GMHS Application

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EMPLOYMENT APPLICATION

GMHS is an equal opportunity employer, and does not discriminate against any individual in any phase of employment in accordance with the requirements of local, state, and federal law. Application must be submitted with two passport pictures.

PERSONAL INFORMATION

NAME:

(Last, First, Middle)

DATE OF BIRTH:

MM slash DD slash YYYY

HOME PHONE:

ALTERNATE PHONE NUMBER(S):

ADDRESS:

(Street, City, State, Zip)

SOCIAL SECURITY#:

ALIEN ID:

AUTOMOBILE AVAILABILITY:

Yes

DRIVER'S LICENSE:

Yes

DRIVER'S LICENSE #:

POSITION DESIRED:

START DATE:

MM slash DD slash YYYY

EMAIL:

PREFERRED DAYS:

PREFERRED SHIFTS:

Morn.

After.

Eve.

EDUCATION

HIGH SCHOOL:

NAME, CITY & STATE

# OF YEARS ATTENDED

DEGREE RECEIVED

COLLEGE:

NAME, CITY & STATE

# OF YEARS ATTENDED

DEGREE RECEIVED

NURSING SCHOOL:

NAME, CITY & STATE

# OF YEARS ATTENDED

DEGREE RECEIVED

SPECIAL TRAINING:

NAME, CITY & STATE

# OF YEARS ATTENDED

DEGREE RECEIVED

EMERGENCY CONTACT

PRIMARY

NAME:

PHONE:

RELATION:

SECONDARY

NAME:

PHONE:

RELATION:

WORK HISTORY

Current Employer:

Address:

Phone #:

Dates of Employment:

MM slash DD slash YYYY

Position:

Salary:

Supervisor:

Title:

Reason for Leaving:

Previous Employer:

Address:

Phone #:

Dates of Employment:

MM slash DD slash YYYY

Position:

Salary:

Supervisor:

Title:

Reason for Leaving:

Previous Employer:

Address:

Phone #:

Dates of Employment:

MM slash DD slash YYYY

Position:

Salary:

Supervisor:

Title:

Reason for Leaving:

Previous Employer:

Address:

Phone #:

Dates of Employment:

MM slash DD slash YYYY

Position:

Salary:

Supervisor:

Title:

Reason for Leaving:

LICENSES AND/OR CERTIFICATIONS

DO YOU HA VE A CURRENT LICENSE OR CERTIFICATION

Yes

STATE ISSUE:

EXPIRATION DATE:

MM slash DD slash YYYY

LICENSE NUMBER:

LPN

STATE ISSUE:

EXPIRATION DATE:

MM slash DD slash YYYY

LICENSE NUMBER:

CNA / GNA / HHA

STATE ISSUE:

EXPIRATION DATE:

MM slash DD slash YYYY

LICENSE NUMBER:

CMA

STATE ISSUE:

EXPIRATION DATE:

MM slash DD slash YYYY

LICENSE NUMBER:

CPR:

Yes

ISSUE DATE:

MM slash DD slash YYYY

EXPIRATION DATE:

MM slash DD slash YYYY

FIRST AID:

Yes

ISSUE DATE:

MM slash DD slash YYYY

EXPIRATION DATE:

MM slash DD slash YYYY

CRIMINAL BACKGROUND CHECK

Yes

CRIMINAL BACKGROUND CHECK

STATE

FEDERAL

ISSUE DATE:

MM slash DD slash YYYY

GENERAL

List any special skills you may have (e.g. multi-lingua, sign language, other medical expertise etc.) or any additional information which you feel will be helpful in evaluating your qualifications for employment.

I authorize the employers, organizations, and persons stated on this application to give GMHS (including all related entities) any and all information (except information which cannot be obtained as a matter of law) and records concerning my previous employment and education, and I release said employers, organizations or persons from all claims and damages arising out of the provision of this information and/or records to GMHS.

I acknowledge that, if hired, my employment will be at will and therefore can be terminated with or without cause, and with or without notice, at any time, at the option of either GMHS or myself I also understand that GMHS at its sole discretion, may alter, amend, or eliminate its existing employment policies, procedures, practices, compensation systems and other privileges and benefits at any time, with or without cause and/or notice (except where notice is required by law).

