APPLICATION FOR EMPLOYMENT

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Step 1 of 15

Position Applied for*

Today’s Date*

MM slash DD slash YYYY

How did you hear about us

Date Available to Start*

MM slash DD slash YYYY

Hire Date

MM slash DD slash YYYY

Social Security #*

Name*

First Middle Last

Social Security #*

Date of Birth*

MM slash DD slash YYYY

Driver’s License #*

Address*

Street, City, State, ZIP

Home Telephone #*

Cellular*

E-mail Address*

Emergency Contact Information

We would like to have the names of two (2) contacts that we could call in the case of emergency. Please provide that information below for our files and reference

Primary Contact

First

Relationship

Address

Street Address

Contact No.

Secondary Contact

First

Relationship

Address

Street Address

Contact No.

Are you 18 years of age or older*

Yes

If No, how old are you?

Have you ever applied/worked for us before?*

Yes

If yes, gives date

Why did you leave

Are you currently employed?

Yes

If yes, with who

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?*

Yes

of citizenship or immigration status will be required upon employment.

Are you available to work*

Full Time

Part-Time

On-Call/Temporary

Shift Preferences*

7am - 3pm

3pm - 11pm

11pm - 7am

Check days available for work

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Comment

Education & Other Information

High School

Name of School

Location

(Mailing Address)

# of Years Completed

Major & Degree

College

Name of School

Location

(Mailing Address)

# of Years Completed

Major & Degree

Bus. Or Trade School

Name of School

Location

(Mailing Address)

# of Years Completed

Major & Degree

Professional School

Name of School

Location

(Mailing Address)

# of Years Completed

Major & Degree

License Information

State

License Number

Expiration Date

MM slash DD slash YYYY

Have you ever had any disciplinary action against any of your licenses?

Yes

If YES, please explain

Employment History

Please list in order with the most recent first

Employer

Date From

MM slash DD slash YYYY

Address

City State / Province / Region

Phone

Position

Reason (s) for Leaving

Supervisor

Title

May we contact this facility for a reference?

Yes

Employer

Date From

MM slash DD slash YYYY

Address

City State / Province / Region

Phone

Position

Reason (s) for Leaving

Supervisor

Title

May we contact this facility for a reference?

Yes

Employer

Date From

MM slash DD slash YYYY

Address

City State / Province / Region

Phone

Position

Reason (s) for Leaving

Supervisor

Title

May we contact this facility for a reference?

Yes

Do you have any physical limitations that we should consider when placing you on an assignment?

Yes

If YES, please explain:

Have you ever been convicted of a felony for the last 5 years?

Yes

If Yes, please explain

Thank you for sharing your work history with Global Healthcare Agency, LLC.*

I certify that the foregoing answers to the questions asked in this application are true and correct to the best of my knowledge.

Misrepresentation or falsification of information may be cause for dismissal

Signature*

Date*

MM slash DD slash YYYY

GENERAL INFORMATION

1. Have you ever pleaded guilty to or been convicted of a crime including convictions or guilty pleas in a court martial (excluding minor traffic violations for which a fine or forfeiture of $50 or less was imposed)?*

Yes

If yes, please explain and provide the date, nature of the offense, the name and location of the court, the penalty imposed, if any, and the disposition of the case. A plea of guilty or a conviction does not necessarily eliminate the possibility of employment. Factors such as the date of the offense, your age at that time, nature of the violation, and rehabilitation will be taken into account (use additional paper if necessary).*

2. Are there any criminal charges currently pending against you (e.g., are you out on bail on your own recognizance in connection with any criminal charges)?*

Yes

If yes, please explain*

3. Have you ever abused, neglected, sexually assaulted, exploited, or deprived any person? Have you ever subjected any person to serious injury as a result of intentional or grossly negligent misconduct?*

Yes

If yes, please explain*

4. Have you ever had any professional or occupational license or certification suspended or cancelled?*

Yes

If yes, please explain*

5. Have you ever had any disciplinary action taken against you by any licensing authority or professional or occupational association?*

