Employment Application First Name:Last Name:SS Number:Address:Home Phone:City:State:Cell Phone:Zip Code:Country:Email: Are you 18 years of age or older?YesNoAre You authorized to work in the US?YesNoUpon employment, are you able to submit verification of your legal right to work in the United States?YesNoHave you ever worked with us before?YesNoIf Yes, please indicate start and ends dates:From: To: Position(s) applying for:EducationType of School (High School/GED)Name of SchoolDate Graduated Major or DegreeType of School (College/Tech School)Name of SchoolDate Graduated Major or DegreeType of School (Professional School)Name of SchoolDate Graduated Major or DegreeAvailabilityWeek Day Preference: Monday Tuesday Wednesday Thrusday Friday WeekendCan you work 12 Hours?YesNo Employment History (Must be filled out completely)1.*Name of Employer:Phone #: *Address:City/State:Zip Code: *Job Title:Name of last supervisor: Reason for Leaving (be specific):* Dates of employment:From: To: 2.Name of Employer:Phone #: Address:City/State:Zip Code: Job Title:Name of last supervisor: Reason for Leaving (be specific): Dates of employment:From: To: 3.Name of Employer:Phone #: Address:City/State:Zip Code: Job Title:Name of last supervisor: Reason for Leaving (be specific): Dates of employment:From: To: PRINT NAME:Date: PATIENT'S BILL OF RIGHTS I feel each resident should expect the highest quality of personal and professional care. In keeping with this philosophy, I support and adhere to the Patient's Bill of Rights. Because of the importance of these expectations in my role, I am attesting to the portions of the Patient's Bill of Rights highlighted below which affirm the rights of a resident: 1. To be treated with consideration, respect and full recognition of personal dignity and individuality. 2. To receive care, treatment and services which are adequate. 3. To receive respect and privacy of his or her personal and medical records. 4. To be free from mental and physical abuse. 5. To enjoy privacy in his or her room. 6. To associate and communicate privately with persons of his or her choice and send and receive his or her personal mail unopened. 7. To meet with and participate in activities of social, religious and community groups at his or her discretion. No roster or rights can guarantee for the resident the kind of treatment they have a right to expect. It is very important that each of my actions is conducted with a main concern for the resident and the recognition of their dignity as a human being. Violations of the Patient's Bill of Rights may result in disciplinary action up to and including revocation of license, termination and jail. By signing this, I state that I have read and understand the Patient's Bill of Rights.PRINT NAME:DATE: HEALTH STATUS AND INJURY HISTORYNAME:TITLE: Person to be notified in case of an emergency:Telephone number(s):Please answer the following by checking YES or NO. Use the space below to comment on any question you answered YES to.1. Reactions to medicationsYesNo2. Skin rashes or eczemaYesNo3. Back TroubleYesNo4. Back InjuryYesNo5. Back SurgeryYesNo6. Back Pain on liftingYesNo7. Knee SurgeryYesNo8. Swollen JointsYesNo9. Rheumatism or arthritisYesNo10. Dislocated shoulderYesNo11. Fracture of a boneYesNo12. Any other type of injuryYesNo13. Work related injury claim within the past five years?YesNoPlease explain nature of injury, place and date:PRINT NAME:DATE: HEPATITIS B VIRUS VACCINE CONSENT OR 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 infection (HBV). At this time I choose the following:Check one, then sign and submit. I have already received the vaccine and so I am declining at this time. I choose not to receive the vaccine at this time. I may choose to be vaccinated against Hepatitis B while working with Reach Adult Recreational Services. I understand that I will NOT BE REIMBURSED the cost of any shots in the Hep B series taken during the time I am working at RARS.PRINT NAME:DATE: OSHA REGULATIONS AND GUIDELINES In accordance with OSHA regulations, each contractor must review the Blood Borne Pathogen, Hazard Communications, Emergency Action Plan, Fire Prevention and Escape Routes. Excel has notified each facility that they are responsible and must review their facility's specific plan with each contractor that works in that facility. Please review all enclosed material, sign and date this sheet. Fax or mail this sheet back to Excel for your personnel file. I have reviewed and understand the presented material as stated. I have been given the opportunity to clarify any questions that I may have.PRINT NAME:DATE: HEALTH CARE PROFESSIONAL CONFIDENTIALITY AGREEMENT(HP113-B) As a health care professional who treats patients and residents of facilities (hereafter referred to as “Health Care Professional”), you may have access to “confidential information.” The purpose of this agreement is to confirm your understanding of and obtain your commitment to your duties regarding confidential information. Confidential information is valuable, sensitive, and protected by law and