An Extra Hand Home Care

Required Documents Form / For Pre-Employment Screening

Name *

First

Last

1. *

☑️ Employment Application / Resume

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2. *

☑️ CPR / First Aid*

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3. *

☑️ Driver's License*

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4. *

☑️ CNA / PCA / Nursing License*

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5. *

☑️ Physical Exam (must be within 1 year)*

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6. *

☑️ Orientation Sheet Signed

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7. *

☑️ Job Description

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8. *

☑️ Background Check ($51.50) and Drug Screening ($39) - Valid from Federal Compliant Source within 90 Days

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9. *

☑️ Emergency Contact Form

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10. *

☑️ Non-Misconduct Form (Signed and Dated)

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11. *

☑️ Proof of Valid Car Insurance

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12. *

☑️ 3 Year Motor Vehicle Record Review (can print from DMV website)

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13. *

☑️ TB Skin Test with in (1) year. Chest Xray if positive (may require doctor clearance)*

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14. *

☑️ Social Security Card or (Proof of eligibility to work in the US)*

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15. *

☑️ Completed Exam (CNA / PCA / Companion Sitter) Based off Position You Were Offered

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Signature *

Applicant Signature

Electronic Signature An Extra Hand Home Care

Linda Cooks / Owner

Check List

Required Documents Form / For Pre-Employment Screening

Electronic Signature An Extra Hand Home Care

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