Nursing – Certified Nursing Assistant, 3East

Duties :

Under the direction and supervision of the RN, assist patients with activities of daily living, provide basic nursing care and the maintenance of a safe and clean environment.

Qualifications :

High School Diploma. Nurse Aide certification required. Previous hospital experience preferred. BLS certification required.

Physical capability of safely executing the duties and responsibilities required of the position (e.g., lifting, transferring).

Mather Hospital provides equal employment opportunity and treats all employees equally regardless of their age, race, creed / religion, color, national origin, alienage or citizenship status, sexual orientation, military or veteran status, sex / gender, gender identity, gender expression, disability, genetic information or genetic predisposition or carrier status, marital status, partnership status, victim of domestic violence, or other characteristics protected by applicable law.

Personal Information (All questions on this form must be answered)

Position DesiredHOURS(Required) Full Time Part Time Per Diem Today's Date(Required) Month Day Year Available Start Date(Required) Month Day Year SHIFT(Required) Day Evening Night Name(Required) First Last

Have you ever been known by any other name? If so, please state :

Other NameAddress(Required) Street Address City State / Province / Region ZIP / Postal Code Country EmailHome PhoneCell Phone(Required)Do you have a legal right to work in the U.

S.?(Required) Yes No Are you 18 years of age or older?(Required) Yes No Were you previously employed by Mather or any other Northwell facility?

Required) Yes No When / Where?Have you ever been a volunteer at Mather?(Required) Yes No When?List any friends or relatives working for Mather : (Name / Relationship)List any friends or relatives working for Mather : (Name / Relationship)

Education

High School School Name Loction Year Graduated Years Completed Nursing / Technical / Trade School Name Loction Year Graduated Years Completed College School Name Loction Year Graduated Degree Graduate School School Name Loction Year Graduated Degree List scholastic honors, fellowships and / or scholarships awardedDo you have any special training or skills?

Required) Yes No If yes, explain :

Professional Licenses

Licenses(Required) I do not have any professional licenses I have a professional license listed below N.Y.S. License Type of License N.

Y.S. License # N.Y.S. License Date (Date of First Issue) I am not licensed in N.Y. State but plan to Take N.Y. State Licensing Exam On This Date MM slash DD slash YYYY I am not licensed in N.

Y. State but plan to Apply for reciprocity Apply for temporary permit On This Date MM slash DD slash YYYY N.Y.S. Temporary Permit Type of Permit Temporary Permit # Expiration Date Other State(s) in which licensed (leave blank if none)To the best of your knowledge, have you ever been reported to the Office of Professional Discipline (OPD) or the Office of Professional Misconduct (OPMC)(Required) Yes No If yes, please explain : Is your license (clinical, driver’s, etc.

currently, or has it ever been, the subject of investigation by licensing authorities, and / or surrendered, restricted, deemed inactive, suspended or revoked?

Required) Yes No If yes, please explain :