Thank You for Your Interest in Coastal Home Care!

Thank you for your interest in Coastal Home Care!

We are a licensed home care agency with over 30 years’ experience assisting individuals with the activities of daily living. If you are a caregiver, you’ve come to the right place!

Coastal Home Care is hiring licensed RNs, LPNs and certified CNAs. If you are not licensed but have a minimum of two years’ caregiving experience, you can take the State of Georgia Personal Care Aide (PCA) exam at your closest Coastal Home Care branch office. You must pass the exam with an 80% or better score.

Please note that in order to be a Coastal Caregiver, you must have a working phone, reliable transportation, a clean background, acceptable Motor Vehicle Report and provide two professional references.

Coastal Caregivers work with the aged, blind and disabled. Experience working with individuals with developmental disabilities is a plus.

Please complete the following application and deliver to your closest Coastal Home Care branch office. We have offices in Barnesville, Brunswick, Hinesville, Savannah and Statesboro, Georgia. You can find detailed information about offices on our Locations tab.

We look forward to meeting you!

800.617.1126

COASTAL HOME CARE

STATEMENT OF NO ABUSE

Employee Name:

Date:

I certify by my signature below that I have never abused, neglected, sexually assaulted, exploited, or deprived any person or subjected any person to serious injury as a result of intentional or grossly negligent misconduct.

SignatureDate

______

WitnessDate

GENERAL INFORMATION – Please list any other names by which you may have been known, such as a maiden name.

Name / Last: First: MI: / SS#:
Address / Street: City: State: Zip Code:
How long at address listed above? years months / Applying for what position?
Phone Number::
Email Address:
Alternate phone number:
Preferred method of Contact: / Salary/Wage expected:
Applying for:  full time  part time
 1st shift  2nd shift  3rd shift / Are you willing to work any day(s), shift(s), including nights, or overtime as assigned?  Yes  No
Have you ever worked for Coastal Home Care or Altrus, Inc.?  Yes  No If yes, please indicate in the Employment History section
Do you have relative and/or members of your household who are employed by Coastal Home Care or Altrus, Inc.?  Yes  No If yes, please explain. ______
Have you ever worked with individuals who have mental retardation or developmental disabilities and/or the elderly?  Yes  No If yes, please explain. ______
Are you age 18 or older?  Yes  No
If not, do you have a work permit?  Yes  No
If hired, can you provide proof that you
are eligible to work in the United States?  Yes  No / Referral  Advertisement  Web Posting  Agency
Source  School  Employee  Walk-in
 Job Fair  Internal Employee
 Other
Have you ever been convicted of a criminal offense?  Yes  No (Record of charges or convictions do not necessarily disqualify
Have you ever been convicted of a felony? Misdemeanor?  Yes  No applicant from employment consideration. Criminal record
Are there any charges pending against you?  Yes  No checks may be required as a condition of your employment)
If yes to either question, provide details including nature of the crime, dates, and location:

REFERENCES: List Name, Address, Contact Number of 3 BUSINESS OR PROFESSIONAL references or former supervisors)

EDUCATION & TRAINING INFORMATION

School/Location / Degree / Course/Major
High School:
College(s):
Graduate School:
Business/Vocation:
Apprentice training or other courses:
LICENSES, CERTIFICATES, OR PROFESSIONAL MEMBERSHIPS:
(Do not include your driver’s license)
EMPLOYMENT HISTORY (Please begin with your most recent employer. Attach additional sheets if necessary)
1. Employer: / Hire Date: / Termination Date:
Address: / Phone Number: ( )
Your job title: / Supervisor:
Starting Pay Rate: $ Final Pay Rate: $ / May we contact your employer?  Yes  No
Describe work performed: / Reason for leaving:
2. Employer: / Hire Date: / Termination Date:
Address: / Phone Number: ( )
Your job title: / Supervisor:
Starting Pay Rate: $ Final Pay Rate: $ / May we contact your employer?  Yes  No
Describe work performed: / Reason for leaving:
3. Employer: / Hire Date: / Termination Date:
Address: / Phone Number: ( )
Your job title: / Supervisor:
Starting Pay Rate: $ Final Pay Rate: $ / May we contact your employer?  Yes  No
Describe work performed: / Reason for leaving:

MILITARY INFORMATION

Service branch: / Final Rank: / Specialty:
Current obligations:

