Premier Application Form

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Last Name: *
Branch: *
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Phone: * (Digits Only)

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Thank you for registering!

You will now be directed to the following:

  • 1. Basic Exam

  • 2. Application

  • 3. References



HHA EXAM

Question 1

How would you feel if you knew someone who was dying and they were angry and depressed because their family was avoiding them?

Question 2

Your neighbor fell down a flight of stairs and has injured her hip and can't get up. She is crying hysterically. While waiting for the ambulance, you say:

Question 3

If a person drinks 200cc of coffee and 150cc of juice with an English muffin in the morning, 250cc milk with a sandwich at lunch time and 300cc of tea in the evening with dinner, what is the total amount of cc fluid intake taken that day?

Question 4

While caring for a relative in a wheelchair, at their home, you see and smell smoke. What should you do?

Question 5

If the Doctor has prescribed a patient to eat 1400 calories a day and this patient has already eaten the following:
Breakfast 300 cal; Lunch 450 cal; Dinner 250 cal; Snack 150 cal.How many more calories must this patient eat to meet the doctor's requirement?

Question 6

When you go to work, you need to be clean, dressed neatly, and on time:

Question 7

A person tells you that they are having chest pain and difficulty breathing. You should:

Question 8

You answer the phone while baby-sitting. The caller asks for Mr. or Mrs. Miller but they are out to dinner and the movies. The caller asks you to take a message stating “ Tell Mrs. Miller that their travel reservations have been confirmed and either she or Mr. Miller can pick up the tickets before Thursday at 5:00pm at the office. Please call before Thursday to let us know if they will need any additional reservations to be made. My phone number is nine-five-six-two-three-eight. My name is Bill. ” How would you record this message?

Question 9

If you become sick and can't work it is not important to let the office know right away.

Question 10

What is the name of our agency and what position are you applying for?



Contact Information

First Name:   
Last Name:   
Address:   
City:   
State:   
Zip:   
E-Mail:   
Position:   




Education


High School:  
Location:  
Last Year Completed:   (Select One) 09 10 11 12
Graduate: Yes No
GED: Yes No




Education (Optional)


College Name:  
Location:  
Last Year Completed:   (Select One) 01 02 03 04
Graduate:   Yes No
Major/Course:  
Diploma/Degree:  




Education (Optional)


Other School Name:  
Location:  
Last Year Completed:   (Select One) 01 02 03 04
Graduate:   Yes No
Major/Course:  
Diploma/Degree:  




Credentials

HHA, CNA, PCA and Companion :   Yes  No   
Type :    
State Issued :    
#:    
Expiration Date:  
RN or LPN License:   Yes  No   
Type :    
State Issued :    
#:    
Expiration Date:  
Do you have professional liability insurance: Yes   No



Eligibility

ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?

Yes   No

HAVE YOU EVER PLEAD GUILTY OR BEEN CONVICTED OF A CRIME?
If Yes, Please Explain:

Yes   No



Availability

Please Indicate Your Availability--Click All That Apply:


  If other, please indicate:
Please Indicate What Languages You Speak:
Other Professional Memberships:



Specialty Areas

PLEASE SELECT THE BUTTONS THAT BEST MATCH YOUR EDUCATION,CREDENTIALS, AND EXPERIENCE:





(Specify)


Please Explain:



Work History

WORK EXPERIENCE:
List all of your work experience beginning with your most recent.
Any gaps in employment must be explained.
Please check here for no prior employment experience.
Please Explain:


Company Name
From 

To      
Address
Position
Name of Supervisor
Phone
Explain Reason for Leaving:

Company Name
From  

To      
Address
Position
Name of Supervisor
Phone
Explain Reason for Leaving:

Company Name
From  

To      
Address
Position
Name of Supervisor
Phone
Explain Reason for Leaving:



Additional Questions

1) Have you ever been bonded or denied bond in connection with any previous job? Yes No
2) Have you been terminated, suspended, or discharged from any previous employment? Yes No
3) Are you a licensed RN or LPN, and has your nursing license ever been suspended, revoked,canceled or allowed to lapse for any reason? Yes No
4) Do you have any relatives or friends who work or who have worked for Premier? Yes No
5) Have you applied for work at, or worked for Premier? Yes No
** If you answered "Yes" to any of the above, please explain:



References

Reference 1 (Required)
Company Name
Supervisor
Supervisor Title
Address
Please select at least one contact :
Telephone
E-Mail
Fax
Reference 2 (Required)
Company Name
Supervisor
Supervisor Title
Address
Please select at least one contact :
Telephone
E-Mail
Fax
Reference 3 (Optional)
Company Name
Supervisor
Supervisor Title
Address
Please select at least one contact :
Telephone
E-Mail
Fax


Terms of use



I am authorizing Premier Home Health Care, Inc. and it's authorized agents permission to verify any job related information given in connection with this application. I understand that any misrepresentations or falsifications may result in removal from employment consideration or dismissal. I also understand that once I submit the required documents / application, I will not be able to go back and change any information.

By selecting the submit button, I agree to the terms of use. You may print a copy of this application & disclaimer for your records.