A Caring Connection R.N. / L.P.N. Onboarding Application

A Caring Connection Onboarding Application

Please complete all of the required fields for onboarding
All fields in this application are required. If a field does not apply to you, please fill it in with the term N/A for not applicable. If you have any questions while filling out this form you can contact A Caring Connection's main office during office hours, (M-F from 9AM-5PM) at 908-232-6484 or email accoffice@acccares.net. You may save your progress throughout your application progress by clicking on the "Save Your Progress" button at the bottom of this page. Note: saved progress may only be saved for a few days.
IMPORTANT: Be sure to have all your personal documents available electronically before starting this application, see below.

Items you will need to have scanned and available electronically in order to complete this form:

Social security number or Alien number
A copy of your most recent physical
A copy and dates of your current vaccines
A copy of your nursing license or aide certification
A copy of your CPR certification(s) and any other certifications, i.e., IV certs, wound care, etc
A copy of your resume

Contact information to Employers and personal references
A copy of your drivers license
A copy of your malpractice insurance
Acceptable identification documents needed for payroll, i.e., passport, social security card, school ID, etc. See I-9 below for more details.

Name*

First NameLast Name
Home Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone Number*

Area CodePhone Number
Personal Email*
example@example.com
Date of birth*

MonthDayYear
Date
County*
Social Security #*
Green Card or Alien number (if applicable)*
List any other languages other than English?*
Gender*

MaleFemaleOther
Position applying for*

R.N. Nurse SupervisorR.N.LPNCHHAOther
RN, LPN or CHHA license/certificate information:
Lic./cert #* State* Expiration date* License type (RN, LPN, CHHA)
Who issued your license? (eg., Board of Nursing)*
Please upload a copy of your nursing license or aide certification*

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Please take a photo of yourself to use for employee ID purposes
Emergency contacts
Family contact name*

First NameLast Name
Family contact phone*

Area CodePhone Number
Family contact email
example@example.com
Colleague/Friend contact name*

First NameLast Name
Colleague/Friend contact phone*

Area CodePhone Number
Colleague/Friend contact email
example@example.com
State required physical and immunization records
Please upload a copy of your current physical exam*

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Last physical date*
Mantoux date (first step)*
Mantoux date (second step)*
Yearly Mantoux date*
Chest X-ray date*
QuantiFERON-TB Gold date*
BCG vaccine date*
Rubella screening date*
Rubella vaccine date*
Rubeolla [N/A ^57] screening date*
Rubeolla [N/A ^57] vaccine date*
Do you have a Hepatitis B vaccine?*

YesNo
Hepatitis B vaccine date*
Do you have a COVID-19 vaccine?*

YesNo
COVID-19 vaccine date (first dose)*
COVID-19 vaccine date (second dose)*
COVID-19 booster date*
Please upload proof of any vaccine documentation. You may attach multiple files.*

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Education, training, work experience and references
Do you have college degree?*

YesNo
Do you have vocational school training?*

YesNo
List all college degrees, dates completed and the name of the college/location*
List all vocational training, dates completed and the name of the school/location*
Do you have a BSN?*

YesNo
If needed, list any other education or certifications, dates of training and location*
Are you currently CPR certified*

YesNo
CPR certification organization?*

American HeartRed CrossOther
What age type are you CPR certified in?*

InfantChildAdultNoneOther
CPR certification date*
List any other certification or licensed classes you may be currently attending.*
Attach a copy of your CPR certification and any other diplomas, certifications or licenses you may have. You may attach multiple certifications if applicable.*

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Work experience

Check all that apply
Locations of clinical experience*

NURSING HOME STAFFINGHOSPITAL STAFFINGHOME PRIVATE DUTYHOME CARE AGENCY/OFFICEGROUP HOMEASS. DEVELOP DISABILITIESDYFSNone
Medical units experience*

PSYCH UNITPEDIATRIC UNITORTHOPEDIC UNITGERIATRIC UNITMED/SURG UNITPSYCH UNITTELEMETRY UNITREHAB UNITNone
Specialized work experience*