Yes

If yes, please explain*

6. If your duties will involve driving, please answer the following: Have you ever had your driver’s license suspended or revoked?*

Yes

If yes, please explain*

7. Please list any additional information you think we should consider in evaluating your application for employment (for example, hobbies, special skills and interests)*

Personal References

Name

First

Address

Street Address

Daytime Phone Number

Relationship

Name

First

Address

Street Address

Daytime Phone Number

Relationship

Name

First

Address

Street Address

Daytime Phone Number

Relationship

Please indicate the languages you can speak, read and/or write

Languages

Speak

Fluent

Good

Fair

Read

Fluent

Good

Fair

Write

Fluent

Good

Fair

Languages

Speak

Fluent

Good

Fair

Read

Fluent

Good

Fair

Write

Fluent

Good

Fair

Languages

Speak

Fluent

Good

Fair

Read

Fluent

Good

Fair

Write

Fluent

Good

Fair

Note: This application for employment shall be considered active for a period of time not to exceed 180 days.

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

In consideration of my employment, I agree to conform to the policies and procedures of the agency that is accepting this application. The agency is in no way obligated to provide me with employment and I am not obligated to accept employment if offered. Furthermore, if employed, I understand that my employment and compensation can be terminated with or without cause, at any time.
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statement on this application or omission of fact on either this application will result in my application being rejected, or, if I am hired, being terminated.
This agency is a “Drug Free Workplace.” I understand I may be subjected to pre-employment drug testing.
I also understand that any offer of employment is conditioned on the completion of pre-employment documentation. I will, upon request, sign all necessary consent forms.

Signature*

Date*

MM slash DD slash YYYY

Employment Reference Information

The person above is applying for an employment with Global Healthcare Agency, LLC and has listed you as current/previous employer. Please note applicant’s authorization and provide us with the information below. State the title of the person giving the references. The reference MUST be someone who the applicant reported to.

Re:

SSN:

Other Names Used:

Position Held:

Name of Reference:

First

Title:

Organization:

Phone:

Fax:

Time Employed or Known:

From:

To:

Relationship to Applicant:

I hereby give consent to release any and all information pertaining to my work experience and status to Global Healthcare Agency, LLC.*

I hereby give consent to release any and all information pertaining to my work experience and status to Global Healthcare Agency, LLC.

Signature of Applicant:*

Date:*

MM slash DD slash YYYY

To Be Completed by Employer We would appreciate your assistance in verifying employment and evaluating job performance. All information will be treated with utmost confidentiality.

Evaluations

Job Knowledge*

Above Average

Satisfactory

Did not meet Expectations

Poor

Quality of Work*

Above Average

Satisfactory

Did not meet Expectations

Poor

Clinical Competency*

Above Average

Satisfactory

Did not meet Expectations

Poor

Attendance / Punctuality*

Above Average

Satisfactory

Did not meet Expectations

Poor

Dependability*

Above Average

Satisfactory

Did not meet Expectations

Poor

Attitude and Cooperation*

Above Average

Satisfactory

Did not meet Expectations

Poor

Personal Appearance*

Above Average

Satisfactory

Did not meet Expectations

Poor

Adaptability to Work Situations*

Above Average

Satisfactory

Did not meet Expectations

Poor

Remarks:

Completed by:

Position:

Date:

MM slash DD slash YYYY

Employment Reference Information

Re:

SSN:

Other Names Used:

Position Held:

Name of Reference:

First

Title:

Organization:

Phone:

Fax:

Time Employed or Known:

From:

To:

Relationship to Applicant:

I hereby give consent to release any and all information pertaining to my work experience and status to Global Healthcare Agency, LLC.*

I hereby give consent to release any and all information pertaining to my work experience and status to Global Healthcare Agency, LLC.

Signature of Applicant:*

Date*

MM slash DD slash YYYY

To Be Completed by Employer We would appreciate your assistance in verifying employment and evaluating job performance. All information will be treated with utmost confidentiality.