Applicant's Signature:*

Date*

MM slash DD slash YYYY

EMPLOYMENTREFERENCE FORM

Name of Employer:

Position:

Address:

Department:

Supervisor:

Phone:

The person whose signature appears beneath mine has applied to Grace and Mercy Health Services for employment and has submitted your name as a former employer for reference purposes. The serious nature of our responsibility to our clients is such that any consideration of the individual by Grace and Mercy Health Services is dependent upon receipt of satisfactory references. We would, therefore, appreciate your cooperation in replying to the questions below. Please be assured that your response will be kept in the strictest confidence. Thank you in advance for this courtesy

Grace and Mercy Health Services

I hereby authorize you to fulfill the above request for information

Applicant's Signature

Applicant's Name:

Social Security #:

Position held in your employ:

Unit/ Area worked:

Employment dates:

From:

MM slash DD slash YYYY

To:

MM slash DD slash YYYY

Did applicant resign or was he/she terminated:

Eligible for rehire?

Yes

Reason for leaving:

Was this a travel assignment?

Yes

PERSONAL EVALUATION

Quality of work

Very Good

Satisfactory

Fair

Poor

Flexibility

Very Good

Satisfactory

Fair

Poor

Attitude

Very Good

Satisfactory

Fair

Poor

Emotional Stability

Very Good

Satisfactory

Fair

Poor

Adaptability to work under pressure

Very Good

Satisfactory

Fair

Poor

Dependability/ Attendance/ Punctuality

Very Good

Satisfactory

Fair

Poor

Cooperation / Ability to get along with others

Very Good

Satisfactory

Fair

Poor

Comments:

Date

MM slash DD slash YYYY

Signature

Title:

For Office Use Only

Reference done by:

Phone:

Mail:

Date:

MM slash DD slash YYYY

Initials:

Employment dates:

Name of Reference:

Relationship:

Address:

Phone:

The person whose signature appears beneath mine has applied to Grace and Mercy Health Services for employment and has submitted your name as a personal reference. The serious nature of our responsibility to our clients is such that any consideration of the individual by Grace and Mercy Health Services is dependent upon receipt of satisfactory references. We would, therefore, appreciate your cooperation in replying to the questions below. Please be assured that your response will be kept in the strictest confidence. Thank you in advance for this courtesy.

Grace and Mercy Health Services

I hereby authorize you to fulfill the above request for information.

Applicant's Signature

Applicant's Name:

Social Security #:

How long have you know this person and where?

PERSONAL EVALUATION

Friendly

Very Good

Satisfactory

Fair

Poor

Flexibility

Very Good

Satisfactory

Fair

Poor

Attitude

Very Good

Satisfactory

Fair

Poor

Emotional Stability

Very Good

Satisfactory

Fair

Poor

Compassionate/Joyful

Very Good

Satisfactory

Fair

Poor

Dependability / Punctuality

Very Good

Satisfactory

Fair

Poor

Cooperation / Ability to get along with others

Very Good

Satisfactory

Fair

Poor

Comments:

Date:

MM slash DD slash YYYY

Signature:

For Office Use Only

Reference done by:

Phone:

Mail:

Date

MM slash DD slash YYYY

Initials:

HEPATITIS B VACCINATION, CONSENT, AND DECLINATION

I. Acceptance of Hepatitis B Vaccine

I acknowledge that I am at risk of exposure or have been unknowingly exposed to the Hepatitis B virus as a result of my employment and acknowledge that I will like to receive the Hepatitis B Vaccine. It is my decision to request that I receive the Hepatitis B Vaccine.

Employee

Date

MM slash DD slash YYYY

II. Declination of Hepatitis B Vaccine

I am refusing the Hepatitis B Vaccine and hold harmless the Agency. 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. I have been given the opportunity to be vaccinated with Hepatitis B Vaccination.

However, I decline Hepatitis B Vaccination at this time. I understand that by declining this vaccine, 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 want to be vaccinated with the Hepatitis B Vaccine, I may receive the Hepatitis B Vaccination Series at no charge to me from Raffa Home Care.

Employee

Date

MM slash DD slash YYYY

Ill. Documentation of Hepatitis B Vaccine Series

If you have received the complete Hepatitis B Vaccine Series, you must attach to this form the documentation, which proves your receipt of the HBV Series and the titer results indicating your immunity. If you are unable to receive the vaccination series for medical reasons please attach supporting documentation.

HEPATITIS B VACCINATION, CONSENT, AND DECLINATION

Please be reminded of the following information:

Patient confidentiality

It is the policy of Grace and Mercy Health Services that all employees, contractors and volunteers of Grace and Mercy Health Services will maintain and uphold confidentiality of patient information at all times.

According to Healthcare regulation it is the policy of GMHS to provide our employees with patient information about a client at the time when an employee is assigned a case.

hereby agree to keep all personal and medical information of Grace and Mercy Health Services, and/or her patients/clients, confidential .. Furthermore, I agree not to releaser any information to any outside organization or agency without the approval of the agency patient/client, or as required by law or third party payment contract.

Name of Employee/Contractor/lntern/Volunteer

Signature*

Date*

MM slash DD slash YYYY

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