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Employment Application
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Employment Application
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
No
How many hours a week are you available for work?
Are you legally eligible for employment in the United States?
Yes
No
How did you learn of our organization?
Online Ad
Agency employee
Other
Are you willing to work
Evenings?
Weekends?
Position applying for
Education
College
School Name
Location of School
Course of Study
Degree/Dip
Vo-Tech or Trade
School Name
Location of School
Course of Study
Degree/Dip
High School
School Name
Location of School
Course of Study
Degree/Dip
Other
School Name
Location of School
Course of Study
Degree/Dip
Employment
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
To
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
To
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
To
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
To
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
To
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
No
If yes, what was your name?
Are you currently employed?
Yes
No
Do you have reliable transportation?
Yes
No
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
No
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
No
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
To
MM slash DD slash YYYY
Position Held
Would you rehire this individual?
Yes
No
Responsibilities
Reason for Leaving
Rate of Pay: (weekly/biweekly/salary)
Additional comments (training/skills)
Reference check performed by
(2) 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
To
MM slash DD slash YYYY
Position Held
Would you rehire this individual?
Yes
No
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
by
and read on
MM slash DD slash YYYY
by
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
No
If the answer is YES, please answer the following:
2. Have you ever had the BCG vaccine?
Yes
No
3. Do you have prolonged or recurrent fever?
Yes
No
4. Have you recently lost weight?
Yes
No
5. Do you have a chronic cough?
Yes
No
6. Do you cough up blood?
Yes
No
7. Do you have sweating at night?
Yes
No
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
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:
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)
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Signature
Date
MM slash DD slash YYYY
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