Pre-Application

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Address*
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Employment Application

Applicant Information

Name
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Address
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Are you a citizen of the United States?
Have you ever worked for this company?
Have you ever been convicted of a felony?
If no, are you authorized to work in the U.S.?

Education

Did you graduate?
Did you graduate?
Did you graduate?

References

Please list three professional references.

Previous Employment

May we contact your previous supervisor for a reference?
May we contact your previous supervisor for a reference?
May we contact your previous supervisor for a reference?

Military Service

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

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Step 1: Enter Personal Information

Address
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at (800) 772-1213 or go to www.ssa.gov.
(c)
Complete Steps 2—4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Do only one of the following. (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3—4). If you or your spouse have self-employment income, use this option; or (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Do only one of the following. (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3—4). If you or your spouse have self-employment income, use this option; or (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate
Complete Steps 3—4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3—4(b) on the Form W-4 for the highest paying job.)

    Step 3: Claim Dependent and Other Credits

    If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

      Step 4 (optional): Other Adjustments

      Step 5: Sign Here

      Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

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      Date

      Employers Only

      Employers Only

      Step 2(b)—Multiple Jobs Worksheet (Keep for your records.) Note:If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
      1 $
      2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3
      2a $
      2b $
      2c $
      Step 4(b)— Deductions Worksheet (Keep for your records.)
      1 $
      • $29,200 if you're married filing jointly or a qualifying surviving spouse
      • $21 ,900 if you're head of household
      • $14,600 if you're single or married filing separately
      3 $
      4 $
      5 $

      Step 1: Figure your basic personal allowances (including allowances for dependents)

      Check all that apply:

      Step 2: Figure your additional allowances

      Check all that apply:
      Address (Street Number and Name)
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      I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.
      Check one of the following boxes to attest to your citizenship or immigrationstatus (See page 2 and 3 of the instructions):
      If you check Item Number 4., enter one of these:
      OR
      OR
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      List A

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      OR
      List B
      OR
      List C
      Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.
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      Employer's Business or Organization Address
      For reverification or rehire, complete Supplement B, Reverification and Rehire

      VISITING NURSES OF ILLINOIS, INC.

      Employee Training: Emergency Operations Plan (EOP) _______Initial Training _______Biennial Training
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      1. Emergency Operations Plan training performed. 2. Community-Based and Facility-Based (Agency) Risk Assessment (Hazard Vulnerability Analysis) presented. 3. Testing/implementation of plan and staff roles reviewed and discussed: o Staff notification. o Prioritized patients. o Agency command structure. o Community command structure. 4. Communication plan reviewed and discussed. Communication during emergency, including back-up communication. o Alternate means of communication: radio, television, in-person. o Sharing patient information with other settings, per HIPAA regulations. 5. Employee educated to develop his/her own individual emergency operations plan.
      Employee was deemed competent with the EOP (through instructor Question and Answer Session).
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      (Note: Copy to Employee Personnel File)

      Visiting Nurses of Illinois, Inc.

      EMPLOYEE HEALTH EXAMINATION RECORD

      Marital Status: M S W D
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      Address

      Have you had any of the following? (Please check)

      Diabetes
      Operations
      Fractures
      Head Injury
      Back Injury
      Other Injuries
      Chronic Back Pain
      Tuberculosis
      Heart Trouble
      Stomach Trouble
      Fainting Spells
      Epilepsy
      Mental Disease
      Jaundice
      Rheumatism
      Asthma
      Sinus Trouble
      Skin Disease
      Hernia
      I have read the above and declare that I have had no injury, illness or ailment other than as specifically herein noted. Any falsification or misrepresentation will be sufficient grounds for my release from employment.

      Physicians Health Examination

      Physical Exam: Skin:
      Eyes /Ears /Throat
      Respiratory
      Cardio Vascular
      Gastro Intestinal
      Endocrine
      Nervous
      Musculoskeletal
      Urinary
      PPD Mantoux Test
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      Chest X-ray
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      Influenza vaccine
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      Covid Vaccine
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      I certify that the above person is free from symptoms indicating the presence of infectious diseases and does not have any condition which would interfere with the performance of his/her duties.
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      VISITING NURSES OF ILLINOIS, INC.

      HEPATITIS B VACCINATION WAIVER FORM

      I understand that due to my occupational exposure to blood or other potentially infectious material, I am at risk of acquiring HBV (Hepatitis B Virus) infection. I have read the Employee Information Sheet: Hepatitis B and Hepatitis B Vaccine and have had an opportunity to ask questions and understand the risks and benefits of the HBV vaccine.

      I have been given the opportunity to be vaccinated at no charge to myself.

