Employment Application Form

BASIC INFORMATION

Name(Last, First Middle Initial) *

Date Of Birth *

MM

/

DD

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YYYY

Security Number *

Address *

City/State *

Zip Code *

Home Telephone *

Mobile *

JOB POSITION

Which position(s) are you interested in? *

RN

LPN

HHA

GNA

CNA

OFFICE STAFF

Select

Types of Employment *

Full-Time

Part-Time

Temporary

On-Call

Select

Time of Availability *

Mornings

Nights

Weekends

Select

Hours of Availability *

Time

:

Desired Start Date of Employment *

MM

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DD

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YYYY

Related Questions *

YES

NO

Are you willing to travel?

Are you authorised to work in the United States on a unrestricted basis?

Have you been a resident of Pennsylvania for more than 2 years?

Do you speak any language other than English? *

YES ( If yes, please specify)

NO

Required

Personal Information

Gender *

Female

Male

Required

Marital Status *

Single

Married

Required

In the case of an Emergency, Please Notify

Name *

Relationship *

Home Telephone *

Alternative

EDUCATIONAL HISTORY

Type of Degree Earned *

High School Diploma

G.E.D.

College

Grad. School

Select

Additional Training

Diploma/Degree? *

YES

NO

Required

Nursing School (If applicable)

City/State *

Dates Attended *

MM

/

DD

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YYYY

EMPLOYMENT HISTORY

Client/Company Name1 *

Address *

Dates of Employment *

MM

/

DD

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YYYY

Supervisor Name *

Phone *

Reason for leaving *

Job Duties *

Client/Company Name2

Address

Dates of Employment

MM

/

DD

/

YYYY

Supervisor Name

Phone

Reason for leaving

Job Duties

Client/Company Name3

Address

Dates of Employment

MM

/

DD

/

YYYY

Supervisor Name

Phone

Reason for leaving

Job Duties

LICENSE VERIFICATION

Employee Name *

Discipline *

Social Security # *

License # *

Status *

FOR OFFICE USE ONLY

Verified By *

Automated System

Verbal Contact( If verbal, complete the following. If not, Skip)

Required

Spoke With and Title

Verified By

Date

MM

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DD

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YYYY

Title

Comments

1st REFERENCE

The undersigned, having applied for a position with our company, hereby authorities you to release any information necessary relating to employment. This hereby releases your organisation unconditionally from all liability for damage whatsoever that might result from furnishing this information.

SECTION - I ( To be complete by Applicant )

Applicant Name *

Company Name and Position *

Referral Name *

Telephone *

Dates Employed *

MM

/

DD

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YYYY

I acknowledge filing an application with AGING WITH CARE and authorize the release of information from my former employee.

Applicant Signature *

Section II: ( Supervisor, please information in Section I and complete Section II ) *

YES

NO ( If NO, please correct Info. )

Is the Applicant's position title correct?

Are the dates of the employment correct?

Is this employee eligible for rehire? *

YES

NO

Conditional ( If no/conditional, please explain )

Required

SECTION II - Evaluation of Performance *

Excellent

Good

Fair

Poor

Job knowledge/Technical skills

Quality of Work

Ability to work with others

Initiative

Punctuatity/ Attendance

Additional Comments

Information Verified By and Title *

Reference record completed by ( Authorized Representative ) and Title *

Name ( Last Name ) *

2nd REFERENCE

The undersigned, having applied for a position with our company, hereby authorities you to release any information necessary relating to employment. This hereby releases your organisation unconditionally from all liability for damage whatsoever that might result from furnishing this information.

SECTION - I ( To be complete by Applicant )

Applicant Name *

Company Name and Position *

Referral Name *

Telephone *

Dates Employed *

MM

/

DD

/

YYYY

I acknowledge filing an application with AGING WITH CARE and authorize the release of information from my former employee.

Applicant Signature *

Section II: ( Supervisor, please information in Section I and complete Section II ) *

YES

NO ( If NO, please correct Info. )

Is the Applicant's position title correct?

Are the dates of the employment correct?

