Registration: Comprehensive Health Services Shiftboard

If you have not yet registered for access to our online scheduling system, please complete the following form.

* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Basic Information
Please list other any names you have previously worked under, such as maiden name.
* Social Security Number
* Position Applying For:
Salary Desired:
* Shifts Available to Work (check all that apply):
Days
Evenings
Nights
Weekends
* Will you accept employment of (check all that apply):
PRN
Part Time
Full Time
* How did you hear about Comprehensive Health Services?

License Information
If you hold a current certification as a nursing assistant (CNA), please indicate any of the certifications you have that are listed below:
Basic Certified Nursing Assistant
Long Term Care (LTC)
Residential Care Aide (RCA)
Home Health Aide (HHA)
Developmental Disability (DDA)
Certified Rehabilitation (CRA)
Certified Medical Office Assistant (CMOA)
Other
List abbreviations, date & state certification obtained for all
Additional Nursing Certifications *please list all, including expired
Certified Infection Control Nurse (CIC)
Critical Care Nurse Specialist (CCNS)
Critical Care RN (CCRN)
Certified Emergency Nurse (CEN)
Certified Dialysis Nurse (CDN)
Certified Pediatric Nurse (CPN)
Certified Occupational Health Nurse (COHN)
Certified Rehabilitation Registered Nurse
Certified Wound Care Nurse (CWCN)
Gerontological Nurse
Certified Hospice and Palliative Nurse (CHPN)
Oncology Certified Nurse (OCN)
Other
List abbreviations, date & state certification obtained for all
RESUSCITATION CREDENTIALS *please complete all that apply
Advanced Cardiovascular Life Support (ACLS)
Basic Life Support for the Healthcare Provider (BLS)
Emergency Nursing Pediatric Course (ENPC)
Neonatal Resuscitation Program (NRP)
Pediatric Advanced Life Support (PALS)
Trauma Nurse Core Course (TNCC)
List abbreviations, date & state certification obtained for all
* Have you obtained the required 12 hours of in-service education per year required?
 Yes  No
If so, are you able to provide proof of completion of these hours?
 Yes  No

Background Information
* Have you ever been convicted of a misdemeanor or felony that would prohibit your employment at a healthcare facility or in a home care setting?
 Yes  No
If yes, please explain.
* Have you been convicted of a felony in the last five (5) years?
 Yes  No
If yes, please provide details and license information.
* Have you ever been found in violation of any state, U.S. jurisdiction, or federal law regulating the practice of a health care profession?
 Yes  No
If yes, please give a full explanation.
* Are any disciplinary actions or allegations, pending or substantiated, against you or your CNA certification or health care professional license in any state or U.S. jurisdiction?
 Yes  No
If yes, please provide details.
* Have you had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, censured or placed on probation by a state or U.S. jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid, or in connection with, action by such authority?
 Yes  No
If yes, please provide information.

Education
* 1 School Name
* 1 School Location
* 1 School Degree or Level
* 1 School Graduation/Certificate Year
2 School Name
2 School Location
2 School Degree or Level
2 School Graduation/Certificate Year
3 School Name
3 School Location
3 School Graduation/Certificate Year
3 School Degree or Level
Military Service
Branch
Date Entered
Date Discharged
Tye of Discharge

Past Employment/References
* Have you ever been terminated or asked to resign for any position?
 Yes  No
If yes, provide reason:
* First Reference Name
* First Reference Relationship
* First Reference Phone

* Second Reference Name
* Second Reference Relationship
* Second Reference Phone

* Third Reference Name
* Third Reference Relationship
* Third Reference Phone
* Previous Employment Company Name
* Previous Employment Supervisor Name
* Previous Employment Phone Number
* Previous Employment Company Start Date
* Previous Employment Company End Date

* Previous Employment Company Name (2)
* Previous Employment Supervisor Name (2)
* Previous Employment Phone Number (2)
* Previous Employment Company Start Date (2)
* Previous Employment Company End Date (2)

* Previous Employment Company Name (3)
* Previous Employment Supervisor Name (3)
* Previous Employment Phone Number (3)
* Previous Employment Company Start Date
* Previous Employment Company End Date

Applicants Certification and Agreement
* I understand that before I am placed in any position and throughout my employment, CHS will proceed with a criminal background check.
 Yes  No
* I understand as a part of the job selection process, I will be required to take a drug screening test at the time of employment and if requested, in accordance with state and federal law, at any time during my employment. I consent to a urine, blood or breath sample for the purposes of an alcohol, drug, intoxicant, or substance abuse screening test. I agree to utilize clinics that are approved by CHS. I understand that a test result that has been confirmed as positive will eliminate me from employment. If I refuse to sign this form and submit to drug testing, CHS will reject my application.
 Yes  No
* I understand that I will be required to have a physical examination and 2-Step TB Test. I hereby consent to obtaining a physical examination and 2-Step TB test at this time, as well as any future times that are required by CHS.
 Yes  No
* I understand providing false, misleading information or omission of facts may disqualify me from employment with CHS and may cause termination if discovered at a later date.
 Yes  No
Please explain any questions marked as NO here:
* Please sign to show you understand



Thank you for your interest!
 
 
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309-808-4409
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