      Having been so informed, I decline to take the HBV vaccine at this time. I understand that by declining the vaccine, I continue to be at risk of acquiring hepatitis. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated, I can receive the vaccination series at no charge to me.

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      AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENTSCREENING

      Driver Record Screening Disclosure

      I hereby authorize Embark Safety LLC and its designated agents and representatives to conduct a comprehensive review of my driver record background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include information about my names, motor vehicle records, license verification. Upon Request, Embark Safety LLC will supply a copy of the completed consumer report along with a copy of an individual's rights under the Fair Credit Reporting Act.

      Authorization and Release

      authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I authorize the full release of the information described above, without any reservation, throughout any duration of my employment at
      (company name). I certify that all information provided below is correct to the best of my knowledge. This authorization and consent shall be valid in original, fax, or copy form. The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose.
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      Notice to California Applicants: Under section 1786.22 of California Civil Code, you have the right to request from Embark Safety LLC, upon proper identification,the nature and substance of all information in files pertaining to you, including the sources of information, and recipients of any reports on you, which Embark Safety LLC has previously furnished within the two-year period preceding your request. You may view the file maintained on you by Embark Safety LLC during normal business hours. You may also obtain a copy of this file upon submitting proper identification. Upon making a written request, you may receive a summary of your report. Notice to Maine Applicants: Under Chapter 210 Section 1314 of Maine revised Statutes, you have the right, upon request, to be informed within 5 business days of such a request to whether or not an investigative consumer report was requested. If such report was obtained, you may contactthe Consumer Reporting Agency and request a copy. Notice to Massachusetts Applicants: Under Mass. Ann. Laws chapter. 93 55 50, a Consumer Reporting Agency may furnish a report if intended to be utilized for employment purposes.
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      VISITING NURSES OF ILLINOIS, INC

      ORIENTATION CHECKLIST

      ORIENTATION TO

      1. Basic Home Safety: bathroom, electrical, environmental and fire
      2. Safe ro ram:
      a. Risks within Agency and patient's home
      b. Actions to eliminate, minimize or report risks
      c. Incident reporting and procedures to follow
      d. Reporting processes for common problems, failures and user errors
      3. Storage/handling/access to/transport of supplies/medical ases/dru s
      4. ID/handIing/disposaI of infectious wastes (Blood and Body Fluids/Precautions)
      5. ID/handIing/disposaI of hazardous waste cytotoxic/chemothera drugs)
      6. Infection Control and Prevention
      a. Personal hygiene (e.g., PPE and handwashing)
      b. Aseptic procedures
      c. Communicable infections (TB, AIDS, etc.)
      d. Cleaning/disinfecting reusable equipment
      e. Precautions to be taken (Standard Precautions, airborne transmission, direct/indirectcontact, compromised immunity)
      7. Confidentiality of patient information/HIPAA policies and ractices
      8. Community resources
      9. Policies/procedures
      10. Responsibilities related to safety and infection control
      11. Advanced directives policies/procedures
      12. Specific job duties/responsibilities and any limitations; performance standards Professional boundaries
      13. Screening for alleged or suspected victims of abuse/neglect reporting
      14. Emergency operations plan and role
      15. Equipment use/management relevant to job description
      16. Tuberculosis Program/Plan (OSHA)
      17. Hazardous Materials in the Workplace Program (SDS) OSHA
      18. Bloodborne Pathogen Program (OSHA)
      19. Managing the environment of care: (pt & Agency site)
      a. Safety
      b. Fire safety — fire escape, fire alarm system, fire extinguishers — and revention
      c. Security — Personal safety during home visits
      d. Utilities
      e. Responding to emergencies
      20. Pt rights/responsibilities, including conveying charges for care
      21. Agency complaint mechanism/Medicarestate hotline # and purpose
      22. QAPI program and role
      23. On-call and answering service
      24. Ethical aspects of care, treatment and services and process to address ethical issues
      25. Philosophy/mission/purpose/vision/goals/conflictof interest
      26. Interpreters/communicating with hearing/speech/ visually im aired
      27. Sentinel event policy/process
      28. Physical safety (e.g., body mechanics and safe lifting)
      29. Cultural diversity and sensitivity
      30. Role of the health team
      31. Family/State Medical Leave Act
      32. Organizational structure, lines of authority and responsibility; supervision process Corporate Integrity Plan
      33. Hours of work; benefits
      34. Documentation requirements, including OASIS, if applicable
      35. Medical Device Reporting Act
      36. Equal Employment Opportunity Act
      37. Sexual Harassment Act
      38. Salary/hourly wage reimbursement
      39. Unemployment and Workers' Compensation
      40. Malpractice coverage
      41. Assessing and managing pain.
      (Note: See Job-specific Competency Checklist for Skills)
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      VISITING NURSES OF ILLINOIS, ING

