Royal Health Services - Multi-Step Employment Application

Personal Information

Step 1 of 7

Last Name *

First Name *

Middle Name

Street Address *

Social Security Number *

City *

County

State *

Zip Code *

Home Phone

Cell / Mobile Phone *

Email Address *

Are you a U.S. Citizen? *

Yes No Resident Alien A#

If not a citizen, are you legally authorized to work in the U.S.?

Yes No

Employment Desired

Position(s) applied for: *

Registered Nurse (RN) Licensed Practical Nurse (LPN) Certified Nursing Assistant (CNA) Caregiver / Homemaker

Other:

Date Available to Start

Preferred Geographic / Service Location

Have you ever applied here before?

Yes No

Previously employed by Royal Health Services?

Yes No

Education & Credentials

Level	School Name & Location	Years	Graduated	Major / Degree
High School
Nursing / Trade School
College / University

Form Verification & Applicant Attestation

Applicant Full Name

Date

Applicant Digital Signature

[ Signature on file ]

Illinois Healthcare Worker Background Check

Illinois Department of Public Health (IDPH) Health Care Worker Registry Authorization

Step 2 of 7

Important Disclosure: Pursuant to the Illinois Health Care Worker Background Check Act (225 ILCS 46/), all healthcare agencies must check the IDPH Health Care Worker Registry and conduct a fingerprint-based criminal history records check prior to or upon hiring.

1. Candidate Legal Demographics

Other Names Used (Maiden/Alias)

Date of Birth *

Gender *

Race / Ethnicity *

Driver's License / State ID #

State of Issuance

Height (feet) *

Height (inches) *

Weight (lbs) *

Hair Color *

Eye Color *

City / State of Birth *

States Where You Have Lived *

2. Previous Residential Addresses (Last 5 Years)

Previous Address 1 (if less than 5 years at current)

Previous Address 2

3. Disqualifying Offenses & History Declarations

Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated delinquent)? *

Yes No

Have you ever had an administrative finding of Abuse, Neglect or Theft? *

Yes No

4. Authorization and Disclosure for Criminal History Records Information (CHRI) Check

I hereby authorize the Illinois Department of Public Health (the Department), the Department's designee, educational entities that train and/or test health care workers, staffing agencies, my current or potential employer, or a health care facility where I want to volunteer to initiate/request a CHRI check on me. I further authorize the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI) to release information and photographs relative to the existence or nonexistence of any criminal record, which it might have concerning me, to any initiator/requestor solely to determine my suitability for testing in a health care training program, employment, continued employment, or to work as a volunteer. I further authorize any entity that maintains criminal records and photographs relating to me, including but not limited to a local unit of government in any State, to release those records and photographs to the ISP, FBI, or the Department. I authorize the Department to provide any health care facility, training program or staffing agency, to which I have provided this authorization and disclosure form, a copy of my ISP CHRI and a determination of eligibility of the FBI CHRI. I certify that the ISP, FBI, any entity that maintains criminal records and photographs, the Department, and any of their employees or officers who furnish this information shall be held harmless from all liability, which may be incurred as a result of releasing such information. I further acknowledge that a educational entity or a health care employer shall not be liable for the failure to hire or retain me as an applicant, student, employee, or volunteer if I have been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25).

I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment, training, or volunteering, if discovered after employment, training, or volunteering begins, and can result in discipline up to and including my termination of employment, being a volunteer, or a student.

I understand that the information requested below regarding gender, race, height, eye color, hair color, weight, place of birth and date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.

I hereby authorize Royal Health Services and the Illinois Department of Public Health (IDPH), or its designated agents/vendors, to perform a background check including fingerprinting, criminal history record search, state registry check, and verification of all statements supplied.

IDPH Background Check Authorization Signature

Applicant Full Name

Date

Applicant Digital Signature

[ Signature on file ]

Job Description & Role Acknowledgement

ROYAL HEALTH SERVICES, LTD – HOME SERVICE FORMS

Step 3 of 7

Job Position

Home Service Worker

Reports To

Home Maker Service Supervisor

Qualifications

To be employed by the agency as a homemaker, an individual must:

a) Have a Social Security number and provide the agency with documented verification of this number.
b) Must be 18 years of age or older. If a minor between 14 and 16 years of age who is not employed during school hours, has an employment certificate, and meets all other requirements of the Child Labor Law [820 ILCS 205], and has an adult who is at least 21 years of age and who is legally responsible for the client who will supervise the worker; or be 16 years of age or older, enrolled in school and not employed during school hours.
c) Have provided to the agency at least two written or verbal recommendations from present or former employers or if never employed, references from at least two non-relatives.
d) Can communicate and be able to follow directions.
f) Have previous experience and/or training adequate and consistent with the specific tasks required for the customer's safe and proper care.
h) Complete an employment application with the agency.