CERTIFICATION & AGREEMENT

I certify that I have never abused, neglected, sexually assaulted, exploited, or deprived any person nor I have I subjected any person to serious injury as a result of intentional or grossly negligent misconduct.
I authorize the release to Coastal Home Care, Inc. (and/or any of its licensed agents) of information held by any parties regarding my previous employment, criminal history record and/or record of convictions in state and local files for violations of any federal, state, local statutes or ordinances, military records, credit history, driving record and scholastic records and hereby release said persons, schools, companies, government agencies, court and law enforcement authorities from any damage whatsoever for releasing this information.
I certify that all the information I have provided on this application is true and accurate. I understand that misstatements, omissions, or false or misleading statements which I have provided on this application, on my resume and/or in interview(s) shall constitute grounds for refusal to hire or immediate termination from
employment.
I understand that the terms and conditions of employment may be changed at any time without notice by the company. In consideration of employment with CHC, I agree to comply with all the policies, procedures and requirements of CHC. I understand this application and/or any CHC policy, manual, handbook or other written document describing such items do not constitute a written contract at this time or in the future. I understand my employment would be at-will and that my employment could be terminated at any time by either party, with or without cause and with or without notice. Any modification of the at-will employment relationship, oral or written, can only be accomplished by a written document signed by Coastal Home Care’s Chairman/President, CEO, or Board of Directors. I have read and understand the above.
______
Applicant’s Signature Date
This employment application is current for sixty (60) days. If you have not heard from us and still wish to be considered for employment, it will be necessary for you to fill out a new application.

APPLICANT SHOULD NOT WRITE BELOW THIS LINE

Interviewed by: / Date:
Recommended action:
Interviewed by: / Date:
Recommended action:

Revised 01/2012 X:\ADMINISTRATION\Human Resources\Hiring Process- Caregivers\Caregiver Application - Part

APPLICANT REFERENCE CHECK

Source of reference:  Written Telephone

Applicant Name: Social Security:

LASTFIRSTMI

Business Name/Location:______

Supervisor Name/Title______Phone#(s):______

Address:______Fax/email:______

Applicant Title:______Brief Description of Job:______

Employment Dates: to Earnings: $ hourly/biweekly (circle one)

I authorize the release to Coastal Home Care (and/or any of its licensed agents) of information held by any parties regarding my previous employment and hereby release said persons, schools, companies, government agencies, court and law enforcement authorities from any damage whatsoever for releasing this information.

Applicant signature: Date: ______

REFERENCE TO COMPLETE BELOW THIS LINE

The individual above has applied for the position of with Coastal Home Care. So as to comply with good employment practices, we ask that you furnish the information requested below. Any and all information will be held in the strictest confidence and not divulged to the applicant. Your reply is greatly appreciated.

Coastal Home Care Representative: Date: ______

Please check the boxes that best describe applicant's performance / Excellent / Good / Satisfactory / Unsatisfactory / Unable to evaluate
Quality of work /  /  /  /  / 
Attendance record /  /  /  /  / 
Dependability /  /  /  /  / 
Working relationship with other employees /  /  /  /  / 
Working relationship with clients /  /  /  /  / 
Skills related to the job /  /  /  /  / 

Are the above employment dates correct?  Yes  No If no, please provide correct dates: to

Reason for separation:

Are the above stated earnings correct?  Yes  No If not, correct amount is $ .

Would you rehire this individual?  Yes  No If no, why not?

Do you recommend this applicant for employment?  Yes  No

Are you aware of any incident for which this individual was convicted of having abused, neglected or mistreated an individual?

If yes, please provide date(s) and circumstance(s) on an attachment.

Additional comments:

SignatureTitleDate

APPLICANT REFERENCE CHECK

Source of reference:  Written Telephone

Applicant Name: Social Security:

LASTFIRSTMI

Business Name/Location: ______

Supervisor Name/Title: ______Phone #(s): ______

Address:______Fax/e-mail:______

Applicant Title:______Brief Description of Job:______

Employment Dates: to Earnings: $ hourly/biweekly (circle one)

Applicant signature: Date:

REFERENCE TO COMPLETE BELOW THIS LINE

Coastal Home Care Representative: Date: ______

Are the above employment dates correct?  Yes  No If no, please provide correct dates: to

Reason for separation:

Are the above stated earnings correct?  Yes  No If not, correct amount is $ .

