Employment Application Form

General Information

 

Full Name *

Current Address (required)




Date of Birth

Place of Birth

Marital Status

Spouse's Name

Number of Living Children

Religious Affiliation

Name and Address of Church

Pastor Phone Number:

Church Phone Number:

Hobbies and Interests

 


 

History

 

Occupation(s):

Clubs, Organizations and Memberships

 


 

Present Physicians

 

Doctor's Name:

Phone Number:

Address:




Dentist's Name:

Address:




Phone Number:

Is The Applicant Scheduled For Any Future Doctor's Appointments That The Braley Care Staff Should Be Aware Of?
YesNo

If Yes, Please Name The Physician(s), Along With The Date And Time Of Appointment:

 


 

Medical Information

 

Known Allergies

Is The Applicant Confined In A Hospital Or Nursing Home?
YesNo

If Yes, What Is The Name And Address Of The Facility?

For What Reason(s)?

List Of Current Medications

 


 

Present Physical Condition

 

Applicant's Present Diagnoses

Primary

Secondary

Has There Been A Drastic Weight Loss?
YesNo

 

Does The Applicant Have Dentures?
UpperLowerFull

 

Control Of Bowels?
YesNo

 

Control Of Bladder?
YesNo
 

Does The Applicant Have Any Self-Managing Colostomies, Urostomies, Or Catheters?
YesNo

 

Frequent Diarrhea?
YesNo

 

Frequent Constipation?
YesNo

 

Is There Any Other Medical Or Health Information Braley Care Homes Should Know About This Applicant?

Is The Resident "CODE" Or "NO CODE"?
CODENO CODEUnsure

 


 

Psychological Information

 

Is The Applicant Generally Able To Communicate Clearly?
YesNo

 

Is The Applicant Generally Alert Or Confused?
AlertConfused

 

How Does The Applicant Feel About Receiving In-Home Service?

How Does The Applicant Spend Their Time?

The Applicant Seems (check all that apply)
DepressedAngryCheerfulFearfulContentConfusedCombativeWonders

 


 

Other Information

 

Each resident shall have a written, signed and dated health assessment by a physician or other licensed health care professional, authorized under the state law to perform this assessment, not more then sixty (60) days prior to the residents admission, or no more than five (5) working days following admission, and at least annually after that. The admission and annual health assessment shall include screening for tuberculosis and other communicable diseases if indicated by exposure, prevalence or risk according to current medial practice in congregate living situations as indicated by the secretary.

 

Responsible Parties To Be Notified In Case Of Emergency, Discharge Or Demise Of The Resident:

 

NAME

Relationship

Address

Phone Number

Does The Applicant Have Legal Representation?
YesNo
 
 

Check If Applicant Has Any Of The Following:


 

A Guardian

YesNo

If Yes, Give Name, Address And Phone Number

Medical Power Of Attorney
YesNo

If Yes, Give Name, Address And Phone Number

Power Of Attorney
YesNo

If Yes, Give Name, Address And Phone Number

Durable Power Of Attorney
YesNo

If Yes, Give Name, Address And Phone Number

A Living Will
YesNo

 

Resuscitation Directives
Yesno

List Any Person, Agency Or Organization Responsible For Payments Of The Resident

List Any Special Directions

 


 

Insurance Information

 

Insurance Company

Address:




Policy #

Group #

Payor #

 
 
* Please note that Braley Care Homes will ask for copies of the applicant's insurance cards, Social Security card, MPOA, POA, Living Will and DNR (if applicable).
 
 

 

General Information

 

Full Name *

Date *

Current Address (required)




Main Phone*:

Cell Phone:

Email Address*:

How Were You Referred To Braley Care Homes?

 


 

Employment Positions

 

Position(s) Applying For:

 

Applying For (check all that apply)
Regular Full-Time WorkRegular Part-Time WorkTemporary Work
 

What Days And Hours Are You Available For Work?