Is this employee eligible for rehire? *

YES

NO

Conditional ( If no/conditional, please explain )

Required

SECTION II - Evaluation of Performance *

Excellent

Good

Fair

Poor

Job knowledge/Technical skills

Quality of Work

Ability to work with others

Initiative

Punctuatity/ Attendance

Additional Comments

Information Verified By and Title *

Reference record completed by ( Authorized Representative ) and Title *

Name ( Last Name ) *

CONFIDENTIALLY STATEMENT

Disclosure of confidential information gained through your employment by AGING WITH CARE is stated as an act of prohibited conduct subject to formal disciplinary action. Any information concerning a patient’s illness, family, financial condition or personal peculiarities is strictly confidential. When a patient’s history or condition is reviewed, it must be done in privacy with only those persons involved with the care of the patient. Any other information coming to you in the course of your work concerning another person or employee is also considered confidential and may not become the topic of conversation with others.

I, hereby agree and pledge that I will honor and respect the privacy and confidentiality of the agency, their clients and business associates.
I will not divulge any information of any type obtained through my services as an employee of AGING WITH CARE.
I agree not to discuss nor release any information obtained within the agency regarding any AGING WITH CARE clients, their medical record or any client’s condition with any individual not directly associated with AGING WITH CARE, nor with AGING WITH CARE employees who are not directly associated with that client.
I also agree that any information that is released regarding the client or client’s record will only be done with proper authorization and/or in accordance with established agency policy for the release of the information: this includes, but is not limited to: the client’s identity, description, medical condition, or addresses, the agency or their business associates, financial status or condition, or any and all commercial or private transactions of the agency.

My signature on this document indicates that I understand, and I am aware of, and agree to abide by the aforementioned policies and that any breach will have significant consequences which may include suspension or termination of employment and/or civil prosecution.

Signature And Date *

Witness and Date ( Aging with care Representative ) *

PERMISSION FOR PPD TEST

I will voluntarily take the PPD test intradermally as a screening method for tuberculosis. I understand that a PPD test must be administered and read annually.
A chest X-Ray must be done every five years as a pre-requisite for employment at AGING WITH CARE.
I release AGING WITH CARE of any liability. I confirm that I have/have not had a PPD test within the last year; and I have no known allergy to the PPD test.

I have submitted or will submit documentation of a PPD test and results of said test. If an employee has a known history of having had a Positive Tuberculin test the Mantoux method, he/she may decline the Mantoux test. He/she must agree to give the agency documentation of a negative chest X-Ray within the past 12 months.

Signature And Date *

HEPATITIS B VACCINE 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. It is strongly suggested that I be vaccinated for HBV. I understand that I may decline the vaccination and I also understand that not being vaccinated; I continue to at risk for acquiring and remain susceptible to HBV, a serious disease.
If in the future I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with the HBV vaccine, I can receive the vaccination series at no charge to me.
AGING WITH CARE has explained to me that I continue to be at risk for HBV until such time that I am immunized.

Signature And Date *

Witness and Date ( Aging with care Representative ) *

UNIVERSAL PRECAUTIONS (OSHA BLOODBORNE PATHOGENS, SECTION 1910.1030 OF TITLE 29, CODE OF FEDERAL REGULATIONS)

I am aware and understand that due to my occupation, I am at risk for exposure to blood or other potentially infectious materials. Therefore, I have been given proper instruction on OSHA regulation and requirements. I also understand, and I am aware of Universal Precautions and know that as a requirement of my job description I will practice Universal Precautions as described in my job description.

Signature and Date *

IN-SERVICE REQUIREMENT

It is the policy of AGING WITH CARE at each licensed employee or independent contractor attends a minimum of four in-service hours per year. This is best accomplished by doing one (3) hour in-service every three (3) months, for a total of 12 hours per year.
AGING WITH CARE offers a variety of in-services throughout the year. You will be notified of scheduled in-services by memo in your paycheck. OSHA, Infection Control, and Tuberculosis are required annually. These courses must be home care focused. Should you attend an in-service elsewhere (i.e. hospital, nursing home, and/or other agencies), we will gladly accept a copy of your attendance record/certificate and will credit you with that in-service requirement.
By signing below, you acknowledge and understand that you must comply with the above requirement to remain in an “Active Status” with AGING WITH CARE.

Signature and Date *

Witness and Date ( Aging with care Representative ) *