CNA Application Forms

First Name: Last Name:

Email:

Phone:

City,State:

 

 

SERVICE DESCRIPTION FOR CERTIFIED NURSING ASSISTANT

CONTRACT LABOR – PHYSICAL, SENSORY, & MENTAL REQUIREMENTS

PHYSICAL REQUIREMNTS (F) – Frequently used (O) – Occasionally used

Please look over this description. Make sure you are able to complete all requirements before submitting this application.

REQUIREMENT

USED

COMMENTS

SIT

(O)

FEED, READ, AND TALK TO PTs.

STAND

(F)

INVOLVING PT. CARE

WALK, BEND, SQUAT

(F)

DAILY

LIFTING UNNASSISTED – UP TO 20 LBS

(F)

WORKING WITH EQUIPMENT

21-50 LBS

(O)

OVER 50 LBS - ASSISTANCE NEEDED

GRASPING USING BOTH HANDS

(F)

RENDERING PT. CARE AND PROCEDURES FOR PT. CARE

PUSHING/PULLING

(F)

WHEEL CHAIRS, CARTS

FINE MANIPULATING USING BOTH

HANDS

(F)

DRESS PATIENTS, WRITE NOTATIONS, OPEN PACKETS, DOCUMENTATION

MOVE AROUND MACHINES

(O)

MACHINES IN PATIENTS ROOMS

MANIPULATING FEET USING BOTH

FEET

(O)

USING FOOT LOCKS AND PEDALS ON BEDS, HOPPERS AND HAMPERS

EXPOSURE TO DUST, FUMES, AND

SHARP OBJECTS

(O)

DUST, CHEMICALS, SAFETY PINS, RAZORS, ETC.

SENSORY REQUIREMENTS

REQUIREMENT

COMMENTS/RELATED JOB DUTIES

CAN DISTINGUISH SMELLS

FOUL ODORS ARE OFTEN SYMPTOMATIC OF

THE DISEASE PROCESS OR INFECTION

CAN HEAR

NORMAL TONES SOFT TONES

PATIENTS CALLS AND CALL BELLS MUST BE

ANSWERED HEARD FROM CLOSE AND FAR DISTANCES

CAN DISTINGUISH TEMPERATURES BY TOUCH OR PROXIMITY

BATH WATER FOR PATIENTS, TEMPERATURE OF

EQUIPEMENT AND PATIENTS.

EYESIGHT: NORMAL OR CORRECTED

AND ABLE TO DO CLOSE EYE WORK

OBSERVE PATIENTS, GIVE PATIENTS CARE

THERMOMETERS, CHARTS, ETC.

MENTAL REQUIREMENTS

REQUIREMENT

COMMENTS/RELATED JOB DUTIES

READ, WRITE AND SPEAK

NECESSARY – TO COMMUNICATE WITH PTs.,

COMPREHEND NURSING SUPPLIES, CHARTS,

DIET CARDS, ETC.

MEMORY AND RECALL

NECESSARY

POSITIVE ATTITUDE TOWARD THE ILL, ELDERLY, HANDICAPPED

NECESSARY

IS COHERENT

NECESSARY

CAN CONTROL EMOTIONS, CAN

HANDLE STRESS

NECESSARY RELATES TO BOTH PHYSICAL AND MENTAL REQUIREMENTS, NOT GETTING ANGRY, etc.

 

TASKS

ASSISTING PATIENTS WITH BATHING, ENSURING THAT WATER IS APPROPRIATE TEMPERATURE

ASSISTING PATIENTS TO AND FROM BATHROOM

RECORDING INTAKE AND OUTPUT INFORMATION

CHECKING VITALS AND WEIGHTS

ANSWERING PATIENT’S CALL LIGHTS AND REQUESTS

REPORTING OBSERVATIONS OF THE PATIENT TO NURSING SUPERVISOR

I have read and understand that the physical, sensory, and mental requirements outlined below are necessary of the services to be performed. I affirm I am able to perform the service without limitation and have not knowingly withheld any information relating to these requirements.

CNA SKILLS CHECKLIST

 
It is mandatory that you read and fill out this form. The checklist is used to assess you experience and skills. Please provide and accurate self-assessment of your skill using the following guidleines.
 
0=No Expeience
1=Limited Experience
2=Experiened
3=Highly Experiened
 

Documentation:

Clincal Note:

Personal Care:

Total Bed Bath: Tub Bath:

Shower: Sponge Bath:

Sitz Bath: Hair Care:

Nail and Foot Care: Skin Care:

Perineal Care: Oral Care:

Denture Care: Shave Patient

Asst. W/ Dressing: Other:

General Nursing:

Admit & Orient Patient: Dischage Patient:
Vital Sign Monitoring: Pulse Ox:
Urine Dipstick: Blood Glucose Monitoring:
Wound Care: Dressing Changes:
Pre-Op Care: Post-Anesthesia Care:
Restraints-Apply/Monitor: Isolation Techniques:
Advance Directives: Postmortem Care:
 

Cardiac:

Use of Cardiac Monitors: Telemetry:

Perform 12-leed EKG: Assist w/ Code

Acute MI: Congestive Heart Failure:

Pre/Post Cardiac Cath: Pre/Post Cardiac Sugery:

Aneursym: Perm Pacemaker:

Temp Pacemaker:

Orthopedic:

Crutch Walking: Cast Care:

Traction: Amputation:

