Careers

Certification Nursing Assistant/Home Health Aide

Medical History Questionnaire

Job Description

Solution On-call Service

Solution On-call Service – Supplier Diversity/Inclusive Questions

Name of Employer:

Address:

City:

State:

Zip:

Telephone Number:

Supervisor’ Name:

Supervisor’s Telephone Number:

Position Held:

Employment Dates to:

Ending Pay (per hour):

Reason for Leaving:

Type of Position:

Full-Time

Part-Time

Per Diem

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ASSIGNMENT PREFERENCES

Keep in mind that Solution On-call Services provides services 24 hours a day - 7 days a week. Your flexibility is greatly appreciated.

Assignment Preferences

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Please check the days and time of day that you would like to work:

Monday:

Morning

Afternoon

Evening

Tuesday:

Morning

Afternoon

Evening

Wednesday:

Morning

Afternoon

Evening

Thursday:

Morning

Afternoon

Evening

Friday:

Morning

Afternoon

Evening

Client Preference(s):

Adults

Geriatric

Rehab

Terminally Ill

Are you willing to cover callouts?

Yes

Are you willing to work Holidays:

Yes

Please List:

Are you able to work cases where public transportation may not be available:

Yes

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Are you willing and able to work in homes with:

Dogs:

Yes

Cats:

Yes

Are you willing and able to work in homes with smoker?

Yes

How many miles are you willing to travel from home?

How many hours per day are you willing to work?

Geographic Preferences:

Other Work Preferences:

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Please note: Solution On-call Services cannot guarantee work or give assurance that you will only be offered cases within the preferences that you have selected. This information will help us try to accommodate your requests.

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PERSONAL INFORMATION

Personal Information

Street Address

Apt. No

City

State

Zip

Telephone

Cell

Alternate Number

Social Security Number

E-mail Address

Languages Spoken

Other Names Used Education or Employment Purposes

Are you authorized to work in the U.S.A

Yes

Have you ever worked for Solution On-call Services

Yes

if yes, where?

How did you learn about Solution On-call Services?

SOS Employee

Direct Mail

Friend/Neighbor/Relative

Internet

Newspaper

Community Referral

Other

Please identify the specific source (e.g., internet):

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EDUCATIONAL BACKGROUND

Name of School

Address/City/State

Years Completed

Degree Received

Name of School

Address/City/State

Years Completed

Degree Received

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PROFESSIONAL LICENSURE, CERTIFICATION, OR TRAINING

License

State of Issue

License Number

Expiration Date

License

State of Issue

License Number

Expiration Date

Certification

State of Issue

Certification Number

Expiration Date

CPR Certified?

Yes

Other (Please Specify)

Training

Type

Where obtained

Length of Course

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EMPLOYMENT INFORMATION

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Please provide information on all employers for the last 5 years, starting with the most recent.

Name of Employer

Address

City

State

Zip

Telephone Number

Supervisor’s Name

Supervisor’s Telephone Number

Position Held

Employment Dates to

Ending Pay (per hour)

Reason for Leaving

Type of Position

Full Time

Part-Time

Per Diem

Name of Employer

Address

City

State

Zip

Telephone Number

Supervisor’s Name

Supervisor’s Telephone Number

Position Held

Employment Dates to

Ending Pay (per hour)

Reason for Leaving

Type of Position

Full Time

Part-Time

Per Diem

Date

Desired Position

LPN

CNA

HHA

Homemaker/Companion

Other

Applicant (Last Name, First Name)

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SOLUTION ON-CALL SERVICES

Breathing New Life into Home Care

Providing a meaningful work environment and opportunity for home care professional that are professional, reliability and caring…

Solution On-call Services is committed to fair and equal employment opportunity and access to home care services. We do not discriminate against employees or applicants for employment in any manner prohibited by federal, state, and local law.

EMPLOYMENT INTEGRITY INSURANCE COVERAGE SCREENING

Personal Information

How many years at your current listed addresses on Page 2 of the application/ (Please Circle) 1 2 3 4 5+?

Previous Address

Apt #

City

State

Zip

How many years at this address?

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Please Circle Your Answer

Have you been convicted or pleaded guilty of any crimes?

Yes

Have you ever worked under a different name?

Yes

Have you ever been bonded in a previous position?

Yes

Have you ever stolen?

Yes

Have you ever worked in a capacity of handling cash or cash equivalents?

Have you ever been reprimanded, suspended, or discharged from a job due to abuse/neglect or children?

Yes

Have you ever been reprimanded, suspended, or discharged from a job due to violent behavior at work?

Have you ever been investigated for suspicion of abuse/neglect of clients or children by a government agency?

Yes

Have you ever been involved in a lawsuit, either directly or through an employer, alleging negligence or malpractice?

Yes

Have you ever been sanctioned or excluded from participating a federal or state healthcare program(s) or been convicted of a crime or surrendered/lost your professional licenses from an offense that could lead to sanction or exclusions?

Yes

Have you ever had disciplinary action filed against your professional license or CCNA/HHA certification in any state?

Yes

Have you ever been reprimanded, suspended or discharged from a job for any reason?

Yes

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Potential Hire/ Employee

The inclusion policy forms an important aspect of the recruitment of staff within the services. Applicants will not be excluded from being considered for a position based specifically on their need, background, culture, religion, gender or economic circumstances, (as pertaining to the Equality Act 2004).

Our employees are selected based on their ability to perform the services outlined in their job description regardless of the background, culture, religion, gender, origins, or in disadvantaged by condition.

Upon commencement of employment, staff will participate in Orientation/Training to the company. All staff will be made aware of inclusive practice within our company’s practices and its’ importance. When possible, staff will attend training pertaining to inclusion, for example, special needs, language development, or cultural differences.

Solution On-Call Services, LLC

Referral

(302) 353-4328

dbritton4@verizon.net

New Castle, DE

Solution On-call Services, LLC