1) Shall provide services to the individual following his/her Service Plan.

2) Shall submit a bi-monthly calendar listing actual hours worked each pay period (1-15; 16-last working day of the month), as verified by the customer and following the number of hours authorized.

3) Shall maintain all customer information as confidential and not for release.

4) Shall not subcontract to any other person any of the services.

5) Shall provide services only while the individual is in his/her home.

Employment Conditions: Employment is conditional upon passing the Criminal Background Check. Initial performance evaluation will be conducted within six months of hire.

I have received a copy of the job description for my records. I have read the entire job description and understand my responsibilities.

I have received a copy of the job description for my records. I have read the entire job description and understand my responsibilities. *

Job Description Acknowledgement Signatures

Employee Name

Date

Employee Digital Signature

[ Signature on file ]

Home Maker Service Supervisor Signature

Royal Health Supervisor (On File)

Homemaker Competency Checklist

ROYAL HEALTH SERVICES - Caregiver & Homemaker Skills Evaluation

Step 4 of 7

Evaluation Date

Evaluator / RN Supervisor Name

Instructions: Check the rating for each homemaker competency standard based on self-evaluation or demonstrated proficiency. Legend: C = Competent / Satisfactory, NI = Needs Improvement / Training, N/A = Not Applicable.

Homemaker Competency Domain & Task Items	C	NI	N/A
1. Household maintenance & housekeeping skills
Sweeping, mopping, vacuuming, and cleaning living areas, kitchen, and bathroom.
Washing dishes, pots/pans, and sanitizing kitchen countertops and appliances.
Laundry care: sorting clothes, operating washer/dryer, folding, ironing, and storing linens.
Changing bed linens and making client beds neatly.
2. Meal planning, food safety & preparation
Planning balanced meals according to client care plan and dietary restrictions.
Safe food handling, proper storage of leftovers, checking expiration dates.
Grocery shopping, errand running, and maintaining accurate receipts/expense logs.
3. Client safety, emergency & personal care assistance
Recognizing home safety hazards (throw rugs, poor lighting) and fall prevention.
Assisting client with mobility, safe transfers (chair to bed), and escorting.
Infection control principles: hand hygiene, donning gloves, surface disinfection.
4. Communication, rights & documentation
Promptly reporting changes in client health, condition, or emergency to supervisor/911.
Maintaining client confidentiality (HIPAA), respecting privacy, and client dignity.
Accurate recording of task timesheets, duty logs, and client visitation logs.

Homemaker Competency Verification Signatures

Employee Name

Date

Employee Digital Signature

[ Signature on file ]

Tuberculosis (TB) Risk Assessment & Screening

ROYAL HEALTH SERVICES, LIMITED - Health Screening

Step 5 of 7

Royal Health Services, Limited

1. Tuberculosis (TB) History Questionnaire

This questionnaire is about tuberculosis. Tuberculosis can be transmitted from one person to another by an individual who lives with or spends a great deal of time with them. Tuberculosis is transmitted by a person with tuberculosis to another person through airborne droplets that are coughed or sneezed into the air and breathed in by the person. This transmission of infection is more likely to occur when the exposed and the infectious person spend a lot of time together in a closed environment, like a small room, a car, or other similar situations.

A person can have tuberculosis infection and not have active tuberculosis.

Not everyone who coughs has tuberculosis.
TB can cause (low-grade) fever for long duration, unexplained weight loss, failure to maintain adequate growth in children, weakness, chest pain, a bad cough, hoarseness and/or coughing up blood.
Tuberculosis is preventable and treatable.
Children with active TB often do not show signs of illness.