ROUTINECRITICALIV CERT.IV THERAPYPOST OPHOSPICENEPHROSOTOMYTRACHREHABASSESSMENTSMATERNITYHI TECH PEDSCATH CARETREATMENTSDRESSINGSG/T FEEDINGTRACH INSERTIONTRACH CAREVENTSNone
Patient experience*

NEONATALICU/CCUINFANTQUADRIPLEGICCHILDREHABILITATIONTEENPARAPLEGICADULTGERIATRICDIALYSISTELEMETRYBURNNone
If vent experience, what type*

1150900TrilogyBipapCpapNone
Other experience*

DR. OFFICECASE MANAGEMENTINSURANCE COMPANYTEACHINGCORPORATEPUBLIC HEALTHNone
Specify the years of experience for each item checked above*
Work experience
Upload your resume here:*

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Write below ALL the names and addresses of all institutions, patients, and agencies you worked for within the one year period preceding the date of this application and any reasons for leaving.*
List the names of ALL supervisors within the one year period preceding the date of this application.*
Personal references

Ex: former employer, minister, teacher, or someone with good standing in the community.
It is required that you please send a link to at least two references to complete for recording purposes. You can, copy and send this link to any of your references.
ACC Employee Reference Request - https://hipaa.jotform.com/220775663045155
I confirm that I have sent the employee reference request to at least two people*

Yes
Reference 1 name*
Reference 1 phone 1*

Area CodePhone Number
Reference 1 phone 2*

Area CodePhone Number
How long have you known this person?*
Reference 1 Contact email*
example@example.com
Company Name where worked with candidate
In what capacity does your reference know you?*

SupervisorCo-workerProfessional acquaintanceOther
Date of Employment From

MonthDayYear
Date
Date of Employment To

MonthDayYear
Date
Reference 2 name*
Contact phone 1*

Area CodePhone Number
Contact phone 2*

Area CodePhone Number
How long have you known this person?*
Contact email*
example@example.com
Company Name where worked with candidate
In what capacity does your reference know you?*

SupervisorCo-workerProfessional acquaintanceOther
Date of Employment From

MonthDayYear
Date
Date of Employment To

MonthDayYear
Date
I give A Caring Connection permission to contact all references listed*

Yes
Criminal background check

You will not be denied employment based solely on your following answers
I authorize A Caring Connection to run a background check with all state and federal agencies*

Clear
Have you ever had your nursing license revoked or suspended?*

YesNo
If yes, what was the nature of the suspension? *
Driver's license and other insurance information
Attach a color image of your current driver's license *

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Confirm that you attached a copy of your driver's license*

Yes
Malpractice insurance carrier name (if applicable)
Malpractice insurance policy number
Malpractice insurance carrier address
Expiration date

MonthDayYear
Date
Attach a copy of your malpractice insurance

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Confirm that you attached a copy of your malpractice insurance

Yes
ACC strongly suggests that all professional nurses carry their own insurance. You may call or go on line, NSO Nurses Service Organization to obtain/purchase your malpractice insurance.
Nurse clinical test

Please click on the link below to launch a brief nurse clinical test. Please acknowledge that you completed the test below.
Click here to open the nurse clinical test
I acknowledge that I reviewed and completed the nurse clinical test:*

YesNo
Employee handbook
It's required that you download a copy of the employee handbook to keep for your personal files and reference. Download here
I have read and understand the Employee Handbook from A Caring Connection. I have been given a copy and I agree to the terms above:*

YesNo
Signature*
Job descriptions

The following are three job descriptions that pertain to this employee application. Please sign the job description that you are applying for to help us ensure you are aware of the job responsibilities of this position.

Territory Nurse Supervisor
Territory Nurse Supervisor

The Territory Nurse Supervisor will oversee a team of nurses who provide highly skilled home healthcare services to our patients. The Territory Nurse Supervisor will evaluate the field nurses upon visit to grade their quality of care, attention to detail and recording of visit notes. The Territory Nurse Supervisor duties will also include training and mentoring the nursing staff and consulting on patient care plans.