Evaluations

Job Knowledge*

Above Average

Satisfactory

Did not meet Expectations

Poor

Quality of Work*

Above Average

Satisfactory

Did not meet Expectations

Poor

Clinical Competency*

Above Average

Satisfactory

Did not meet Expectations

Poor

Attendance / Punctuality*

Above Average

Satisfactory

Did not meet Expectations

Poor

Dependability*

Above Average

Satisfactory

Did not meet Expectations

Poor

Attitude and Cooperation*

Above Average

Satisfactory

Did not meet Expectations

Poor

Personal Appearance*

Above Average

Satisfactory

Did not meet Expectations

Poor

Adaptability to Work Situations*

Above Average

Satisfactory

Did not meet Expectations

Poor

Remarks:

Completed by:

Position:

Date:

MM slash DD slash YYYY

Employment Reference Information

Re:

SSN:

Other Names Used:

Position Held:

Name of Reference:

First

Title:

Organization:

Phone:

Fax:

Time Employed or Known:

From:

To:

Relationship to Applicant:

I hereby give consent to release any and all information pertaining to my work experience and status to Global Healthcare Agency, LLC.*

I hereby give consent to release any and all information pertaining to my work experience and status to Global Healthcare Agency, LLC.

Signature of Applicant:*

Date*

MM slash DD slash YYYY

To Be Completed by Employer We would appreciate your assistance in verifying employment and evaluating job performance. All information will be treated with utmost confidentiality.

Evaluations

Job Knowledge*

Above Average

Satisfactory

Did not meet Expectations

Poor

Quality of Work*

Above Average

Satisfactory

Did not meet Expectations

Poor

Clinical Competency*

Above Average

Satisfactory

Did not meet Expectations

Poor

Attendance / Punctuality*

Above Average

Satisfactory

Did not meet Expectations

Poor

Dependability*

Above Average

Satisfactory

Did not meet Expectations

Poor

Attitude and Cooperation*

Above Average

Satisfactory

Did not meet Expectations

Poor

Personal Appearance*

Above Average

Satisfactory

Did not meet Expectations

Poor

Adaptability to Work Situations*

Above Average

Satisfactory

Did not meet Expectations

Poor

Remarks:

Completed by:

Position:

Date:

MM slash DD slash YYYY

Disclosure of Physical Limitations

I certify that I have no physical limitations which would prevent me from safely performing any tasks normally expected from an individual employed as RN/LPN, Home HHA or CNA. In the event that such condition should arise. I will notify Global Healthcare Agency, LLC. Within 24 hours of my becoming aware of the condition and/or prior to performing any of the healthcare functions, whichever comes first? In the event that I do not advise Global Healthcare Agency, LLC. of a change in my condition, Global Healthcare Agency, LLC. shall be blameless of any injuries which might occur.*

Signature*

Date*

MM slash DD slash YYYY

Witness*

First

Date*

MM slash DD slash YYYY

Female Employees Only

Female Employees Only*

In the event of pregnancy, I will advise Global Healthcare Agency, LLC. within 24 hours of being informed of the pregnancy. This will allow for Global Healthcare Agency, LLC. to evaluate the physical activities inherent in the cases before assigning them to you. I understand that this is not for the purpose of limiting my work but simply to make sure that I am not, unknowingly place in a position of risk.

In the event that Global Healthcare Agency, LLC. Is not notified about this and any future risk development, I will hold Global Healthcare Agency, LLC. Blameless for any injuries or loss related to this matter.

Signature*

Date*

MM slash DD slash YYYY

Witness*

First

Date*

MM slash DD slash YYYY

Trainings Acknowledgement

I acknowledge that I have been trained to perform duties as a Direct Support Personnel for Individuals with Intellectual Disability and have completed trainings in:

Direct Support Personnel (DSP)

Registered Nurse

Certified Nurse’s Assistant

Companion

Occupational Therapist

Licensed Practical Nurse

Home Health Aide

Trained CPR

I hereby acknowledge that I may not work in any healthcare facility and for Global Healthcare Agency, LLC. without a valid Certificate or current state license and current CPR card. Further, it is my responsibility to carry this documentation on my person while on assignment as Global Healthcare Agency, LLC. staff. Failure to possess these documents may result in being cancelled from an assignment. It is against the state of licensure board to work without a valid license. Penalties are involved and revocation of license is possible.*