Would you rehire this individual?  Yes  No If no, why not?

Do you recommend this applicant for employment?  Yes  No

Are you aware of any incident for which this individual was convicted of having abused, neglected or mistreated an individual?

If yes, please provide date(s) and circumstance(s) on an attachment.

Additional comments:

SignatureTitleDate

Coastal Home Care

Applicant Information Sheet

Applicant Name:______

Please put a check mark next to the areas you are able and willing to work:

______Savannah/Chatham County: Downtown, Islands, Southside, Westside, Pooler, Bloomingdale, Garden City, Port Wentworth

______Effingham County: Rincon, Springfield

______Bryan County: Richmond Hill, Pembroke______McIntosh County: Darien

______Liberty County: Hinesville, Midway, Walthourville

______Glynn County/Golden Isles: Brunswick, St. Simons, Jekyll Island

______Camden: St. Marys, Kingsland, Woodbine

______Charlton County: Folkston______Ware County/Waycross

______Long County/Ludowici ______Wayne County/Jesup

______Barnesville and surrounding counties (Butts, Henry, Lamar, Monroe, Pike, Upson, Spalding)

Which days and hours are you able and willing to work?

Hours availablefor CHC Not available to work for CHC

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Are you a PCA (Personal Care Assistant) or CNA? ____ How many years of experience do you currently have?_____

Do you have Hoyer Lift Experience? _____ Yes _____ No If no, would you like additional training? ______

Do you have any pet restrictions? ______Yes _____ NoIf yes, please list the pet/s ______

Do you have a preference working with male/female clients?_____ Yes Preference ____ No Preference

If you check yes, please list which client you would prefer to work with ______

Would you be comfortable working in a home where the client or family members smoke? ___ Yes ___ No

My signature on this form indicates that I agree to work the above following shifts/days. I understand that I can stay as busy as I would like to stay as long as my work ethic complies with Company policy. In the event that I accept a case/s and I do not show up, I will be immediately terminated and will not be eligible for re-hire with any other Coastal Home Care Services Agency. I also agree to give a two week notice before resigning and I understand that if I do not give proper notice and work the schedule that I agreed to, I will not be eligible for re-hire and I will be terminated. No exceptions. I understand that one of the requirements for this position, will be to work at least two shifts, two weekends per month.

Signature: ______Date: ______

Contact Info: Home ______Cell______

Email address: ______

What area do you currently live in including the zip-code? ______

NURSING ASSISTANT SKILLS ASSESSMENT
Please check if you have performed and can adequately demonstrate the following:

VITAL SIGNS BEDMAKING

___ORAL TEMPERATURE ___UNOCCUPIED
___RECTAL TEMPERATURE ___OCCUPIED
___PULSE
___RESPIRATION HOUSECLEANING
___BLOOD PRESSURE ___LAUNDRY

___ HOME CLEANING

PERSONAL HYGIENE ___GROCERY SHOPPING
___BED BATH
___SPONGE BATH
___TUB BATH URINARY
___SHOWER ___USE OF REGULAR BED PAN

___USE OF FRACTURE BED PAN

SKIN CARE ___USE OF URINAL/MALE

___BACK RUB
___SIMPLE DRESSING CHANGES CATHETER

___POSITIONING TO RELIEVE PRESSURE AREAS___FOLEY CATHETER-EMPTY BAG

___WASH WITH SOAP/WATER___CLEANING PERINEUM AT CATHETER INSERTION POINT ___CARE/CHANGING OF OVERNIGHT DRAINAGE BAG ___CONDOM CATH-EMPTY BAG CARE/CHANGING OF LEG BAG

___APPLICATION OF CONDOM CATHETER

MOUTH CARE
___BRUSH TEETH BOWEL
___BRUSH DENTURES ___COLOSTOMY CARE-EMPTY BAG
___MOUTH CARE FOR UNCONSCIOUS PATIENT ___SOAPSUDS ENEMA ___TAPwATER ENEMA

___FLEETS ENEMA

___USE OF PORTABLE COMMODE

HAIR CARE ___BOWEL PROGRAM FOR QUADRIPLEGIC

___SHAMPOO/COMB
___USE OF SHAMPOO TRAY

TRANSFERS ___TO/FROM BATH BENCH

NUTRITION ___TO/FROM WHEELCHAIR

___SIMPLE MEAL PREPARATION ___TRANSFER BOARD
___OFFERING FLUIDS TO PATIENTS ___HOYER LIFt
___MEASURING INTAKE /OUTPUT
___FEEDING PATIENTS W/CHEWING & MISCELLANEOUS
SWALLOWING PROBLEMS ___BASIC COMMUNICATION
___ G-TUBE FEEDINGS ___ACTIVE LISTENING