Staff management:
- Management of field staff which includes (RNs, LPNs and Aides).
- Address staff concerns.
- Complete performance evaluations for staff.
- Perform orientations and teaching the staff on trach, ventilator and g-tube patients.
- Oversee the quality of nurse note submission.
Client management:
- Create and/or maintain all patient clinical charts:
  - Care plans
  - Medication documentation
  - 485 physician signatures
- Visit each nurse and patient every 30 days.
General duties and responsibilities:
- Ensure patient short and long term goals are being met.
- Communicate with staff and department heads.
- Keep and organize records of the patient list through our online clinical software.
- Solve any problems patients might have on site.
- Ensure agency quality assurance.
- Listening to the concerns of family members and answering their questions.
Required skills:
- Current RN license in good standing.
- Experience in home healthcare or public health nursing preferred.
- A completed apprenticeship or experience in a similar role.
- Excellent observational and problem-solving skills.
- The ability to follow instructions but also to act independently where necessary.
- Excellent reporting and writing skills.
- Active listening skills and empathy.
- Physical and mental strength.
Sign for Territory Nurse Supervisor Job Description

Clear

Registered Nurse
Licensed Registered Nurse

Position Scope:
• To ensures quality and safety delivery of home health services for assigned clients
• To assist in the provision of home health care services that reflect agency philosophy and standards in the care of assigned clients.
• To ensure provide adequate qualifications to service those patients that fall under various levels of care, including, but not limited to high-tech nurses.
• Position Qualifications:
• Graduate of an accredited School of Practical Nursing required
• Those LPN's who service high tech cases must have evidence of high tech skills or education, not limited to, but including such experience as vent, pediatric, ER, or acute care.
• Current licensure as a Practical Nurse with the New Jersey with the New Jersey Board of Nursing required.
• Experience in home health care preferred
• Good verbal and written skills required.

Physical Requirements:
• Visual/hearing ability sufficient to comprehend written/verbal communication.
• Ability to perform tasks involving physical activity, which may include heavy lifting and
• Extensive bending and standing.
• Ability to deal effectively with stress.

Performance Responsibilities:
• To ensure quality and safe of practical nursing services provided to assigned clients
• Complies with agency policies and procedures
• Fulfills assignments as scheduled by the agency.
• Physician orders are accurately implemented
• Provides practical nursing services to assigned clients that are in accordance with the Individual’s plan of care.
• Client clinical record documentation is completed in a timely manner and accurately reflects delivery of practical nursing services
• Accurately reports observations of client condition to the Registered Nurse in a timely manner
• Communicates information regarding the client to appropriate individuals.
Sign for Licensed Registered Nurse / Case Manager / Supervisor Job Description

Clear

Licensed Practical Nurse
Licensed Practical Nurse

Position Scope:
• To ensures quality and safety delivery of home health services for assigned clients
• To assist in the provision of home health care services that reflect agency philosophy and standards in the care of assigned clients.
• To ensure provide adequate qualifications to service those patients that fall under various levels of care, including, but not limited to high-tech nurses.
• Position Qualifications:
• Graduate of an accredited School of Practical Nursing required
• Those LPN's who service high tech cases must have evidence of high tech skills or education, not limited to, but including such experience as vent, pediatric, ER, or acute care.
• Current licensure as a Practical Nurse with the New Jersey with the New Jersey Board of Nursing required.
• Experience in home health care preferred
• Good verbal and written skills required.

Physical Requirements:
• Visual/hearing ability sufficient to comprehend written/verbal communication.
• Ability to perform tasks involving physical activity, which may include heavy lifting and
• Extensive bending and standing.
• Ability to deal effectively with stress.

Performance Responsibilities:
• To ensure quality and safe of practical nursing services provided to assigned clients
• Complies with agency policies and procedures
• Fulfills assignments as scheduled by the agency.
• Physician orders are accurately implemented
• Provides practical nursing services to assigned clients that are in accordance with the Individual’s plan of care.
• Client clinical record documentation is completed in a timely manner and accurately reflects delivery of practical nursing services
• Accurately reports observations of client condition to the Registered Nurse in a timely manner
• Communicates information regarding the client to appropriate individuals.
Sign for Licensed Practical Nurse Job Description

Clear

Home Health Aide
Home Health Aide

Summary
Responsible for providing care for people confined to their homes due to being disabled, cognitively impaired, or chronically ill. Cares for elderly people who prefer to remain in their home as opposed to health facilities or institutions. Applicants are considered appropriate for hire after the agency is satisfied that the potential employee can treat clients with respect, consideration, individuality and personal property. This can be satisfied by reference checks before start of employment, have provided evidence that they have met the standards of the Board of Nursing, are certified in good standing and have passed their application requirements.