Nurse/Aide Signature:*

Date*

MM slash DD slash YYYY

Name*

First

Date*

MM slash DD slash YYYY

Employee Orientation Checklist

Name*

First

Job Title*

Date of Hire:*

MM slash DD slash YYYY

Date Form Completed:*

MM slash DD slash YYYY

Training

Objectives and philosophy of organization

Date Completed

MM slash DD slash YYYY

Confidentiality

Date Completed

MM slash DD slash YYYY

Human Rights Regulations

Date Completed

MM slash DD slash YYYY

Applicable personnel policies and procedures

Date Completed

MM slash DD slash YYYY

Emergency Preparedness

Date Completed

MM slash DD slash YYYY

Person-centeredness

Date Completed

MM slash DD slash YYYY

Infection Control Practices, including flu Epidemics

Date Completed

MM slash DD slash YYYY

HCBS Settings (Home and Community Based Settings)

Date Completed

MM slash DD slash YYYY

Serious Injury Reporting

Date Completed

MM slash DD slash YYYY

Other Policies applicable to specific job duties

Date Completed

MM slash DD slash YYYY

I certify that I have received training on the above topics.*

I certify that I have received training on the above topics.

Signature of Employee:*

Date*

MM slash DD slash YYYY

Signature of Supervisor:*

Date*

MM slash DD slash YYYY

Behavior Based Competencies

Organizational Behaviors

Change and Grow
Achievement
Respect & Respond
Energy & Initiative
Adaptability & flexibility
Superior skills

Organizational Competencies:

Educating clients and families & transferring knowledge
Identify & resolve problems
Anticipate & address client needs
Function as an effective team member
Acquire & apply superior skills to achieve quality outcomes
Respond to a changing set of circumstances

Client/Patient Specific Competencies:

Providing comfort to another in emotional/physical pain.
Responding to a crisis.
Providing a continuum of care approach.

Skills Based Competencies:

A graduate from an RN/LPN/CNA/HHA/DSP or PCA School at least 6 months of continuous work experience in a healthcare setting within the last year or years.
A current license as a RN/LPN for the state in which the nurse practices and free from disciplinary action.
Successful completions of the Global Healthcare Agency, LLC. tests for the specialty area(s) in which the nurse practices with a score of 75% or greater.
Proof of fulfillment of the health screening criteria required by Global Healthcare Agency, LLC. And/or client facilities indicating the nurse is in good health and able to work without physical limitations and is free from communicable disease.
A current CPR card, Hands on Training with Ink expiration date.
Completion and annually thereafter of the Global Healthcare Agency, LLC. Employee Development and Self Study In-service Programs.
Meet the minimum clinical criteria of Global Healthcare Agency, LLC. Clinical skills checklist for those areas of clinical expertise.
Full command, verbal and written, of the English language.

I have read the descriptions of my professional responsibilities as an employee of Global Healthcare Agency, LLC. and agrees to adhere to the standards described above.

Signature*

Date*

MM slash DD slash YYYY

Hepatitis-B Immunization Release

DECLINATION

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection.

This is to certify that I*

Put Your Name Here

do not have documentation of Hepatitis B immunity and choose not to receive the immunization for Hepatitis B. I release Global Healthcare Agency, LLC.
from all liability for any hazards that may result from possible exposure to the disease.