___ASSIST W/OXYGEN NASAL PRONGS

SHAVING ___UNIVERSAL PRECAUTIONS
___WITH ELECTRIC RAZOR ___CPR
___WITH SAFETY RAZOR ___FIRST AID

NAIL CARE

___SOAK & FILE TOENAILSAGE SPANand specialties
___CLEAN & FILE FINGERNAILS ___PRENATAL

___POSTPARTUM

ASSIST WITH CLOTHING ___NEWBORN/INFANCY
___BEDBOUND PATIENT ___CHILDREN
___WHEELCHAIR PATIENT ___ADULTS

___GERIATRICS

BODY MECHANICS ___developmentally disabled
___USE OF TRANSFER BELT ___brain injured

___RANGE OF MOTION EXERCISE ___quadriplegia/paraplegia
___“STAND BY” AMBULATION
___ASSISTING W/CANES
___ASSISTING W/ WALKERS
___ASSISTING W/CRUTCHES

BED POSITIONING

___SIDE LYING

___PRONE (BACK LYING)

___USE OF TROCHANTER ROLLS USE OF DRAwSHeeet

EMPLOYMENT REQUIREMENTS

The items listed below are mandatory requirements for employment by Coastal Home Care. All field staff (Personal Care Assistants, Certified Nursing Assistants, Licensed Practical Nurses and Registered Nurses) are required to HAVE and KEEP CURRENT the following requirements. If you are offered employment, Coastal Home Care, Inc. will administer a TB test to you at NO additional charge if your current test has expired. Once these items are received we will be able to proceed with the review of your application for employment. Please check the appropriate boxes below and add the expiration date that your requirements expire.

YES or NO

CPR Expiration Date ______

First Aid Expiration Date ______

TB Test Expiration Date ______

If not current, when is the last time you had one?

______

CNA, LPN or RN License:

State of ______License Number ______

Expiration Date ______

**Please be sure to give us copies of all your requirements. If you have any questions, please let us know.

We appreciate your interest in Coastal Home Care!

Sincerely,

The Coastal Home Care Staff /

912.354.3680

PERSONAL CARE ASSISTANT
Job Description

Job Summary: The Personal Care Assistant (PCA) is responsible for the client’s personal care needs and surroundings and may supply temporary relief (respite) for the client’s primary caregiver. The PCA provides care in the home, in a hospital, or in a nursing home. The PCA is also referred to as a nursing assistant, respite care worker, or personal support aide.

ALL EMPLOYEES MUST never have been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by this written statement to this effect

Qualifications: The Personal Care Assistant must have one of the following:

Certification as a CNA on the Georgia State Registry.
Credentials indicating successful completion of a health care or personal care credentialing program.

Successful completion of a 40-hour training program provided by a private home care provider.
Successful completion of a competency exam.

Performance Requirements: The Personal Care Assistant must be able to:

Lift and/or transfer clients without restrictions. Must be able to lift at least 30 lbs.
Show patience and respect in dealing with sick, elderly, or disabled clients.
Work under close supervision of agency staff and cooperate with the client’s family and staff from other agencies involved in the client’s care.
Maintain CPR and First Aid certification and annual TB screening.

Essential Job Functions: The PCA follows the care plan established for the individual client. This care plan may include any or all or the following:

Activities of Daily Living assistance including personal care needs, meal preparation, and assistance with eating. Personal Care needs may include giving or assisting with bath or shower, dressing, grooming, toileting, ambulating, and transferring from bed to chair or other locations.
Routine housekeeping chores including: laundry, changing bed linens, dusting, washing dishes, vacuuming, and other light household duties.
Errands as necessary and directed by supervisor.
Serve as companion to client and/or provide temporary relief to caregiver.
Provision of specialized client care as instructed by the supervisor and as evidenced by documentation of training.
Communicate to CHC the client’s needs and any changes in the client’s status through written documentation and verbal communication.

I have read this job description, and I can meet the position’s qualifications, performance requirements, and essential job functions.

Signature ______Date ______