Application for Employment
Persons who can furnish information about job performance
Conviction will not necessarily disqualify an applicant from employment
Credentials/Specialized Skills and Qualifications/Equipment Operated
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.
I authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the agency.
I understand and agree that if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire whether or not applications are being accepted at that time.
Vo-Tech or Trade
List the last five years of employment history, starting with the most recent employer.
Applicant Reference Check (1)
To be filled out by applicant:
I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
Applicant Reference Check (2)
Employee Emergency Contact Information
In case of emergency, please contact:
Please notify this Agency immediately if any of the emergency control information changes
Confidentiality of Protected Health Information
It is both the Agency's and the employee's responsibility to ensure that every patient's health information is protected at all times. By signing below you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency's policy regarding patient's Protected Health Information will be provided to you upon hire.
I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated for use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with HIPAA Rule and Regulations.
Protection of Health Information
There are specific guidelines to ensure patient's Protected Health Information is kept private. I understand that my employment with the agency involves handling Protected Health Information. I will ensure patient's records are protected by enforcing the following measures:
Patient Protected Health Information will be transported in a protected travel chart when traveling
When transmitting and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area
Patient Protected Health Information will be returned to the agency upon acknowledgement of the patient being discharge
I pledge to make every effort to keep patient's Protected Health Information protected at all times.