Applicants

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• Employment verification form -Please complete two (2) forms

• Employment Eligibility Form {1-9 Form)

• Conflict of Interest Form (Annual Requirement)

• State W-4 Form

• Federal W-4 Form

• Two Professional references (one is required to be a Charge RN or Manager who can evaluate your skills) Please give•·us both home and work numbers.

• Criminal Background Check

• Influenza Education & Education Status Form -annual Flu vaccination is

required to staff many of our clients

• Clinical skills checklist(s) and Signed Job Description

2.Health Requirements

• Physical Examination/ Physician's Statement-Must be within the last 12 months (annual requirement)

• Hepatitis B Documentation -Vaccination series, Titer, or Signed Declination

• TB Test-Must be within the last 12 months or a recent chest X-Ray (Annual Requirement)

■ TB Questionnaire -Must be only be completed if you test

positive for TB

3. Licenses and certificates

• Copies of current Indiana or Michigan license and QMA and CNA

certification

• Current CPR card (Only American Heart Association is accepted)

• Proof of eligibility to work in the United States