Careers Form

* = Required Information

Personal

Position Applied*

Last Name *

First Name *

Middle Name

Date *

Street Address *

City *

State

Zip Code

Social Security Number

Date of Birth *

Home Phone

Business Phone

Emergency Contact (person not living with you) *

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Newspaper Ad

Agency Employee

Other

Are you willing to work?

Evening

Morning

Position Applying For?

LVN

Therapist

Other

Specify

Application for Employment

Was your last name different from your present name during the above listed jobs?

Yes

What was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Professional Reference

Persons who can furnish information about job performance

Name

Telephone

Fax

Address

Name

Telephone

Fax

Address

Name

Telephone

Fax

Address

General

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment

Describe in full

Are you capable of performing the job set forth in the job description?

Yes

Which job requirement can you not meet?

Application for Employment

Credentials/Specialized Skills and Qualifications/Equipment Operated

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience

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.

Date

Name

Education

College

School Name

Location of School

Course of Study

Years of

Degree/Study

Vo-Tech or Trade

School Name

Location of School

Course of Study

Years of

Degree/Study

High School

School Name

Location of School

Course of Study

Years of

Degree/Study

Other

School Name

Location of School

Course of Study

Years of

Degree/Study

Employment

List the last five years of employment history, starting with the most recent employer.

Company Name

Address

Telephone

Dates of Employment From

Dates of Employment To

City

State

Zip Code

Starting Pay

Job Title

Describe your work

Reason of Leaving

Company Name

Address

Telephone

Dates of Employment From

Dates of Employment To

City

State

Zip Code

Starting Pay

Job Title

Describe your work

Reason of Leaving

Company Name

Address

Telephone

Dates of Employment From

Dates of Employment To

City

State

Zip Code

Starting Pay

Job Title

Describe your work

Reason of Leaving

Applicant Reference Check (1)

To be filled out by applicant:

Application Name

Date of Application

Previous Employer

Contact Person

Address

Phone

Fax

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.

Applicants Signature *

Clear

Applicants Name

Date

Date of Employment from

Date of Employment to

Position Held

Responsibilities

Reason for Leaving

Rate of Pay (Weekly/biweekly/salary)

Reference check performed by

Additional Comments (Training/Skills)

Applicant Reference Check (2)

To be filled out by applicant:

Application Name

Date of Application

Previous Employer

Contact Person

Address

Phone

Fax

Applicants Signature *

Clear

Applicants Name

Date

Date of Employment from

Date of Employment to

Position Held

Responsibilities

Reason for Leaving

Rate of Pay (Weekly/biweekly/salary)

Reference check performed by

Additional Comments (Training/Skills)

Employee Emergency Contact Information

Employee Name

Current Address

Home Phone

Cell Phone

Next of Kin

Phone

Relationship

Address

In case of emergency, please contact:

Name

Phone

Relationship

Address

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.

Employee Signature *

Clear

Employee *

Date

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.

Employee Signature *

Clear

Employee *

Date