wear the PearlCare Medical Staffing Identification Badge whenever I am on staff at any of the Facility’s I work at. I understand that should I become employed by PearlCare Medical Staffing, my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of PearlCare Medical Staffing.

X_____________________________________________ Signature

___________________________________________ Date -4-

Job Description_____________________________________________________________________________ Position Title: Certified Nursing Assistant (CNA) Position Summary: The certified nursing assistant performs direct patient care under the direct supervision of a registered nurse of his/her licensed designee. The nursing assistant performs a variety of individualized patient care activities and related non-professional services necessary in caring for the personal needs and comforts of patients. Position Requirements: Prefer one year experience as a certified nursing assistant within the last three years. Graduate from certified nursing assistants program with subsequent documentation as a certified nursing assistant. Knowledge of medical terminology and knowledge of clerical functions. Current Physical, PPD. Current BLS card (If Required by Client). Full command, verbal and written, of the English language. Responsibilities: Maintains patient confidentiality of all clients. Performs duties, as assigned, in an accurate and timely manner. All procedures are performed in an accurate and timely manner as directed by facility and/or licensed designee within the scope of practice. Safeguards the client/patient by observing appropriate infection control procedures including but not limited to universal precautions. Notifies the supervising nurse of any abnormal findings or conditions. Adheres to standards and procedures of PearlCare Medical Staffing and all facilities. Arrives at the facility on time, before the scheduled shift starts to sign-in at the nursing office and report to the floor-unit for orientation. Represents PearlCare Medical Staffing with a positive image at all times. Demonstrates flexibility and adaptability in meeting the needs of all facilities. Essential Job Functions: Employee is required to stand, walk, bend, squat continuously. Reach above shoulder level frequently. Strength up to 50 pounds occasionally, up to 20 pounds frequently, or negligible amount continuously. Fine manipulation requirements of both hands. Employee is exposed to blood borne pathogens continuously, and frequently-occasionally exposed to chemotherapeutics and toxic chemicals

X_________________________________________________________________________________________________ Signature Date Print Name

Professional Reference Request_____________________Please Fax Back to (914) 777-9801 Applicant Section__________________________________________________________________________ __________________________________________________________________________________________ Applicants full name used while working at this facility ____________________________________________________________________________________________________________ Facilities Name ____________________________________________________________________________________________________________ Facility Address ____________________________________________________________________________________________________________ City State Zip County ____________________________________________________________________________________________________________ Manager/Supervisor’s Name Position/Title Phone Number The facility listed above has my consent to release any information to PearlCare Medical Staffing pertaining to my employment on the application. I also authorize PearlCare Medical Staffing to disclose this reference to any of its Client Facilities and PearlCare Medical Staffing affiliates.

X________________________________________________________________________________________ Signature

Date

Social Security Number

Facility Section____________________________________________________________________________ Facility: The individual named above has applied for employment with PearlCare Medical Staffing. In order to maintain JCAHO standards, we ask that you provide the information requested below. Your response will be held in the strictest confidence. A business reply envelope has been enclosed for your convenience. Thank you for your assistance. Check One:

□ Applicant Resigned

□ Applicant was a Temp.

□ Applicant was terminated

□ Other______________

____________________________________________________________________________________________________________ Would you rehire employee? Please explain a reason for your answer ____________________________________________________________________________________________________________ Answer Continued DATES OF EMPLOYMENT ____________________________________________________________________________________________________________ Unit/Floor/Department Specialty Number of Beds Average Patient Caseload

Professional Reference______________________________________________________________________ Key:

A: Excellent ___ Adaptability ___ Initiative ___ Cooperative

B: Above Average

C: Average

___ Communication Skills ___ Professionalism ___ Thorough Documentation

D: Barely qualified

F: Does not meet standard

___ Competency ___ Quality of Work ___ Enthusiasm

___ Follows Protocol ___ Reliability/Attendance ___ Relates well with others

Comments___________________________________________________________________________________________________

X________________________________________________________________________________________ Signature

Date

Print Name

Title

Phone Number

I agree that the above information is true to the best of my knowledge. By signing this document, I attest to this information.

