Prefix

First Name

Middle Name

Last Name

Date of Birth

Street Address

Home Phone

City

State

Zip Code

Business Phone

Social Security Number

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?YesNo

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?YesNo

How did you learn of our organization?Newspaper AdAgency employeeOther

Are you willing to workEveningsWeekendEvenings and Weekend

EDUCATION

School Name(College)

Location of School

Course of Study/Degree/Study

Years of Diploma

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

Company Name

Telephone

Street Address

Date Started

Date Ended

City

State

ZIP / Postal Code *

Starting Pay

Job Title and Describe your work

Reason for leaving

APPLICATION FOR EMPLOYMENT

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

Are you currently employed?YesNo

Do you have reliable transportation?YesNo

PROFESSIONAL REFERENCESPersons who can furnish information about job performance

Name

Telephone

Street Address

Fax

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?YesNoConviction will not necessarily disqualify an applicant from employment.

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

CREDENTIALS/SPECIALIZED SKILLS & 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 herby 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 arid 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 as to whether or not applications are being accepted at that time.

Date

Signature

APPLICANT REFERENCE CHECKClick to add more reference checks

APPLICANT REFERENCE CHECK

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

Applicant Name

Date of Application

Previous Employer

Contact Person

Street 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.

Date

Applicant’s Signature

To be completed by previous employer:

Date of employment: From

Position Held

Would you rehire this individual?YesNo

Responsibilities

Reason for Leaving

Rate of Pay(weekly/biweekly)

Salary

Additional comments (training/skills)

Reference check performed by

Employee Emergency Contact Information

Employee Name

Current Address

City

Home Phone

Cell Phone

Next of kin

Next of kin phone

Relationship

Street Address

Apartment, suite, etc

City

*In case of emergency, please contact:

Name

Current Address

Apartment, suite, etc

Relationship

Phone

*Please notify this Agency immediately if any of the emergency contact information changes.

License Copy/Verification For Professional Staff See Personnel Policies *

No file chosen

Diploma/Degree Transcript *

No file chosen

Social Security Card *

No file chosen

CPR Card *

No file chosen

Driver's License *

No file chosen

Auto Insurance *

No file chosen

Motor Vehicle Record Check *

No file chosen

ORIENTATION PROGRAM

Firm Mission, Vision and Plan and Organizational Chart

Advance Directives

Types of Care Provided by the Firm including Information Provided to Patients Regarding Charges

Firm Policies and Procedures, HIPAA, TB

Personnel Policies, Job Descriptions and Professional Boundaries of All Disciplines

Training Specific to Job Descriptions

Cultural diversity Domestic Violence

Patient Rights and Grievance Policy

Ethics in Delivery of home care delivery, Conflict of Interest and Confidentiality of Patient Information

Supervision and Evaluation

Home Safety (including Bathroom, Electrical, Environment, Fire and Hazards)

Safety Issues in the Home (Including Security and Guns in the Home)

Emergency Preparedness Plan/Actions to Take in the Event of a Disaster

Actions to Take in Unsafe Situations

OSHA Requirements, Safety and Infection Control in the Home/Standard Precautions

Patient Care Responsibilities Including Charges for Care

Incidences and Occurrences reporting Blood Borne Pathogens

Understanding and coping with Alzheimer’s Disease & Dementia

Identifying and Reporting Elder & Child Abuse, Neglect and Exploitation

Fraud/Abuse, False Claims, False Statements, Whistle Blowing

Community Resources

Quality Assurance

Documentation - Record Keeping including assessment

ID Badge Issued

Medical Device/Hazards reporting

Exposure Control Plan

Corporate Compliance

Mandatory In-services

Employee

Employee Print Name

Employee Title

Employee

Signature

Date

Trainer

Print Name / initials

Trainer Title

Trainer

Signature

Date

Save as Draft

Join Us in Making a Difference.

ORIENTATION PROGRAM

Application Form

Contact Details