Independent Contracted Private
Home Care Nursing
Welcome to our private contract home nursing services, where we focus on delivering personalized care. Whether you're looking for a few extra hours of work, wish to keep your nursing skills sharp in retirement, or prefer one-on-one patient interactions, this opportunity might be ideal for you. Come join us in making a positive impact on the lives of those we serve!

The following questionnaire is designed for private contract nurses who provide in-home care services. Its purpose is to gather valuable insights about your professional experiences, practice standards, challenges encountered, and the quality of care delivered to clients in home settings. Your responses will help improve the standards of home-based nursing care and contribute to a better understanding of the needs and expectations of both the Independent Contracted Nurses and our Contracted Clients.

First name

Last name

Phone

Address

Position

Certifications or Licenses in Iowa?

yes

Nursing Qualifications

ARNP

BSN

LPN

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.

Yes, I understand

"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.

Yes, I understand and acknowledge.

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.

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)

Structured assessment tools

Clinical interview

Collaboration with client’s physician

Family input

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?

yes

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?

yes

How do you communicate with other healthcare professionals regarding clients’ care? (select all that apply)

Phone calls

In-person meetings

Other

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.

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.)

Thank you for taking the time to complete this questionnaire. Your insight is invaluable in shaping the future of in-home nursing care, refining best practices, and ensuring that private contract nurses continue to provide compassionate, effective, and safe care in the homes of those who need it along with coordinating Client Contracts that match that.

How would you like us to communicate with you?

Phone call

Text via phone

Date and time

Month

Day

Year

Time

HoursMinutes

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:

Purpose of Data Collection: I am aware that my personal information is being collected for the purposes stated on the website and that it will be used only as described.

Accuracy of Information: I confirm that the information I am providing is accurate, complete, and up-to-date to the best of my knowledge.

Consent to Processing: I give my explicit consent for my personal information to be processed in accordance with applicable laws and the website’s privacy policy. I attest that no private health information was placed in this questionnaire.

By signing below, I confirm that I have read, understood, and agree to the above attestation regarding the submission and use of my private and personal information via website forms.

Signature

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By signing below, I confirm that I have read, understood, and agree to the above attestation regarding the submission and use of my private and personal information via website forms.

Leichtman Heritage Health at Home PLLC

L3HPLLC

Please do not submit personal health information on this website,
as requested by our company.

Leichtman Heritage Health at Home pllc

Terms & Conditions

Privacy Policy

Please do not submit personal health information on this website, as requested by our company.

Leichtman Heritage Health at Home pllc

Terms & Conditions

Privacy Policy

Please do not submit personal health information on this website,
as requested by our company.