Signature*

Date*

MM slash DD slash YYYY

CLIENT’S BILL OF RIGHTS IN-SERVICE

Please read over the Clients’ Bill of Rights and sign below. Each of our clients receives an information sheet on their “Rights” when they are admitted by our agency. Please adhere to the Clients’ Rights it is our policy and Virginia State Law. Each client will be:

Treated with courtesy, consideration, respect, and assured of the right to privacy.
Assured confidential treatment of his medical and financial records as provided by law.
Free from mental and physical abuse and property exploitation.
Assured the right to participate in the planning of his home care and the right to refuse services.
Served by individuals who are properly trained and competent to perform their duties.
Assure the right to voice grievances and complaints related agency services without fear of reprisal.
Assured at least 5 days written notice prior to any reduction in service.
Assured at least written notice prior to any discharge or referral in service, except when a medical emergency exists, when the client’s physician order’s admission to an in-client facility, or when discharge is determined by the chief administrative officer to be necessary to protect the health and welfare of the staff member providing services.

My signature verifies that I have read and understand the Clients’ Bill of Rights.

Employee Signature*

Date*

MM slash DD slash YYYY

Confidentiality Agreement

All information obtained by Global Healthcare Agency, LLC. Is about its patients and their families shall be kept confidential. This information shall not be disclosed to any party outside of the Agency and its contractors providing patient care, except in aggregate form and without identifiers, unless there is a written released signed by the patient or the patient’s responsible representative. The only exception to this prohibition on disclosure is that essential information necessary for making the Agency care plans, prior to a visit to the patient may be disclosed to appropriate agencies for the sole purpose of making arrangements for the patient’s care. This shall be explained to the referring party. Within the Agency and contracting organizations, information about patient/families shall be shared only with those individuals who have a need to know. Questions regarding disclosure shall be referred to the Administrator or the Medical director.

Medical Records

All Medical Records of deceased/discharged patients’ shall be kept in the Medical Records Department/Director’s office which shall be locked when unoccupied, or in locked storage areas, or if out for completion or patient accounts billing, they shall be in a locked or supervised area. Records of active patients currently in the field file with the professional staff shall be kept in a closed file drawer, which shall be locked during evening and weekend hours. Only patient/family care staff and supervisory staff, shall have access to Medical Records and then only on an as-needed basis. All materials to be added to the Medical Records shall be kept in the Medical Records Department/Director’s office, and shall be inserted in the record as quickly as possible.

Volunteers

Only volunteers required to have access to records in order to meet their volunteer responsibilities shall have access to Medical Records. Only information that is necessary for volunteers to know in order to carry about their duties shall be shared with them. These volunteers shall have received and signed this form before assuming their duties.

Employee Personnel (Hospice and Contracting Agencies)

Only personnel required to have access to records in order to meet job responsibilities shall have access to identifiable patient/family information. Only information that is necessary for them to know in order to care out their responsibilities shall be shared. Each staff member shall receive a copy of this policy at the time of their employment. All contracted shall receive a copy and will sign this policy and conformance with it shall be a part of any negotiated contract.

Use of Patient/Family Information for Education, Public Information or Research Purpose

Generally, only aggregate information shall be used for these purposes. If individual case examples are required, all identifying information must be removed so that it is impossible to identify the patient and /or family member, or written release must be obtained.

All information protected for patients/families is also protected for employees

Only personnel required to have access to records in order to meet job responsibilities shall have access to any other employee’s records. Questions regarding disclosure shall be referred to the Director of Administration. I have read and understood the preceding policy on Confidentiality and agree to abide by it.

Signature:*

Name (printed or typed):*

First

Date*

MM slash DD slash YYYY

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Comments

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APPLICATION FOR EMPLOYMENT

Emergency Contact Information

Education & Other Information

License Information

Employment History

GENERAL INFORMATION

Personal References

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Employment Reference Information

Employment Reference Information

Employment Reference Information

Disclosure of Physical Limitations

Female Employees Only

Trainings Acknowledgement

Employee Orientation Checklist

Training

Behavior Based Competencies

Hepatitis-B Immunization Release

DECLINATION

CLIENT’S BILL OF RIGHTS IN-SERVICE

Confidentiality Agreement

Confidentiality Agreement

Medical Records

Volunteers

Employee Personnel (Hospice and Contracting Agencies)

Use of Patient/Family Information for Education, Public Information or Research Purpose

All information protected for patients/families is also protected for employees

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Our Mission

Who We Are

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