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APPLICATION FOR EMPLOYMENT

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

PERSONAL

Last Name

First Name

Middle Name(s)

Date

MM slash DD slash YYYY

Street Address

Home Phone

City

State

Zip Code

Business Phone

Social Security #

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

Others

Are you willing to work:

Evenings?

Weekends?

Position applying for:

LPN

CNA

PCA

Therapist (Specify)

Others

Therapist (Specify)

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance

1. Name:

Telephone:

FAX:

Address

2. Name:

Telephone:

FAX:

Address

3. 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.

If yes, describe in full:

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

Yes

If you answered No, which job requirement can you not meet?

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 understanding. I understand that, if employed, any falsified statements on this application shall be grounds for dismissal.

I authorize a 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. I authorize them to provide the Agency with any and all information concerning my previous employment and any other relevant information they may have. I release all former employers and others listed above from any liability for any damages that may result from furnishing such information 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 or 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 not to exceed 45 days. Any applicant wishing to be considered for employment beyond this period must inquire whether applications are being accepted at that time.

I hereby authorize the Agency to request and receive from all prior employers within one year of the date of this application all pertinent information concerning my previous employment and its termination, including the reason for such termination.

Date

MM slash DD slash YYYY

Signature

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 PRINT NAME

TITLE

Employee SIGNATURE

Date

MM slash DD slash YYYY

Trainer PRINT NAME/Initials

TITLE

TRAINER SIGNATURE

Date

MM slash DD slash YYYY

ORIENTATION CHECKLIST FOR CURRENT EMPLOYEES ASSIGNED TO A NEW JOB CLASSIFICATION

1. Review of all Agency policies and procedures related to new job duties

2. Review of Federal, state and accreditation regulations

3. Review confidentiality of patient information

4. Review contracts for all programs, agencies and individuals related to new job duties

5. Review employee benefits

6. Review infection control, safety and disaster programs

7. Consult with and observes other staff in the same job classification regarding patient job issues

8. Review implementation of patient goals and objectives

9. Ensuring safe and effective services to patients and families

10. Establishing and maintaining effective lines of communication

11. Practicing staff development including orientation, in-service education and continuing education

12. Following job description in performance of duties

13. Implementing and evaluating patient care services related to new job

14. Participating in selected in-service programs related to new job

15. Encouraging staff participation in problem solving

16. Performing other duties as assigned by the Administrator

Employee PRINT NAME

Employee SIGNATURE

Date

MM slash DD slash YYYY

Trainer PRINT NAME/Initials

TITLE

TRAINER SIGNATURE

Date

MM slash DD slash YYYY

ACCEPTANCE STATEMENT

I have read, understand, and agree to the terms specified in this job description for the position I presently hold. A copy of this job description has been provided to me.

I further understand that this job description may be reviewed and revised at any time, and that I will be provided with a copy of any updated version.

Employee SIGNATURE

Date

MM slash DD slash YYYY

EVALUATION FROM PERFORMANCE EVALUATION MANUAL

Performance evaluations are to be completed for each employee 90 days after the date of hire and annually thereafter.

Each evaluation must be signed by both the employee and the evaluator and must include established performance goals.

Employee SIGNATURE

Date

MM slash DD slash YYYY

Acknowledgement of Employee Handbook

We are pleased to welcome you as a member of the Seek2Find Home Care Services team. As an employee, you are an essential part of our organization, and we hope you find your position rewarding, challenging, and fulfilling. Every team member plays an important role in our success, and we value the skills, experience, and dedication you bring to our agency.

