* = Required Information
Yes No

POSITION / Type of Employment Desired

RN LPN LVN MSW
HHA CNA PT OT
ST Other
Yes No
Part-Time Full-Time
Temporary Live-in
Day Swing Graveyard Rotating

EDUCATION AND TRAINING

Yes No

College, Business School, Military (Most recent first)

Yes No
Yes No

SPECIAL SKILLS (List all pertinent skills and equipment that you can operate)

WORK EXPERIENCE (Most Recent First) (Include voluntary work and military experience)

Yes No
Yes No
Yes No

Physical Record /Limitations

Yes No
Yes No

Check all that apply

Pediatrics
Director of Nursing
Mental Health
Hospice
Home Health
Alzheimer’s or Dementia
Autism
Other

Experience:

less than a year
1‐3 years
3‐5 years
More than 5 years

Skills Inventory:

Private Home

less than a year
1‐3 years
3‐5 years
More than 5 years

Meal Prep

less than a year
1‐3 years
3‐5 years
More than 5 years

Special Diets

less than a year
1‐3 years
3‐5 years
More than 5 years

CVA

less than a year
1‐3 years
3‐5 years
More than 5 years

IV Therapy

less than a year
1‐3 years
3‐5 years
More than 5 years

Foley Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Tracheostomy

less than a year
1‐3 years
3‐5 years
More than 5 years

Transfer ROM

less than a year
1‐3 years
3‐5 years
More than 5 years

Bathing

less than a year
1‐3 years
3‐5 years
More than 5 years

TPR

less than a year
1‐3 years
3‐5 years
More than 5 years

Blood Pressure

less than a year
1‐3 years
3‐5 years
More than 5 years

Dressing Change

less than a year
1‐3 years
3‐5 years
More than 5 years

Warm/Cold Compress

less than a year
1‐3 years
3‐5 years
More than 5 years

Respiratory Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Ostomy Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Ventilator

less than a year
1‐3 years
3‐5 years
More than 5 years

Geriatric Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Pediatric Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Psychiatric Care

less than a year
1‐3 years
3‐5 years
More than 5 years

AIDS Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Maternal

less than a year
1‐3 years
3‐5 years
More than 5 years

Intellectual Disability Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Alzheimer’s Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Oncology/ Hospice Care

less than a year
1‐3 years
3‐5 years
More than 5 years

Emergency Contact Information 1

Emergency Contact Information 2

AVAILABILITY (NOTE: YOU ARE REQUIRED TO WORK AT LEAST ONE WEEKEND PER MONTH AND SOME HOLIDAYS)

7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM
7AM-3PM
3PM-11PM
11PM-7AM
7AM-7PM
7PM-7AM

FOR EACH COUNTY, INDICATE CITIES AND ZIP CODES IN WHICH YOU ARE WILLING TO WORK

BREVARD

ORANGE

OSCEOLA

SEMONILE

NOTE: The DON/Scheduler will notify of your shift at least one week in advance, however situations may arise when we may need to call upon you at the last minute. Also, you are expected to be available at least one weekend a month. This could be on-call or on assignment based on the company needs.

Attach Documents

PLEASE READ CAREFULLY

In exchange for the consideration of my job application by Accolade Healthcare Services, LLC, I agree that:

  • Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position. Both the undersigned and Accolade Healthcare Services, LLC may end the employment relationship at any time.
  • I further understand that my employment with the company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary or thereafter, my employment relationship with Accolade Healthcare Services, LLC is terminable at will for any reason by either party.
  • I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Accolade Healthcare Services, LLC permission to contact schools, all previous employers (unless otherwise indicated), references, and perform a local and level2 criminal background check on me as required by Florida state law. I hereby release Accolade Healthcare Services, LLC from any liability as a result of such contact.

I certify the information contained in this application is true, correct, and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal.

Clear

Accolade Healthcare Services, LLC is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with Accolade Healthcare Services, LLC depends solely on your qualifications.