      INSERVICES LOG

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      TOPIC

      Compliance Program

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      Patients' Rights and Responsibilities

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      How to handle patient and caregiver complaints/ grievances

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      Infection Control Training

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      OSHA/Workplace and Patient Safety

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      Communication Barriers

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      Emergency preparedness

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      Sexual Harassment

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      Cultural Diversity

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      Ethics Training

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      Home Health Best Practices - Telligen

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      Alzheimers/Dementia

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      VISITING NURSES OF ILLINOIS

      INSERVICE ATTENDANCE SHEET:

      PRESENTED BY: MARIA THANUGUNDLA

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      Company Information

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      Employee Information Authorization

      Important! Please read and sign before completing and submitting.

      I hereby voluntarily authorize the Company named above (hereafter "Employer"), either directly or through its payroll service provider, to deposit any amounts owed me, by initiating credit entries to my account (s) at the financial institution (s) of my choice (hereinafter "Bank") indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Employer, either directly or through its payroll service provider, to my account. To the extent permitted by law, in the event that Employer or its payroll service provider deposits funds erroneously into my account (s), I authorize Employer, either directly or through its payroll service provider, to debit my account for an amount not to exceed the original amount of the erroneous credit.
      To the extent permitted by law, I understand that I have the right to refuse consent or revoke authorization of direct deposit at any time without fear of retaliation, and I have the right to receive any payment owed to me by other means. This authorization is to remain in full force and effect until Employer and Bank have received written notice from me of its termination in such time and manner as to afford Employer and Bank reasonable opportunity to act on it.

      Name
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      Deposit/Account Information

      Employee Direct Deposit Banking Authorization Form

      RUN Powered by ADPO

      1. Deposit/Account Information

      Choose only one account type:
      Or

      2. Deposit/Account Information

      Choose only one account type:
      Or

      3. Deposit/Account Information

      Choose only one account type:
      Or

      4. Deposit/Account Information

      Choose only one account type:
      Or

      Take advantage of Employee Access@ in RUN Powered by ADP@ to let your employees manage their own direct deposits.

      Attention Payroll Contact: Employers must keep each original Employee Direct Deposit Banking Authorization form on file as long as the employee is using direct deposit, and for two years thereafter. Employers may be subject to certain federal and state direct deposit notice, authorization and record retention requirements. Please review your applicable federal, state and local laws. This form is provided for convenience only and is not meant and should not be construed as legal, HR, financial, insurance, tax or accounting advice. You should consult with your own legal counsel, human resource, accounting or Other professional advisor for circumstances pertaining to your business.

      GLUCOMETER AND/OR COAGULATION TESTING COMPETENCY ASSESSMENT

      Employee was observed/competency assessed in the following areas:
      1. Performance of test on unknown specimen:
      2. Quality control performance maintained:
      3. Cleaning/maintenance of equipment:
      Successfully passed written test for:
      1. Glucometer:
      2. Coagulation Testing:
      Employee demonstrated competency in laboratory testing.
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      Note: This acknowledgement will be included in your personnel file.

      VNofIL - Application - RN Addendm

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      Clear Signature
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      Clear Signature

      VISITING NURSES OF ILLINOIS, INC

      INITIAL COMPETENCY CHECKLIST

      RN/LPN/LVN

      Date and RN's si nature indicates that the nurse has been checked off on the rocedure.

      SKILLS

      1. Urinary catheters:

      a. Foley insertion—male/female

      COMPETENT
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      b. Suprapubic insertion/removal

      COMPETENT
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      2. Central Cath Lines

      COMPETENT
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      3. Enteral Feedings:

      a. Bolus

      COMPETENT
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      b. Continuous

      COMPETENT
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      c. Removal/insertion PEG tubes

      COMPETENT
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      4. Equipment:

      a. IV pumps

      COMPETENT
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      b. Enteral pumps:

      COMPETENT
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      c. Oxygen concentrator:

      COMPETENT
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      d. Oxygen tank

      COMPETENT
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      e. Nebulizer

      COMPETENT
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      5. IV therapy:

      a. Peripheral/INT

      COMPETENT
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      b. Adm fluids/meds

      COMPETENT
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      c. Dressing change

      COMPETENT
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      6. Irrigations:

      a. Bladder

      COMPETENT
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      b. Colostomy

      COMPETENT
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      7. Suctioning:

      a. Nasal

      COMPETENT
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      b. Oral

      COMPETENT
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      c. Tracheal

      COMPETENT
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      8. Tracheostomy Care

