Careers Forms

* Required Information

PERSONAL INFORMATION

Full Name *

Address *

City *

State / Province *

Zip / Postal Code *

Email Address *

Phone Number *

Position Applying for *

Wage Expectation *

Salary / Hourly *

Referral Source *

Are you over the age of 18?

Yes

Are you eligible to work in the United States?

Yes

Are you fluent in a foreign language?

Yes

Are you currently employed? *

Yes

Date available for work

Are you available to work

Full Time

Part Time

Contract

Have you applied here before?

Yes

Have you been convicted of a felony/misdemeanor (other than traffic violations)? *

Yes

EMPLOYMENT HISTORY

Employer

Job Title

Address

Start Date

End Date

Start Wage

End Wage

Responsibilities

Reason for Leaving

May we contact your Employer

Yes

Supervisor's Name

Phone Number

Employer

Job Title

Address

Start Date

End Date

Start Wage

End Wage

Responsibilities

Reason for Leaving

May we contact your Employer

Yes

Supervisor's Name

Phone Number

Employer

Job Title

Address

Start Date

End Date

Start Wage

End Wage

Responsibilities

Reason for Leaving

May we contact your Employer

Yes

Supervisor's Name

Phone Number

EDUCATION

	Name & Location of school	Degree or Certification	Number of Years Attended	Did You Graduate?
GED / High School
Trade School
College
Graduate

Do you have a U.S. military service record? *

Yes

Discharge date and rank

List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.

List any additional information you would like us to consider:

REFERENCES
List three professional references, (business or work, not relatives) that you have known for atleast one year. List at least one previous supervisor.

Full Name	Company	Best phone number to reach them	Years acquainted	Relationship

AUTHORIZATION

I understand that KindHearted Healthcare INC. is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination if employed. I authorize Kindhearted Healthcare INC. to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, credit history, driving record, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to Kindhearted Healthcare INC. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original. Pre-employment testing may be required (drug testing, background checks, physical examinations, motor vehicle checks). Testing may be an applicant or employer-paid based on the employer. I understand that any offer of employment may be withdrawn if drug tests are positive and/or if a condition is discovered for which no reasonable accommodation can be made. I understand that this application is current for 60 days. At the conclusion of this time, if I have not heard from Kindhearted Healthcare INC. and still, wish to be considered for employment, it will be necessary to complete a new application. I understand that if hired, employment is at-will, regardless of the employer, and may be terminated by myself or Kindhearted Healthcare INC. at any time, with or without cause or notice, for any reason or no reason.

By entering your name, you agree to accept the terms of the above document with an electronic signature

I agree

I do not agree

You must agree to accept the terms of the document in order to submit an application

Signature *

Clear

Date

Name of Employer

Position

Supervisor

Address

Phone

Email

The person whose signature appears beneath mine has applied to Kindhearted Healthcare Service Inc. 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 Kindhearted Healthcare Service Inc 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.

Agency Rep

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

Applicant's Signature

Clear

(Typed name constitutes legal signature)

Applicant's Name

Social Security #

Position held in your employ

Area worked

Employment dates - From

Employment dates - To

Did applicant resign or was he/she terminated?

Eligible for rehire?

Yes

Reason for leaving

Was this a travel assignment?

Yes

	VERY GOOD	SATISFACTORY	FAIR	POOR
Quality of work
Flexibility
Attitude
Emotional Stability
Adaptability to work under pressure
Dependability / Attendance / Punctuality
Cooperation / Ability to get along with others

Comments

Signature

Clear

(Typed name constitutes legal signature)

Title

Date

FOR OFFICE USE ONLY

Reference done by

Phone

Mail

Fax

Date

Initials

Name of Employer

Position

Supervisor

Address

Phone

Email

Agency Rep

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

Applicant's Signature

Clear

(Typed name constitutes legal signature)

Applicant's Name

Social Security #

Position held in your employ

Area worked

Employment dates - From

Employment dates - To

Did applicant resign or was he/she terminated?

Eligible for rehire?

Yes

Reason for leaving

Was this a travel assignment?

Yes

	VERY GOOD	SATISFACTORY	FAIR	POOR
Quality of work
Flexibility
Attitude
Emotional Stability
Adaptability to work under pressure
Dependability / Attendance / Punctuality
Cooperation / Ability to get along with others

Comments

Signature

Clear

(Typed name constitutes legal signature)

Title

Date

FOR OFFICE USE ONLY

Reference done by

Phone

Mail

Fax

Date

Initials

Applicant Name

Position

Character Reference Name

Phone

1) Are you related to the applicant?