Primary responsibilities:
• Provide healthcare in someone's residence.
• Assist people in hospices and day programs.
• Go to same home or homes every day or months or even years.
• Work under direct supervision of a nurse.
• Keep records of services performed.
• Record and note clients' condition and progress.
• Report changes to case manager.
• Check patient's pulse rate, temperature, and respiration rate.
• Perform prescribed exercises and other physical therapy.
• Remind patient to take medications.
• Change dressings.
• Turn or ambulate patient.
• Provide skin care.
• Massage limbs.
• Assist with braces and artificial limbs.
• Assist with medical equipment.
• Ensure equipment is functioning properly.
• Replace batteries on equipment.
• Prepare food and feed patient.
• Provide counseling on diet and exercise.
• Implement behavior plans.
• Teach self-care skills.
• Perform light housekeeping.
• Provide patient with groceries.
• Pick up medication.
• Transport patient to doctors' office or hospital.
• Signs and dates documents such as necessary per policy manual standards, Best Practices, accrediting agencies and federal/state regulations

Organizational Relationship:
The position of Home Health Care Certified Home Health Aide reports to the Director of Nursing
Sign for Home Health Aide Job Description

Clear

Handbook summary
1. Your shift clock in/clock out must be submitted online via our Alayacare clinical management software.
2. Nurses notes must be submitted online via our Alayacare clinical management software.
3. Care plans, vent sheets, and MARS sheets should be dropped at the office monthly or coordinated for pickup with Nurse Supervisor.
4. Any changes in patient's care must be submitted daily to your Nurse supervisor.
5. A Caring Connection reserves the right to deduct a penalty and hold pay for any employee that does not abide by the agency polices specified above and in the employee handbook.
Initial all below and sign your name
Inital* I have received the entire handbook, and have had a full explanation of all agency policies, forms, and expectations. I agree to fulfill my obligations in a professional manner at all times.
Inital* I have signed the office permission documents that will be used to obtain references, NJ Central Registry of Offenders.
Inital* I understand the Right to Privacy Policy as explained in the right to know area with only the exception of Abuse and Neglect (HIPPA Guidelines).
Inital* I understand the Caregiver Agreement.
Inital* I have received the required annual in-service education including initial orientation and annual education on:
·      Complaints & Grievances
·      Emergency disaster training
·      Clients/patients right and responsibilities
·      Ethics training
·      Workplace and client/patient safety (OSHA)
·      Compliance Program
I hereby authorize A Caring Connection to request and receive from all prior employers within one year of the date of this application, and all pertinent information concerning my prior employment and its termination, including the reasons for such termination.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Payroll and tax information
Below is the informaiton needed for payroll and tax benefits. First download the employee I-9 form. Once completed, scan and upload your I-9 form below along with any unexpired acceptable identification documents seen on page 3 of the I-9 form. Download I-9 form here.

Once we recieve all of the required documentation needed for payroll, you will recieve an email requesting bank information, routing information and tax withholding selections directly from our payroll company.
Upload completed I-9 form and acceptable forms of identification.*

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I confirm that I have completed and uploaded the required payroll and tax forms.*

Yes
Please verify that you are human*
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A Caring Connection Onboarding Application

IMPORTANT: Be sure to have all your personal documents available electronically before starting this application, see below.

Emergency contacts

State required physical and immunization records

Education, training, work experience and references

Work experience

Work experience

Personal references

Criminal background check

Driver's license and other insurance information

Nurse clinical test

Employee handbook

Job descriptions

Handbook summary

Initial all below and sign your name

Payroll and tax information