LECOM Health Visiting Nurse Association of Erie County

(814) 454-2831 1-800-441-6821 1-855-805-9620

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PERSONAL RECORD
Name*
First Last
Title
Organization
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Fax
Email*
EDUCATION
High School Name
Location (City/State)
Last Year Completed
Did You Graduate?
- Yes
- No
Major or Specialty
Professional License #
PA Nurse Aide Registration #
List Abilities, Activities, Honors, Hobbies
COLLEGE
College Name
Location (City/State)
Last Year Completed
Did You Graduate?
- Yes
- No
Major or Specialty
List Abilities, Activities, Honors, Hobbies
TRADE SCHOOL
Trade School Name
Location (City/State)
Last Year Completed
Did You Graduate?
- Yes
- No
Major or Specialty
List Abilities, Activities, Honors, Hobbies
Do you have any special activities which start late in the summer, such as football or soccer practice, college orientation, etc.? If so, list and give approximate starting dates
PAST EMPLOYMENT REFERENCES
Reference 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Reference 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
You may check my references
- Yes
- No
A LITTLE ABOUT YOURSELF…
Are you employed?
- Yes
- No
If so, where?
Occupation
Do you have any special abilities, awards, hobbies?
Do you have a valid driver’s license?
- Yes
- No
Are you fluent in a language other than English?
- Yes
- No
If so, which?
Have you ever done any volunteer work?
- Yes
- No
If yes, please explain
How did you hear about VNA Hospice?
Why do you wish to become involved with VNA/Hospice?
Total number of hours per week you will be available for Hospice volunteering:
AVAILABILITY
Select All That Apply
- Daytime
- Evening
- Weekend
- Other
If other, please specify
Have you ever had experience with the terminally ill or are you presently caring for a terminally ill patient?
- Yes
- No
If yes, please explain
Has someone close to you recently died?
- Yes
- No
If yes, please explain
AREAS OF INTEREST
Select All That Apply
- Patient home visits
- Teen Programs
- Special Events
- Nursing home visits
- Support groups
- Office Work / Clerical
- Bereavement
- Other
If other, please specify
Have you ever been excluded, suspended, or otherwise sanctioned by any federal or state health care program?
- Yes
- No
I CERTIFY, by hitting ‘Submit’ that this information is accurate and complete.

Home Health Care
Hospice Services
Comfort/Palliative Care
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Recent News

Saint Vincent Hospital and LECOM Health Consolidate Home Health and Hospice Services September 28, 2017
Philips Lifeline– easy to use & our patients love it! October 7, 2015
“A letter from Heaven” card from the sister of a hospice patient September 29, 2015
Ready Steady Go Fall Prevention Seminar a HUGE success! September 24, 2015
Fall Prevention Seminar Weds. Sept 23rd, 2015 from 11-1pm September 21, 2015

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