Professional Reference Request_____________________Please Fax Back to (914) 777-9801 Applicant Section__________________________________________________________________________ __________________________________________________________________________________________ Applicants full name used while working at this facility ____________________________________________________________________________________________________________ Facilities Name ____________________________________________________________________________________________________________ Facility Address ____________________________________________________________________________________________________________ City State Zip County ____________________________________________________________________________________________________________ Manager/Supervisor’s Name Position/Title Phone Number The facility listed above has my consent to release any information to PearlCare Medical Staffing pertaining to my employment on the application. I also authorize PearlCare Medical Staffing to disclose this reference to any of its Client Facilities and PearlCare Medical Staffing affiliates.

X________________________________________________________________________________________ Signature

Date

Social Security Number

Facility Section____________________________________________________________________________ Facility: The individual named above has applied for employment with PearlCare Medical Staffing. In order to maintain JCAHO standards, we ask that you provide the information requested below. Your response will be held in the strictest confidence. A business reply envelope has been enclosed for your convenience. Thank you for your assistance. Check One:

□ Applicant Resigned

□ Applicant was a Temp.

□ Applicant was terminated

□ Other______________

____________________________________________________________________________________________________________ Would you rehire employee? Please explain a reason for your answer ____________________________________________________________________________________________________________ Answer Continued DATES OF EMPLOYMENT ____________________________________________________________________________________________________________ Unit/Floor/Department Specialty Number of Beds Average Patient Caseload

Professional Reference______________________________________________________________________ Key:

A: Excellent ___ Adaptability ___ Initiative ___ Cooperative

B: Above Average

C: Average

___ Communication Skills ___ Professionalism ___ Thorough Documentation

D: Barely qualified

F: Does not meet standard

___ Competency ___ Quality of Work ___ Enthusiasm

___ Follows Protocol ___ Reliability/Attendance ___ Relates well with others

Comments___________________________________________________________________________________________________

X________________________________________________________________________________________ Signature

Date

Print Name

Title

Phone Number

I agree that the above information is true to the best of my knowledge. By signing this document, I attest to this information.

HIPAA Training Test_________________________________________________________________________ 1. HIPAA stands for Health Insurance Portability Accountability Act.

T

F

2. The hospital elevator is not an appropriate setting to discuss your patient’s condition.

T

F

3. The HIPAA regulation affects only electronic transmission of health information.

T

F

4. PHI stands for Protected Health Information.

T

F

5. PearlCare Medical Staffing is a “business associate” of hospitals, nursing homes, and other healthcare providers.

T

F

6. You must know and comply with the privacy policies and procedures of any organization where you work.

T

F

7. The HIPAA regulation affects me and my responsibilities to the patients that I provide services for.

T

F

8. You are allowed to repeat protected health information only when it is necessary to to do your job.

T

F

9. Only information that would virtually be impossible to identify the person is not subject to the privacy rules.

T

F

10. No one will ever know that I don’t follow the law about privacy, so I can ignore the part about criminal penalties.

T

F

I certify that I have completed the HIPAA privacy training. I understand and will honor all of the organization’s privacy policies and procedures. I’m aware that violations of the privacy policies and procedures may result in disciplinary action including termination.

__________________________________________________________________________________________ Print Name

Date

X________________________________________________________________________________________ Signature

Date

OSHA Standards Post – Test________________________________________________________________________ Directions: Circle the one correct answer to each question. When finished, check your answers against those given on the next page. When finished, give it to your employer to file as a part of your personnel record.