Yes

If yes, please explain

2) How many years have you known applicant?

3) In what context, have you known applicant (supervisor, colleague, friend, etc)?

4) Have you ever had to question the applicants reputation for:

a. Honesty

Yes

Don't know

b. Trustworthiness

Yes

Don't know

c. Diligence

Yes

Don't know

d. Reliability

Yes

Don't know

e. Good character

Yes

Don't know

f. Maturity

Yes

Don't know

Overall Recommendation

Highly recommended

Recommended, but with reservations

Recommended

Not recommended

Comments

FOR INTERNAL USE ONLY

Results

Date Checked

By Phone

By Mail

By Fax

Signature

(Typed name constitutes legal signature)

Date

Name (Last Name)

EMPLOYEE ACKNOWLEDGEMENT OF HANDBOOK

I acknowledge receipt of KINDHEARTED HEALTHCARE Employee Handbook. In consideration of my employment, I agree to read and abide by the rules and the policies of this handbook. Since the information, policies, and benefits described in this booklet may be subject to change, l understand and agree that any such change can be made unilaterally by the company in its sole and absolute discretion, and that material changes will be made known to employees through the usual methods of communication within a reasonable period of time.

Employee Name

Employee Signature *

Clear

Date

Name (Last Name)

UNIVERSAL PRECAUTIONS

(OSHA BLOOIJBORNE PATHOGENS. SECT/Ol'-1'19/0.J0J0OFTITLE29, 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.

Print Name

Signature *

Clear

Date

Witness

Date

Name (Last Name)

IN-SERVICE REQUIREMENT

It is the policy of Kindhearted Healthcare 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.

Kindhearted Healthcare 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 inservice requirement.

By signing below, you acknowledge and understand that you must comply with the above requirement to remain in an "Active Status" with Kindhearted Healthcare.

Print Name

Signature *

Clear

Date

Name (Last Name) *

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.

Kindhearted Healthcare has explained to me that I continue to be at risk for HBV until such time that I am immunized.

Print Name

Signature *

Clear

Authorized Signature *

Clear

Title

Date

DRUG AND ALCOHOL POLICY

Informed Consent and Release of Liability

I authorize KINDHEARTED HEALTHCARE or Client Company company to obtain a specimen of my urine for chemical analysis. l understand that this analysis is to determine or exclude the presence of alcohol, drugs or other substances, in accordance with the Substance Abuse and drug Testing Policy of Company. I. understand that decisions regarding my continued employment may be made as a result of this analysis. I understand that test results will be divulged only to authorized personnel. I hereby consent to this test and release Company from any liability for decisions resulting from this test.

Employee/Applicant Signature *

Clear

Date

Employee/Applicant Signature *

Clear

Policy and Procedure Agreement

ALL STAFF:

I, have read, understand and agree to abide by the policies and procedures set forth by KINDHEARTED HEALTHCARE. I also understand that I may view or copy any or all of KINDHEARTED HEALTHCARE's policy and procedure manual for review or retention. I also agree to -adhere to all local, state, and federal procedures regulated as precedent for the home health care industry for compliance in providing care to Agency clients as designated.

Employee Signature *

Clear

Date

Administrative Signature

Clear

Date

EMPLOYMENT OFFER

Congratulations. We are pleased to inform you that you have been offered , employment with Kindhearted Healthcare as a: , , responsible to provide services to Kindhearted Healthcare.

Duties and Responsibilities: During the period of this, employment, employee/contractor shall perform His/her duties and responsibilities diligently and consistent with Kindhearted Healthcare Agency policies and procedures and practices in accordance with accepted professional practices. While providing services at clients work site-, employee/contractor shall work under the supervision of Agency Director of Nursing and or Client and shall be required to abide by all the client's needs.

Compensation: Employee/contractor shall be compensated at regular hourly rate of $- __ _ compensation shall be paid in by weekly remuneration and shall be in accordance with the company normal payroll cycle (biweekly).

Confidentiality: Except as authorized, employee/contractor shall not directly or indirectly publish or disclose any confidential information of the company neither shall employee abuse a client's information due to their privileged position.

General Conditions: This agreement may be terminated by either party upon written or verbal notice to other party. Upon termination, the employee/contractor shall prepare and submit final invoice for final services rendered.

In witness thereof, the parties hereto execute this agreement.

Kindhearted Healthcare, Representative

Employee/Contractor Name

Date

Social security number

First and Last Name

Address Line 1

Address Line 2

County

DOB

Tax claims: How many dependants are you claiming? 0, 1, 2 etc

Tax status: Filing single or joined ?

Single

Joined

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.