1-561-672-8333

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Certified Nursing Assistants
Specialized Care

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Employment

Home Health Services of Southeast Florida

Home Care Services for transportation, meal preparation, dressing,
bathing, personal care and assistance.
Appreciate a caring visit. Schedule a consultation today.

Certified Nursing Assistants Specialized Care

Application for Employment | Pre-Employment Questionnaire

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information
Name:*
First Last
Phone:*
Email:*
Present Address:*
Street Address City State ZIP Code
Permanent Address (if applicable):
Street Address City State ZIP Code
Referred by:
Employment Information
Position:*
Date you can start:
Date Format: MM slash DD slash YYYY
Salary Desired:
Are you employed?
- Yes
- No
May we inquire of your present employer?
- Yes
- No
Have you ever applied to the company before?
- Yes
- No
Where?
When?
Education History
Grammar School:
Years attended?
Did you graduate?
- Yes
- No
High School:
Years attended?
Did you graduate?
- Yes
- No
College:
Years attended?
Did you graduate?
- Yes
- No
Trade, Business or Correspondence School
Years attended?
Did you graduate?
- Yes
- No
Do you have a high school diploma or GED? (required)*
- Yes
- No
Additional Education (vocational, undergraduate, etc.)
- Yes
- No
Please list the name of the school(s) and years attended (From/To)
Certifications/Licenses/Credentials
Do you have your CNA license (required)*
- Yes
- No
What is your CNA nmuber?*
Do you have your HHA Certificate? (required)*
- Yes
- No
What is the name of the institute that issued your certificate?
Do you have a communicable disease statement?*
- Yes
- No
Do you carry Professional Liability Insurance?*
- Yes
- No
Do you have a valid CPR Card?*
- Yes
- No
Have you completed HIV/AIDS training (2 hours)?*
- Yes
- No
Have you completed Alzheimer/Dementia Training (2 hours)?*
- Yes
- No
Have you completed Assistance with Self Administered Medication Training (2 hours)?*
- Yes
- No
Contact Information
What is the best way to contact you for an interview?*
- Phone
- E-mail
- Text
I certify that I have read and understand the application note on page one of this form and that answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or removal from the registry at anytime. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.*
- Yes
- No
Untitled

Contact Us Today!

Name:*
First Last
Email:*
Phone:*
Message:

Urgent Home Care – Palm Beach’s Home Health Agency

Phone
1-561-672-8333
Address
8983 Okeechobee Blvd #214, West Palm Beach, FL 33411

Our Reviews

Iris Rodriguez

Very friendly and caring staff. They take good care of their Client

Gail Khan

When going through a tough time with my parents who live with me Urgent Home Care helped alleviate so much of the burden with their professional team and efficient services that helped in the comfort of my home. The staff diligently always made sure, as a client, that all their needs were well taken care of. I am incredibly grateful and would Highly Recommend it!

Services

Special Needs Respite Care

Home Care Services for transportation, meal preparation,
dressing, bathing, personal care and assistance.

Specialized Care

A Live-In caregiver stays in the home with you for 24 hours a day. We offer complete coverage so the patients never left alone.

Alzheimer’s / Dementia Care

Our in-home care services allow your loved one to maintain their daily routine and familiar surroundings, preserving their independence.

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Home Healthcare Services by Home Health Services of Southeast Florida dba/ Urgent Home Care Specialized Care call 1-561-257-0877 8983 Okeechobee Blvd. Suite # 214, West Palm Beach, FL 33411

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