1. OSHA recommends that all workers who come into contact with blood be vaccinated to prevent HBV infections. True False 2. HIV can cause a flu-like illness with fever, aches and swollen glands. True False 3. OSHA has introduced a standard based on guidelines developed by the CDC that are designed to protect you from blood borne disease. True False 4. An HBV or HIV carrier may have no symptoms but can spread the disease to others. True False 5. Which group faces the greatest risk of getting AIDS? a. Healthcare workers

b. Married couples

c. Drug users who share needles

d. Blood donors

6. Blood tests are used to determine if you have been infected with HIV or HBV. True False 7. Blood is the most common source of HIV and HBV in the workplace. True False 8. Universal Precautions should be observed when working with which group? a. Male homosexual’s

b. Only patients with AIDS

c. Drug users

9. Blood on instruments or equipment cannot infect you. True

d. All patients

False

10. Acceptable practice as recommended by the CDC is to immediately re-cap your needle after use. True False 11. Which task requires wearing protective gloves? a. Cleaning up blood b. Assisting in minor surgery

c. Changing a dressing

d. All of the above

12. Masks and protective eyewear are designed to protect you from ________________. a. Needlestick injury b. Clothing contamination c. Mucous membrane contact d. All of the above 13. Clearly marked, puncture-resistant containers should be available to dispose of used needles or other disposable sharps. True False 14. Which activity can spread HIV or HBV from one person to another outside of work? a. Using a toilet

b. Giving blood

c. Shaking hands

d. Having sex

15. You can get HIV or HBV from puncture wounds, broken skin contact, and mucous membrane contact. True False

________________________________ ____________________________ ___________________________ Name

Signature

Date

2011 National Patient Safety Goals

I acknowledge that I have received a copy of the 2011 National Patient Safety Goals. My Signature below acknowledges that I understand the 2011 National Patient Safety Goals and will incorporate them into my clinical practice.

____________________________________________________ Employee Signature ____________________________________________________ Professional Classification (RN, LPN, CNA) ____________________________________________________ Date

Back Care Education and Brace Acceptance Form_________________________________________________

I have reviewed the education packet about back care, and understand that my job may require lifting weight that will put abnormal resistance on my back. PearlCare Medical Staffing has offered me the choice to purchase a back brace for the cost of $30 deducted from my paycheck.

□ Yes, I would like to purchase a back brace at this time

□ No, I decline the option to purchase a back brace at this time

__________________________________________________________________________________________________ Employee Name X_________________________________________________________________________________________________ Signature Date

Annual Mandated Topics Acknowledgement Form________________________________________________ I hereby acknowledge receipt and understanding of the following Mandated Topics from PearlCare Medical Staffing, LLC. Topics Included:               

Advanced Directives Fire Safety Electrical Safety Infection Control/Universal Precautions Hepatitis C Hepatitis B HIV Testing and Related Information Age Specific Care Confidentiality of Patient Information/HIPAA (2003) Sexual Harassment Pain Management Patient Abuse Patient Rights Multi-Cultural Aspects of Patient Care Ethics

I understand that as an Employee of PearlCare Medical Staffing, LLC. at any client Facility, it is my responsibility to protect the confidentiality of the patients’ medical information. Failure to maintain patient confidentiality may lead to discharge or other disciplinary action. I have read and understand the above policy. __________________________________________________________________________________________________ Print Name Date X_________________________________________________________________________________________________ Signature Social Security Number

Payment Options___________________________________________________________________________ PearlCare offers you 3 different methods for payment. Please select one of the following methods: 

Check- Payroll is processed on Wednesdays and Checks are sent by Thursday morning.



Direct Deposit- Payroll is processed on Wednesday, the deposit is sent through the ACH that day.



PearlCare PowerCash Card- Payday every time you work! Fax us a signed, verified time sheet, before 4pm on the day you want to be funded, and call to make sure we received your time sheet and request to be added to the powercash list for the day! (Associated Fee’s: $5.00 funding fee)

Authorization for Direct Deposit _______________________________________________________________ This authorizes PearlCare Medical Staffing, LLC. to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my (our) accounts(s) indicated below and to other accounts I (we) identify in the future (the “Account”). This authorizes the financial institution holding the Account to post all such entries.

Account Information_________________________________________________________________________ Account Type  Checkings

 Savings

Bank Name ____________________________________

Branch ___________________________________________

City __________________________________________

State _____________________________________________

Routing #___ ___ ___ ___ ___ ___ ___ ___ ___

Account # _________________________________________

Attach check here.

