Certifications or Licenses in Iowa?*
Years of Nursing Experience?*
Years of In-Home Care Experience?*
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. *
"Although 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 may be 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. Please check if you are able to provide if asked to do so.*
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 place 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 place personal health information here or in any part of this website, thank you.)*
How do you assess the initial needs of a new client?
(select all that apply)*
How do you organize your daily schedule when providing in-home care? *
On average, how many hours do you want to contract per week?*
On average, how many hours do you want to contract per day? *
On average, how many clients do you or do you want to serve per week? *
What is the average duration of each home care visit that you prefer? *
What safety precautions do you take in unfamiliar home environments? (Please do not place personal health information here or in any part of this website, thank you.)*
What resources or equipment do you routinely bring with you to home visits? (Please do not place personal health information here or in any part of this website, thank you.)*
How do you maintain professional boundaries while working in clients’ homes? (Please do not place personal health information here or in any part of this website, thank you.)*
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 place personal health information here or in any part of this website, thank you.)*
How do you address cultural, linguistic, or religious factors in your care? (Please do not place personal health information here or in any part of this website, thank you.)*
What strategies do you use to promote clients’ independence? (Please do not place personal health information here or in any part of this website, thank you.)*
How do you manage difficult emotional situations, such as grief or end-of-life care? (Please do not place personal health information here or in any part of this website, thank you.)*
What continuing education activities do you participate in?
(please check all that apply)*
How do you ensure client confidentiality in the contracted home setting? (Please do not place personal health information here or in any part of this website, thank you.)*
Are you familiar with relevant legal requirements for in-home care in your region? *
Describe a situation where you encountered an ethical dilemma in home care and how you resolved it. (Please do not place personal health information here or in any part of this website, thank you.)
What electronic health record or documentation systems have you used? *
Have you ever completed paper charting?
How do you communicate with other healthcare professionals regarding clients’ care? (select all that apply)
If answered other above please indicate
What aspects of in-home care do you find most rewarding? (Please do not place personal health information here or in any part of this website, thank you.)*
What aspects do you find most challenging? (Please do not place personal health information here or in any part of this website, thank you.)
How do you manage stress related to your role? (Please do not place 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.*
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 place personal health information here or in any part of this website, thank you.)
How would you like us to communicate with you?*
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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