      COMPETENT
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      9. TPN:

      a. Administration

      COMPETENT
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      b. Labs

      COMPETENT
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      c. Starting/stopping

      COMPETENT
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      d. Additives

      COMPETENT
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      10. Venipunctures

      COMPETENT
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      11. Transporting lab specimens

      COMPETENT
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      12. Wound care:

      a. Aseptic technique

      COMPETENT
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      b. Sterile technique

      COMPETENT
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      13. Standard Precautions:

      a. Gloves

      COMPETENT
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      b. Gowns

      COMPETENT
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      c. Masks/goggles

      COMPETENT
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      d. Shoe covers

      COMPETENT
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      e. CPR resusci masks

      COMPETENT
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      Clear Signature
      Clear Signature

      VISITING NURSES OF ILLINOIS, INC

      ONGOING COMPETENCY ASSESSMENT

      Skilled Nurses

      DEMONSTRATEDCOMPETENCY IN:
      Patient rights/responsibilities
      Agency complaint mechanism
      Respect of patient property
      Basic home safety
      Infection control/standard precautions
      Communicating with patient
      Patient assessment/reassessment
      Patient education
      Emergency management plan
      Home care record documentation
      Care Observed:
      Venipuncture: Competent
      Wound Care: Competent
      Foley Insertion: Competent
      IV Start: Competent
      Employee competent to provide care?
      Needs improvement?
      Clear Signature
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      Clear Signature
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      VISITING NURSES OF ILLINOIS, INC.

      PERFORMANCE APPRAISAL/EVALUATION

      Registered Nurse (RN)

      Provides services in accordance with the Ian of care.
      Makes the initial evaluation visit and regularly reevaluates the patient's nursing needs.
      Initiates the pIan of care and necessar revisions.
      Provides those services requiring substantial specialized nursing skills.
      Initiates appropriate preventive and nursing procedures.
      Initiates appropriate preventive and nursing procedures.
      Prepares clinical and progress notes for each patient visit and summaries of care conferences on his/her patients in a timely manner as per Agency policy
      Coordinates services.
      Informs personnel of changes in the condition and needs of the patient.
      Counsels with the patient and family in meeting nursing and related needs.
      Participates in and presents in service programs.
      Processes orders and notifies physician of patient needs and changes in condition.
      Completes comprehensive assessments within fort -eight 48) hours.
      Completes certification/recertification orders as specified in policy
      Implements and documents in nursing notes actions/interventions as outlined in the pIan of care.
      Determines the amount and type of nursing needed for the patient
      Initiates individualized care plans based on admission assessment and physician orders according to Agency policy.
      Involves the patient/family in developing the plan of care.
      Reviews, evaluates and updates the care plan based upon assessments.
      Prepares discharge summaries which reflect the care provided and outcomes.
      Refers to PT, OT, SLP and MSW those patients requiring their specialized skills.
      Supervises and teaches other nursing personnel.
      Provides appropriate information regarding the patient to other agencies/individuals involved in the patient's care.
      Directs and supervises performance of LPN as specified, and reports findings as appropriate.
      Supervises HHA's work every fourteen days, either in the presence of or absence of the HHA, and completes supervisory visit form.
      Participates in after hour on-call duty as assigned.
      Provides total patient care as needed.
      1 - Does Not Meet Standards 2 - Needs Improvement 3 - Meets Standards 4 - Exceeds Standards
      Obtains knowledge and supervised practice of new skills.
      Observes confidentiality, safeguards all patient related information.
      Attends staff meetings and patient care conferences as scheduled.
      Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames.
      Appropriately utilizes ICD-10 codes.
      Completes documentation and paperwork in a timely manner per Agency policy.
      Immediately reports to Clinical Manager/Director of Clinical Services any patient incidents/variances or complaints.
      Demonstrates competent performance of technical skills according to established procedures.
      Participates in peer review and QAPI activities as requested.
      Understands and adheres to established policies/procedures.
      Adheres to Agency standards and consistently interprets and accurately performs all assigned responsibilities.
      Maintains acceptable attendance status, per Agency policy.
      Maintains acceptable level of tardiness, per Agency policy.
      Reports all incomplete work assignments to Director of Clinical Services/Clinical Manager.
      Appearance is always within Agency standard; is clean and well groomed.
      Demonstrates effective time management skills through daily documentation and infrequent overtime for routine assignments.
      Participates in inservice programs and presents inservices as assigned.
      Maintains clean and neat work environment.
      Demonstrates sound judgment and decision making.
      Maintains current CPR certification, if required.
      Performs other duties as assigned.
      Clear Signature
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      Clear Signature
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      1 - Does Not Meet Standards 2 - Needs Improvement 3 - Meets Standards 4 - Exceeds Standards