Skeletal Traction: Arthoscopy:

Total Hip Replacement: Total Knee Replacement:

Activity:

Postitioning: Transferring:

Walker: Passive Range of Motion:

Active Range of Motion: Walking W/ Assistance:

Walking with Supervision: Hoyer Lift

Assist W/ Exercise Program:

Vascular:

Apply Noninvasive BP Monitor: Monitor Noninvasive BP Monitor:

Peripheral Pulses: Discontinue Peripheral IV:

Intake and Output: Ultrasound Doppler

Respiratory:

Open/Monitor Airway: Asst. W/ Intubation

Asst. W/ Extubation 02 Saturation Spot Checks

02 Saturation Monitors: Incentive Spoirometry:

Nasal Cannula: Face Masks:

Asthma/COPD: Pre/Post Thoracic Sugery:

Tracheostomy: Chest Tubes:

Neurology:

Neurological Eval: Glascow Coma Scale

Assist W/ Lumbar Puncture: Seizure Precautions:

Open/Close Head Surgery: CVA:

Spinal Cord Injury Craniotomy:

Drug Overdose:

Gastrointestinal:

Asst. W/ Nutritional Eval: Asst. W/ Feeding:

Gastrostomy Tube Monitor/Feed: Ostomy Care

GI Bleed: Abdominal Wound:

Drains:

Genitourinary:

Straight/Foley Cath Female: Straight/Foley Cath Male:

Obtain/Instruct Clean Catch Urine Shunts/Fistuals:

Renal Failture: Nephrectomy:

Renal Transplant: Mastectomy:

Hysterectomy: Prostate Surgery:

Other:

Diabetes: AIDS

Multiple Traumas: Burns:

Oncology: Bone Marrow Transplant:

Liver Transplant:

Age:

Newborn: Toddler (1-3):

Preschooler (3-5): School Age (5-12):

Adolecents (12-18): Young Adult (18-39):

Middle Adult (39-64): Older Adult (64+)


*

By clicking Sign & Send below you agree to the terms contained herein, and that terms are binding in your jurisdiction as defined in our Electronic Signature Disclosure & Consent

E-Sign Act Disclosure and Agreement

Your Consent To Use Electronic Records and Electronic Signatures

This website has elected to use electronic signatures as the default choice in lieu of paper. Be advised that according to the U.S. Federal E-SIGN Act in addition to various state laws an electronic signature is legally the same as a paper and ink signature. Also be advised in event enforcement is needed, all signatures are held in trust by SwiftSignature.com, as a neutral 3rd party, and may be legally enforced in court of law as per the terms of your respective contract.

Federal law requires certain safeguards to ensure that both consumers and vendors have the capability to receive copies of documents upon signature and are advised of the consequences of agreeing to receive documents electronically. Federal law also requires your consent to use e-mail and electronic versions of said contract and/or agreements, disclosures, and other documents and records, herein referred to as simply "electronic documents" that would otherwise be legally binding only if provided to you on paper as a printed physical document.

Electronic Documents for purpose of this disclosure include any documents signed using the Swift Signature service. All documents once signed cannot be revoked or canceled and will be stored for a minimum period of ten (10) years, and are available to either party at any time through our electronic web portal.

Free Document Storage Account

All signors are automatically entitled to a free document storage account within Swift Signature, the cost of which is given to you by the owner of this website. After signature, you may follow the prompts to save your document to your free account, where it will be accessible for a minumum of 10 years. This account is optional and available as a courtesy to you.

Right to withdraw consent

Note you do have the right to withdraw your consent to receive and/or use electronic documents, but be advised this does not cancel or revoke any prior documents for which permission existed at that time. The legal validity and enforcement of electronic documents, signatures, and deliveries used prior to revocation of consent will not be affected. To withdraw your consent, please contact the owner of this website.

Right to receive paper document

You have the right to have any document in paper form, should you choose at no charge to you. To request paper documents, please contact the party who referred you to this service.

By clicking "Sign and Send" on any document posting to SwiftCloud servers, you are agreeing to the terms contained herein, and are providing your consent to the use of electronic documents and signatures, as well as e-mail or sms phone message delivery of related electronic documents. You are also acknowledging receipt of this disclosure.

Hardware & Software Requirements

Use of this Service Requirements

  1. Connection to the internet
  2. Any internet web browser with graphical interface and a pointing device, aka "a mouse" for desktop computers or a touch screen for tablets or modern phones common after 2004
  3. a PDF reader or browser capable of displaying Adobe PDF documents
  4. A printer, should you wish to print and retain a paper copy of signed documents.

Acknowledgement of your access and consent to electronic records and electronic signature

By clicking "Sign & Send" on any document posting to this service, you agree that

  • You were able to read this E-SIGN Act Disclosure & Agreement
  • Should you desire, you were able to print on paper or electronically save this agreement for future reference
  • You have an active email on file with the owner of this website
  • That the device on which you indicated your agreement or signature, including both your hardware and your software comply with the terms above and were able to render the agreement in a fashion functionally equivalent to paper, and that the document agreed to was both readable and understandable.
  • That any indication of signature and/or initials in addition to information provided is wholly yours and subject to the terms above.
  • You consent to receive electronically any records, notices, agreements or disclosures made to you by our client, the referring service, during the course of your relationship with that company, subject to revocation per terms above.

Electronic Signature         Disclosure & Consent