• 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
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