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Personal Information

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Current Home Address
Current Home Address
Apt #
City
State
Zip
In the last 7 years have you lived at any other address?
Prev. Address 1
Prev. Address 1
Apt #
City
State
Zip
Are there any other addresses in the last 7 years?
Prev. Address 2
Prev. Address 2
Apt #
City
State
Zip
Are there any other addresses in the last 7 years?
Prev. Address 3
Prev. Address 3
Apt #
City
State
Zip
License Type

Emergency Contact Information

Background Information

No Place Like Home will perform the following BEFORE considering your application for employment:

  • Professional license verification
  • Abuse registry check
  • Sexual-offender registry check
  • Criminal background check

DISCLOSURE REGARDING BACKGROUND INVESTIGATION
No Place Like Home, Inc. may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends or associates. These reports may contain information regarding your criminal history, credit history, motor vehicle records (“driving records”), verification of your education or employment history or other background checks.

Disc Consent

AUTHORIZATION FOR BACKGROUND INVESTIGATION
I acknowledge receipt of: DISCLOSURE REGARDING BACKGROUND INVESTIGATION (given above), and SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT, AND RIGHT TO OBTAIN MORE INFORMATION REGARDING INVESTIGATIVE CONSUMER REPORTS (click HERE to view). I certify that I have read and understand those documents. I hereby authorize the obtaining of “consumer reports” by No Place Like Home, Inc. at any time during the hiring process and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, insurance company or other party to furnish any and all background information requested by Blue Line Investigations, Inc., 6025 Stage Road, Suite 42-146, Bartlett, TN 38134, (901) 266-7100.

Bkg Consent

Failure to disclose an offense, regardless of degree of severity, may result in preclusion of employment up to immediate termination of employment.

Have you ever had an incident which resulted in an allegation of sexual or physical abuse; OR been convicted of a crime, felony, or sexual-offense?

Prev incident

Work Reference 1

Work Reference 2

reference chk

Patient Service Area

We serve patients located in Shelby, Fayette, & Tipton counties.

Please note that if you are unable to work the cases/areas that you are hired to work, and we are unable to find you work elsewhere; your employment may be suspended until such time we have shifts open that match your availability.

Please specify the areas that you ARE WILLING to work in...

Svc area

Availability

Check the boxes to indicate the days & shifts that you ARE ABLE to work...

Any
Day
Eve
Night
None
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Pet Preferences

Please indicate which pet types that you ARE WILLING to work around:
Inside
Outside
None
Cats
Small Dogs
Large Dogs
No Pets At All

Patient Preferences

Are you able/willing to lift/move patients who weight 50 lbs. or more?
Are you a smoker?
We don't consider this for employment; however families have the right to refuse smokers

Experience

Please review all of the following skills. Check the boxes for skills that you HAVE experience with as an employee, indicating if you have MORE or LESS than ONE YEAR of experience.

If you have no experience with a skill please leave it blank... Do not include educational experience.

Less
More
Adult assessment
Pediatric assessment
Seizure documentation
Seizure precautions
Pressure ulcer prevention
Pressure ulcer treatment
Recognizing & treating skin tears
Active ROM
Passive ROM
G tube care
G tube feedings
Mic-Key button care
Mic-Key button feedings
Mic-Key button change
G-J tube care
G-J feedings
Enteral feeding pump
Colostomy
Enemas
Bowel training programs
Rectal tubes
Bowel irrigation
Stoma irrigation

Skill Assessment, cont'd

Less
More
Adult trach care
Pediatric trach care
Pediatric trach change
Passey Muir valve
HME/Humidi-Vent
Trach suction
Oral suction
Nasal suction
Oxygen concentrator
Oxygen tank
Ambu bag
Home ventilators
Cough assist devices
CPT/Chest physiotherapy
I&O cath
Place indwelling cath
Remove indwelling cath
Indwelling cath care
Bladder irrigation
Oral med admin
G tube med admin
J tube med admin
Rectal med admin
Injections
Glucometer
Hoyer lift
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Contact:

354 New Byhalia Rd Collierville, TN 38017

Monday - Friday 9a - 5p

(901) 853-3999

© 1996-2021 No Place Like Home, Inc. All Rights Reserved.