Private Duty Nursing Job Application

1. Please fill in the following:
2. What is your gender?
3. How long have you worked as a LPN?
4. Which of the following best describes your home care work experience? (Check all that apply.)
5. Are you enrolled as a Medicaid Provider (i.e. Do you have both a Medicaid Provider and National Provider Identification number)?
6. Please answer the following:
I smoke cigarettes
I'm able to bend, lean, kneel, push and pull
I'm able to lift more than 80 lbs
I am willing to perform light housekeeping tasks
I have a working cellular phone
I use text messaging
I have regular access to email
7. What type of transportation would you use to get to/from work? (Check all that apply.)
8. Which of the following categories best describes your current employment status?
9. Which of the following days and times are you available and/or willing to work? (Check all that apply.)
Mornings (7a - 1p)Evenings (4p - 8p)Overnights (10p - 7a)
10. Please take this opportunity to tell me something about yourself and/or why you're interested in this job.
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