Desired Start Date

Desired Start Salary

 


 

Personal Information

 

Have you ever applied to Braley Care Homes before?*
YesNo
 

If Yes, Please Explain (include date):

Do You Have Any Friends Or Relatives Working For Braley Care Homes? *
YesNo

If Yes, Please State Name And Relationship:

If Hired, Would You Have Transportation To / From Work? *
YesNo
 

Are You Over The Age Of 18? (If under 18, hire is subject to verification of minimum legal age.) *
YesNo
 

If Hired, Would You Be Able To Present Evidence Of Your U.S. Citizenship Or Proof Of Your Legal Right To Work In The United States? *
YesNo
 

Are You Able To Perform The Essential Functions Of The Job For Which You Are Applying, Either With Or Without Reasonable Accommodation?
YesNo
 

If No, Describe Functions That May Not Be Able To Be Performed:

 

(Note: Braley Care Homes complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)
 

Have You Ever Been Convicted Of A Criminal Offense (felony or misdemeanor)? *
YesNo
 
If Yes, Please Describe The Crime. Include The Nature Of The Crime(s), When And Where Convicted And Disposition Of The Case:

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

 


 

Education, Training, And Experience

 

HIGH SCHOOL *

Did You Graduate? *
YesNo

UNDERGRADUATE COLLEGE

Course Of Study:

Years Completed:

Did You Graduate?
YesNo

Diploma/Degree:

GRADUATE / PROFESSIONAL COLLEGE

Course Of Study:

Years Completed:

Did You Graduate?
YesNo

Diploma/Degree:

VOCATIONAL SCHOOL

Course Of Study:

Years Completed:

Did You Graduate?
YesNo

Diploma/Degree:

 


 

Additional Information

 

Do You Speak, Write Or Understand Any Foreign Languages?
YesNo

If Yes, Which Language(s), And How Fluent Do You Consider Yourself To Be?

Describe Any Other Experience, Training, Qualifications, Or Skills Which You Feel Make You Especially Suited For Working With Braley Care Homes:

 


 

Work History

 

Start with last employment. Include job related military service or volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.
 

LAST/CURRENT EMPLOYER

Address

Dates Employed:
 
From:

To:

Job Title

Supervisor

Describe Work Performed:

Hourly Pay/Salary:
 
Starting:

Final:

Reason For Leaving

May We Contact?
YesNo
 
 

PREVIOUS EMPLOYER

Address

Dates Employed:
 
From:

To:

Job Title

Supervisor

Describe Work Performed:

Hourly Pay/Salary:
 
Starting:

Final:

Reason For Leaving

May We Contact?
YesNo

 


 

Personal/Professional References

 

(Do not include family members or past supervisors.)
 
Reference Name #1:

Phone Number

Association:
PersonalProfessional
 

Reference Name #2:

Phone Number

Association:
PersonalProfessional
 

Reference Name #3:

Phone Number

Association:
PersonalProfessional

 


 

Applicant Statement

 

- I certify that answers given herein are true and complete.
 
- I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
 
- In the event of employment, I understand that false or misleading information given in my application or interview(s) may resulting discharge.
 
- I understand a criminal background check is required for employment, and that I will be responsible for the cost of the background check, and further if the results are not in compliance with WV State regulations I will be dismissed from employment immediately.
 
- I understand it is mandatory to have a tuberculosis PPD test before the first date of employment.
 
- I understand it is mandatory to have a current CPR/First Aid certification. Braley Care Homes will provide the class at no cost, and I must have this certification within 15 days of hire.
 
- I understand the Alzheimer’s Dementia Training is required for employment at Braley Care Homes III. The training may be obtained by several mean, however is offered at no charge at Braley Care Homes III. Employment begins the first day of shadowing. You are not compensated for the Alzheimer’s Dementia Training.
 
- I understand that the Nurse/Nurse Aid Abuse Registry check will be performed before beginning employment.

 
The Last Four Digits Of My Social Security Number Are: *

My Nursing License Number Is:

 


 

An Equal Opportunity Employer

 

Braley Care Homes is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.
 
 

Contact Us

Location:

Braley Care Homes

6192 US 60

Hurricane, WV 25526

 

Phone Numbers:

Referrals and Inquiries: (304) 767-4033

Facility Phone: (304) 201-3677

Facility Fax: (304) 201-3678

© 2020 Braley Care Homes, Inc.