Our Employee Handbook provides important information regarding company policies, procedures, and expectations, including but not limited to:

Nature of Employment / Patient & Business Relations
Equal Employment Opportunity / Non-Discrimination Policy
Immigration Compliance and Form I-9 Requirements
Introductory / Orientation Period
Appropriate Conduct
General Work Rules / Field Practice Statement
Discrimination & Harassment Policy
Rules of Conduct / Prohibited Conduct
Sexual Harassment Policy
Drug & Alcohol Policy / Drug-Free Workplace / Drug Testing Policy
Employee Responsibilities and Reporting Misconduct Procedures
Receipt of Gifts / No Borrowing Money from Patients, Families, or Co-Workers / Theft & Embezzlement Policy
Corporate Compliance
Abuse & Neglect Policy
HIPAA / Privacy Notice / Non-Disclosure of Patient Health Information
Use and Return of Company Property
Complaint, Grievance, and Anti-Retaliation Policy
Conflict of Interest / Standards of Business Ethics and Conduct
Dress Code & Professional Image
Office Hours / On-Call Hours / 24/7 RN Availability
Open Door Policy
Employee Classifications and Categories
Time Recording / Timesheet Submission / Mileage Reimbursement
Expense Reports and Receipt Submission
Payroll, Pay Periods, Payroll Deductions, Direct Deposit, and Payroll Corrections
Attendance, Punctuality, and Call-Out Policy
PTO, Sick Leave, Overtime, Holidays, Bereavement Leave, and FMLA Leave of Absence
Jury Duty, Voting Time Off, and Military Leave
Job Descriptions
Employment of Relatives
Communication Methods (Email, TigerConnect Text, Bulletin Board)
Employee Health and Dental Coverage Eligibility and Enrollment Timeframes
Continuation of Health Coverage under COBRA
Safety in the Workplace / Violence-Free Workplace
Personal Protective Equipment (PPE) Availability
Workers' Compensation, Injury Reporting Procedures, and Approved Physician Panel
Emergency Plans and Emergency Closings
In-Service Training and Continuing Education
Electronic Signatures and Password Protection
Information Management, Computer Usage, and Security
Termination of Employment and Voluntary Resignation

I acknowledge that I have received a personal copy of the Employee Handbook. I understand that I am responsible for reading, understanding, and complying with all policies, procedures, and guidelines contained within it.

I further understand that if I have any questions or do not understand any policy or procedure, I will refer to the Employee Handbook and seek clarification from my direct supervisor or the Agency Administrator.

Employee Signature:

Date

MM slash DD slash YYYY

Agency Representative Signature:

Date

MM slash DD slash YYYY

HEPATITIS VACCINE REQUIREMENT

I acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself. It is my decision to:

Certify

Request that I receive the Hepatitis vaccine.

Certify

Refuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to me.

Certify

Provide written proof of immunity (attach)

Certify

Provide written proof of previous vaccination (attach)

Certify

Provide written proof of medical contraindication (attach)

Signature*

Date*

MM slash DD slash YYYY

TB TARGETED MEDICAL QUESTIONNAIRE FORM

Print Name*

1. Have you ever had a positive TB skin test or history of TB infection?

Yes

If the answer is YES, please answer the following:

2. Have you ever had the BCG vaccine?

Yes

3. Do you have prolonged or recurrent fever?

Yes

4. Have you recently lost weight?

Yes

5. Do you have a chronic cough?

Yes

6. Do you cough up blood?

Yes

7. Do you have sweating at night?

Yes

Do you have any of the following risk factors which may substantially? Increase the risk of tuberculosis?

Silicosis (Lung Disease)

Gastrectomy

Intestinal Bypass

Weight 10% or more below ideal body weight?

Chronic Renal Disease

Diabetes Mellitus

Prolonged high-dose corticosteroid therapy or other Immunosuppressive therapy

Hematologic Disorder i.e., leukemia or lymphoma

Exposure to HIV or AIDS

Other malignancies

Employee Signature

Date

MM slash DD slash YYYY

Reviewed by Signature

Date

MM slash DD slash YYYY

Submit Job Application Online

APPLICATION FOR EMPLOYMENT

PERSONAL

Social Security #

PROFESSIONAL REFERENCES

GENERAL

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

ORIENTATION PROGRAM

ORIENTATION CHECKLIST FOR CURRENT EMPLOYEES ASSIGNED TO A NEW JOB CLASSIFICATION

ACCEPTANCE STATEMENT

EVALUATION FROM PERFORMANCE EVALUATION MANUAL

Acknowledgement of Employee Handbook

HEPATITIS VACCINE REQUIREMENT

TB TARGETED MEDICAL QUESTIONNAIRE FORM

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