Authorization______________________________________________________________________________ This authorization will be in effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it. X_________________________________________________________________________________________________ Signature Date Print Name

Automobile Insurance Attestation______________________________________________________________

Check one box only:

□

I hereby attest that I do drive an automobile and I do hold an active automobile insurance policy. I understand that I may be requested to use my vehicle for work related purposes. In the event that I do, my automobile insurance policy provides for minimum liability limits of $50,000 per occurrence.

□

I hereby attest that I do not drive an automobile and/or do not hold an automobile insurance policy. However, I understand that in the event that I obtain an automobile or I am placed on an insurance policy, I will submit this information to PearlCare Medical Staffing. Furthermore, I realize that without active insurance I may not drive a vehicle in connection with any job activities whatsoever.

__________________________________________________________________________________________________ Employee Name X_________________________________________________________________________________________________ Signature Date

Physician’s Statement________________________________________________________________________ __________________________________________________________________________________________ Employee Name Date Telephone ____________________________________________________________________________________________________________ Street Address City State Zip ____________________________________________________________________________________________________________ Physician’s Name Office/Company Name Telephone

Date of last Physical Examination____________________ □ Positive □ Positive □ Positive

PPD Skin Test Results (req. q 1 year) Chest X-Ray (req. if + PPD) BCG Value Rubeola Titer (Measles)

□ Negative □ Negative □ Negative

Date______________ Date______________ Date______________

___________________________/____________________ Titer Value/Immune/Date

Rubella Titer (German Measles) Mumps Titer Varicella Titer (Chicken Pox) Hepatitis B (Titer or Vaccine)

Vaccine/Date

___________________________/____________________ Titer Value/Immune/Date Vaccine/Date ________________________________/_________________________ Titer Value/Immune/Date Vaccine/Date ________________________________/_________________________ Titer Value/Immune/Date Vaccine/Date

____________/_____________/_____________/________ Initial Date

Date (4 weeks)

Date ( 6 Mos.)

Titer Value

I. Does the individual have any physical limitations?___________________________________________ _____________________________________________________________________________________ II. Does the individual take any prescribed medications?________________________________________ _____________________________________________________________________________________ III. Which of the following have you had since your last review? Weight Gain/Loss_________lbs. Change in Vision Frequent cough/night sweat/chills Recurrent fever Generalized swollen glands Indigestion/difficulty swallowing Hoarseness Difficulty breathing Palpitation/irregular heartbeat Pain/pressure in chest

Y Y Y Y Y Y Y Y Y Y

N N N N N N N N N N

Change in bowel habits Black/bloody/stool Persistent diarrhea Burning/blood in urine Problem Urinating Muscle or joint pain Low back pain Breast lump/discharge Skin rash/sores or lumps Dizziness

Y Y Y Y Y Y Y Y Y Y

N N N N N N N N N N

I have determined that the above is free from any physical and mental impairment which if of potential risk to patients or which might interfere with the performance of the person’s duties, including but not limited to, the habituation of addiction to depressants, stimulants, narcotics, alcohol, or other drugs or “substances” which may alter the individual’s behavior.

X________________________________________________________________________________________ Signature of Physician

Date

Physician’s Stamp with License #

Hepatitis B Vaccination Acknowledgement______________________________________________________ __________________________________________________________________________________________________ Name Date

The Hepatitis B Vaccination will be made available to all PearlCare Medical Staffing employees. I understand that the risk of HBV (Hepatitis B Vaccination) is a serious disease and understand that due to my occupational exposure to blood and other potentially infectious materials, I may be at a higher risk of acquiring Hepatitis B. Please state below whether or not you will be accepting or declining the Hepatitis B Vaccination at this time. Please provide a reason for the acceptance or declination as well. Thank you. □

Accept

□ Decline __________________________________________________________________________________________________ Reason: □

Antibody testing indicates me to be immune □

The vaccine cannot be given for medical reasons

□

I have received the complete Hepatitis B Vaccination series

□

I am currently receiving the Hepatitis B Vaccination

□

Other___________________________________________

__________________________________________________________________________________________________ Signature Date I attest by signing this document that all information provided is true to the best of my knowledge