Home Health Aide Training School – Lifestyle Homecare Service

Embark on a Rewarding Career as a Home Health Aide.

We Offer Education and Job Placements for Nurses and Healthcare Professionals
Lifestyle Homecare Home Health Aide Training specializes in home health aid training. Our staff of skilled, registered nurses has several years of experience and offers friendly, helpful service. For more information, contact us in New Jersey on

978-300-3070

Personal Information

Prefix

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone Number *

Email Address *

Gender

Social Security Number *0 / 9

Height *

Weight in Pounds *

Eye Color *

Hair Color *

Country of Birth *Select Country of birth

Race *

Full Name *

Phone Number *

Relationship

What is your primary language? *

What other language(s) do you speak?

Preferences & Shift Availability

Are you currently working at another agency? *

Have you ever worked with a difficult patient? *

What hours?:

What type of case can you accept?

Can you work with dogs? *

Can you work with cats? *

Can you work around smokers? *

Work Experience

Company Name

Position Held

Employed Start Date: *

Day

Month

Year

Employed End Date: *

Day

Month

Year

Home Health Care Services of NJ, Inc. (“HCS”) personnel are required to follow the rules of conduct and avoid actions that result in conflict of interest. *I am currently employed by another Licensed Home Care Services Agency (LHCSA)I am currently employed by another organization but not Licensed Home Care Services Agency (LHCSA)I am not currently employed by any Licensed Home Care Services Agency (LHCSA) or organization

Select from the following: *I have specific hours and days of employment with another agency or OrganizationMy hours of employment with another agency or organization vary and I do not have a specific day or hours that I work

W4 & I9

Tax Marital Status *Single or Head of HouseholdMarried Filling JointlyMarried Filling Separately

Total number of children UNDER age 17 *

Other Dependents *

Are you a U.S. Citizen? *

Legal & Background Checks

Do you give Home Health Care Services of NY, Inc. permission to conduct a Criminal Background check? *YesNo

Have you been convicted of a crime? *

Have you had a final finding of patient abuse? *YesNo

Health Questionnaire

Do you have any medical conditions? *

Hep B Vaccine – Please select from one of the followingI do not wish to be given the Hapatitis B Vaccine at this time. I am aware that I may require to be provided the vaccine at a later date during my employment with the agencyI am requesting to receive Hep B VaccineI have already received Hep B Vaccine

I have been provided with information on the Hepatitis B Vaccine and have been evaluated by an agency health professional. I have had the opportunity to ask questions about the benefits and risks of the Hepatitis B Vaccination. I also understand that there is no guarantee that I will be come immune and that there is a possibility that I will experience an adverse side effect from the yeast products *I am not allergic to yeast or yeast productsI am not currently immune suppredded, neither by disease nor medication

I understand that due to my occupational exposure to the influenza virus, I may be at risk of acquiring the influenza virus. I have also been asked if I have any questions regarding this information and if I had questions, they were fully answered to my satisfaction. Despite these facts, I am choosing to decline the influenza vaccination for the following reason(s): *Mediacal reasonsPersonal (Non-medical) reasonsReligious reasons

Do you have any of the below symptoms? *YesNo

If "YES", State symptoms

Do you drink alcoholic beverages? *YesNo

Do you take depressant or narcotic drugs that alter your behavior? *YesNo

Do you take prescription medications? *YesNo

Do you smoke? *YesNo

Name of your Physician:

Physician Phone Number

Government Assistance

Are you a member of a family that received SNAP (Food Stamps) benefits during the past 6 months? *YesNo

Did you get SNAP for 3 out of the past 5 months but are no longer getting them? *YesNo

Are you a member of a family that received TANF/Welfare for the last 18 months before you were hired? *YesNo

Are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired? *YesNo

Did you start receiving TANF for any 18 months after August 5, 1997 which ended within 2 years before you were hired? *YesNo

Are you no longer receiving TANF/Welfare because you reached the maximum allowable? *YesNo

Did you receive TANF/Welfare for 9 months out of the past 18 months? *YesNo

Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days? *YesNo

Were you Unemployed for the past 27 weeks and you received any unemployment benefits? *YesNo

Did you receive a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit? *YesNo

Were you referred by a Network under the Ticket to Work program? *YesNo

Were you referred by a Network under the a Vocational Rehabilitation Agency approved by a State? *YesNo