Employment History (List from most recent)
Experience and Skills Inventory for CNAs and Home Care Assistants
We have the responsibility for the care of patients/families with a wide variety of needs. We are interested in assisting you to enhance your current skills and to learn new skills. The following questions are designed to identify your individual skills in order to provide orientation and assignments that will be as meaningful and appropriate. Using the following skill codes, circle your skill level for each task.
Skill Level Codes (0 – No experience; 1 – Needs Review/Limited Supervision; 2 – Can perform independently)
References (Please include two professional references and one personal reference.)
In case of emergency, please contact:
I certify that the facts contained in this application are true and complete to the best of my knowledge, and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the reference and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have,personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing unless it is in writing and signed by an authorized company representative.