Years of experience in a Hospital setting? (please indicate if as a Nurse, CNA, Ect.)*
Years of experience in Clinic setting? (please indicate if as a Nurse, CNA, Ect.)*
Years of experience in a Nursing Home/long term care setting?(please indicate if as a Nurse, CNA, Ect.)*
Do you have any specialized areas such as ED, ICU, Pediatric, Oncology, labor and Delivery?(please indicate if as a Nurse, CNA, Ect.) Please elaborate. (Please do not put any personal health information here or in any part of this website, thank you.)*
Certifications or Licenses in Iowa?*
You understand that as an independent contractor, you are self-employed. This means that you are not and will not be employed by Leichtman Heritage Health at Home. *
You understand that though our company does not have a general drug-testing policy, you may be required to complete a drug test prior to working at a contracted facility. This is a condition set by the contracted facility.*
Certifications.
You must be able to provide proof of all and must be up to date. This will include a background check. Can you provide proof of the following if asked? *
What types of services are you qualified or trained to complete? (Check all that apply)*
Any other services you are qualified for? (Please do not put any personal health information here or in any part of this website, thank you.)*
Typical age range of clients cared for. (please check all that apply)*
Do you specialize in caring for clients with specific medical conditions? (please specify) (Please do not put any private health information on this or any part of this website)*
On average, how many weeks do you prefer to contract out? *
On average, how many hours do you want to contract per week?*
On average, how many hours do you want to contract per day? *
Which environments you would rather contract to (please check all that apply)*
How do you evaluate the effectiveness of your care?
(please check all that apply)*
Describe any challenges you have faced in building trust with clients or their families. (Please do not put any private health information on this or any part of this website)*
How do you address cultural, linguistic, or religious factors in your care? (Please do not put any private health information on this or any part of this website)*
What strategies do you use to promote clients’ independence? (Please do not put any private health information on this or any part of this website)*
How do you manage difficult emotional situations, such as grief or end-of-life care? (Please do not put any private health information on this or any part of this website)*
What continuing education activities do you participate in?
(please check all that apply)*
How do you ensure client confidentiality in the contracted setting? (Please do not put any private health information on this or any part of this website)*
Are you familiar with relevant legal requirements for contract services in your region?*
What electronic health record or documentation systems have you used? *
What aspects of healthcare do you find most rewarding? (Please do not put any private health information on this or any part of this website)*
What aspects do you find most challenging? (Please do not put any private health information on this or any part of this website)
How do you manage stress related to your role? (Please do not put any personal health information here or in any part of this website, thank you.)*
How would you rate your overall job satisfaction? (Scale 1-10 with 10 being most satisfaction)*
Employment History: Please tell us about your last three jobs, listing Company name, address, phone number, and years worked starting with your most recent.*
Employment History: Please tell us about your last three jobs, listing Company name, address, phone number, and years worked.*
Employment History: Please tell us about your last three jobs, listing Company name, address, phone number, and years worked.*
Is there anything else you would like to add? (Please do not put any private health information on this or any part of this website)
How do you wish to be contacted?*
Attestation Statement:
I, the undersigned, hereby attest that I am voluntarily submitting my private and personal information through the website forms provided. I acknowledge and understand the following:*
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