Application Form

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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 Information

Last Name

First Name

Middle Name

Date

MM slash DD slash YYYY

Street Address

Home Phone

City, State, Zip Code

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?

Online Ad

Agency employee

Other

Are you willing to work

Evenings?

Weekends?

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

1. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

2. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

3. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

4. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

5. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

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

Yes

If yes, what was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Professional References

Persons who can furnish information about job performance

1. Name

Telephone

Address

2. Name

Telephone

Address

3. Name

Telephone

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 jobrelated skills and qualification acquired from employment or other experience.

Please read all statements below before signing this application

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.

This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.

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

MM slash DD slash YYYY

Signature

(1) 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:

MM slash DD slash YYYY

Previous Employer

Contact Person

Address

Phone

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’s Signature

Date

MM slash DD slash YYYY

To be completed by previous employer:

Date of employment:

From

MM slash DD slash YYYY

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay: (weekly/biweekly/salary)

Additional comments (training/skills)

Reference check performed by

(2) Applicant Reference Check

Applicant Name

Date of Application:

MM slash DD slash YYYY

Previous Employer

Contact Person

Address

Phone

Applicant’s Signature

Date

MM slash DD slash YYYY

To be completed by previous employer:

Date of employment:

From

MM slash DD slash YYYY

Position Held

Would you rehire this individual?

Yes

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

Home Phone

Cell Phone

*In case of emergency, please contact:

Name

Phone

Relationship

Address

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

Statement Of Good Health/free Of Communicable Disease

Explanation and Instruction:

Our company policy requires all employees who have direct contact with patients in the home setting to submit a statement from an appropriately licensed health care professional, based on an exam performed within the last twelve months. The employee must show no apparen signs or symptoms of communicable disease.

Statement to be signed by a Physician or appropriately licensed Healthcare professional.

Name

was examined by me on

MM slash DD slash YYYY

He/She is in adequate health to perform home health duties and show no apparent signs or symptoms of communicable disease.

Professional Signature

Date

MM slash DD slash YYYY

Address

Phone number

A PPD test was done in this office on

MM slash DD slash YYYY

and read on

MM slash DD slash YYYY

Rt. Forearm

Lt. forearm

Result

If redness present, size/description

Manufacturer name

Lot number

Tb Targeted Medical Questionnaire And Risk Form

Employee Printed 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

8. Do you have any of the following risk factors

a. Silicosis (lung disease)

b. Gastrectomy

c. Intestinal Bypass

d. Weight 10% or more below ideal body weight

e. Chronic Renal Disease

f. Diabetes Mellitus

g. Prolonged high-dose corticosteroid therapy or other Immunosuppressive therapy

h. Hematologic Disorder i.e. leukemia or lymphoma

i. Exposure to HIV or AIDS

j. Other malignancies

Baseline Individual TB Risk Assessment

Answer “Yes” or “No”. Employee should be considered at risk for TB if any of the following statements are marked “Yes”.

Temporary or permanent residence of > 1 month in a country with a high TB rate (any country other than the U.S., Canada, Australia, New Zealand, and those in Northern or Western Europe)

Current or planned immunosuppression, including HIV infection, organ transplant recipient, treatment with a TNF alpha antagonist, chronic steroids, or other immunosuppressive medication.

Close contact with someone who has had infectious TB disease since the last TB test

Employee Signature

Date

MM slash DD slash YYYY

Reviewed by Signature

Date

MM slash DD slash YYYY

Hepatitis Vaccine Requirement

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:

Request that I receive the Hepatitis vaccine

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.

Provide written proof of immunity (attach)

Provide written proof of previous vaccination (attach)

Provide written proof of medical contraindication (attach)

Attach Files

Drop files here or

Max. file size: 512 MB.

Signature

Date

MM slash DD slash YYYY

Application Form

Personal Information

Education

College

Vo-Tech or Trade

High School

Other

Employment

Professional References

General

Credentials/specialized skills & qualifications/equipment operated

Please read all statements below before signing this application

(1) Applicant Reference Check

(2) Applicant Reference Check

Employee Emergency Contact Information

Statement Of Good Health/free Of Communicable Disease

Tb Targeted Medical Questionnaire And Risk Form

Hepatitis Vaccine Requirement

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