Since your last TB skin test... (check the one that applies)

Screening Question	Yes	Don't Know	No	NA
1. Has anyone in your family had tuberculosis (TB)? *
2. Have you had a skin test conversion from negative to positive in the past 2 years? *
3. Have you been on steroids (cortisone) in the past 6 weeks? *
4. Have you recently had mucous (coughed-up) tested for TB? *
5. If yes, were you told that it was positive for TB? *
6. Have you ever been treated with medication for infectious TB? If yes, how many months and how many medications? *
7. Are you still taking TB medication? *
8. Did you take all the TB medications until the physician told you that you were finished? *
9. Have you ever had a positive TB test? If yes, when? *
10. Have you ever received a BCG Vaccine? *
11. TB can cause fever of long duration, unexplained weight loss, weakness, chest pain, a bad cough, hoarseness or coughing up blood. Have you been around anyone who has these problems? *
12. Have you ever had an abnormal chest x-ray? *
13. Do you have a cough that has lasted more than three weeks? *
14. Do you live with anyone or have been in close contact with someone who was recently diagnosed with TB? *
15. Have you lost appetite (not hungry)? *
16. Have you lost weight 10 lbs in the last 2 months without intention? *
17. Do you have night sweats (need to change the sheets or your clothes because they are wet) in the middle of the night? *

If any answers are "yes" or "I don't know" the employee must have a TB skin test completed.

2. Annual TB Questionnaire

The Annual Tuberculosis Questionnaire is used to evaluate your current TB status. We cannot utilize the tuberculin skin test (PPD or Mantoux) if you have a positive reaction to the test. A positive skin test means that sometime during your life you came into contact with tuberculosis or have had a vaccination to prevent you from contracting tuberculosis. It does not mean that you have TB now.

In the past yearly chest x-rays were performed; however, recent studies show that they are unnecessary. Instead, this health survey will assist Employee Health to monitor possible TB symptoms. Chest x-rays are required every two years.

TB symptoms can progress slowly and/or mimic other diseases. You can develop symptoms of TB a few weeks after contracting the bacteria, or not until years after the initial infection. This questionnaire targets some of the most common symptoms. Please familiarize yourself with them. You are the first to know when you are not feeling well and may have TB symptoms.

Tuberculosis Health Check Survey

Have you ever experienced any of the following symptoms NOT associated with a specific illness (i.e. flu or cold) and lasting 3 weeks or longer?

Symptom	Yes	No
Cough *
Blood Streaked Sputum (phlegm) *
Loss of Weight (unplanned) *
Night Sweats *
Fever *
Anorexia (loss of appetite) *

This authorization will expire one year from the dated signature below.

TB Screening Verification Signature

Employee Name

Date

Employee Digital Signature

[ Signature on file ]

Work Availability & Schedule Preferences

Specify your desired shift preferences and transport capability

Step 6 of 7

Desired Employment Status *

Transportation Available?

Service Travel Distance

Availability Schedule Verification Signature

Applicant Name

Date

Applicant Digital Signature

[ Signature on file ]

Review Application & Digital Signature

Review your responses, confirm they are accurate, and sign to submit

Step 7 of 7

Summary Review

Candidate Name: ---

Email: ---

Phone: ---

Positions: Caregiver / Homemaker

IL BG Consent: Agreed

Job Description: Acknowledged

Homemaker Checklist: Evaluated

Submitting to: Royal Health Services HR

Applicant Declaration & Statement of Truth:

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize Royal Health Services to investigate all statements contained in this application for employment.

Sign Below (Draw using mouse or touchscreen) *

Saved with your application

Type Full Legal Name (Electronic Signature) *

Date Signed

Personal Information

Employment Desired

Education & Credentials

Form Verification & Applicant Attestation

Illinois Healthcare Worker Background Check

1. Candidate Legal Demographics

2. Previous Residential Addresses (Last 5 Years)

3. Disqualifying Offenses & History Declarations

4. Authorization and Disclosure for Criminal History Records Information (CHRI) Check

IDPH Background Check Authorization Signature

Job Description & Role Acknowledgement

Qualifications

Job Description Acknowledgement Signatures

Homemaker Competency Checklist

Homemaker Competency Verification Signatures

Tuberculosis (TB) Risk Assessment & Screening

1. Tuberculosis (TB) History Questionnaire

2. Annual TB Questionnaire

TB Screening Verification Signature

Work Availability & Schedule Preferences

Availability Schedule Verification Signature

Review Application & Digital Signature

Summary Review

Submitting your application...