Essential Caregiver Application

Resident Name*

First Name

Last Name

Essential Caregiver Applicant Name*

First Name

Last Name

Applicant Phone Number*

Applicant Email Address*

Date of Application*

Ex: 1/1/1900

Facility*

Recognizing the critical role family members and outside caregivers often have in the care and support of residents, and pursuant to the New Jersey Department of Health Executive Directive No, 20-026, this facility will permit approved outside Essential Caregivers to assist in the care of individual residents.

As an essential Employee, please describe:

1. How you feel you were actively engaged with the resident/patient prior to the COVID-19 pandemic (i.e., what care did you previously provide and during what time-period)?*

2. How you will support and encourage the above-named resident with activities of daily living or other care needs?*

Signature of applicant*

[clear]

Use your mouse or finger to draw your signature above

Date*

Ex: 1/1/1900

For Office Use Only

Information*

Resident/patient (or rep when applicable) consulted; they Agree to designation this EC Don’t agree to designation of this EC (this results in automatic denial)

Decision*

Application Approved Application Denied (explain if reason is other than resident not authorizing the designation)

Denial Explanation*