the facility policies. As a Health Care Professional, you are required to conduct yourself in a strict conformance to applicable laws and the facility policies and to abide by the duties described below governing confidential information. You will be responsible for any alteration, destruction, misuse or wrongful disclosure of confidential medical information by you and for any failure by you to safeguard any authorization codes to access confidential information. You understand that your failure to comply with the duties described below and this agreement may also result in loss of privileges to access confidential information, loss of privileges to treat patients and residents at facilities and to legal liability. As a Health Care Professional, you understand that you will have access to such confidential medical information that may include, but is not limited to, information relating to: - Patients and residents (such as medical records, private conversations, admittance information, resident financial information, etc.) - Other employees (such as salaries, employment records, disciplinary actions, etc.) - Facility information (such as financial and statistical records, strategic plans, internal reports, memos, contracts, peer review information, communications, proprietary computer programs, source code, proprietary technology, etc.) - Third party information (such as computer software programs, client and vendor proprietary information, proprietary technology, etc.). As a condition of and in consideration of your access to such confidential information, you promise that: 1. You will use confidential information only as needed to perform your legitimate duties at facilities. a) You will only access confidential information needed to treat your patients and residents or fulfill your responsibilities. b) You will not in any way divulge, copy, release, sell, loan, review, alter, or destroy any confidential information except as properly authorized within the scope of your professional activities as a Health Care Professional and caretaker of residents affiliated with facilities. c) You will not misuse or fail to safeguard confidential information. 2. You will safeguard and will not disclose any authorization codes or keys you have that allow you to access confidential information. You accept responsibility for all activities undertaken using your authorization codes or keys.,/p> 3. You will report to the Facility Privacy Officer activities by any individual or entity you suspect may compromise the confidentiality of confidential information described in this agreement. 4. You understand that your obligations under this agreement will continue after termination of your privileges or permission to treat patients and residents of facilities. You understand that facilities may review, revise or terminate your privileges to access and use confidential information as reasonably warranted to protect confidentiality of such information. 5. You understand that you have no right to ownership interest in any confidential information referred to in this agreement. The facility may at any time revoke your key, access code, other authorization, or access to confidential information. 6. Health Care Professional shall indemnify and hold facilities harmless from and against all claims, liabilities, judgments, fines, assessments, penalties, awards, or other expenses, of any kind or nature whatsoever. This indemnification includes without limitation, attorneys' fees, expert witness fees, and costs of investigation, litigation or dispute resolution, relating to or arising out of any breach or alleged breach of this agreement by Health Care Professional. 7. You will respect ownership of proprietary software. 8. You will not operate any non-licensed software on any computer provided by any facility. By signing this, I agree that I have read, understand and will comply with this agreement. PRINT NAME:DATE: CONSENT FOR DRUG SCREENING I am aware that as a contract laborer, pre-employment drug testing is not necessary but that it may be requested that I voluntarily consent to a drug screening at my own expense. I hereby give my consent for this screening. Reach Adult Recreational Service will give site location of where this service may be performed.PRINT NAME:DATE: EMPLOYEE TEST AGREEMENT Reach Adult Recreational Service requires every employee to have a physical examination, drug screen, and a TB Skin Test, which will be provided through Olive Branch Family Medical Center. Employees must also have a background check provided through SentryLink and a driver safety report (drivers only) provided through the Department of Public Safety records. The total fees are $197.97, which will be divided and deducted from the employee first two paychecks. Reach Adult Recreational Service will reimburse test fees of anyone who is employed for 6 months or more. Below is a list of the required test and fees. Please initial that you agree to the fees below: Physical Examination ($60) Drug Screen ($60) TB Skin Test ($25) Background Check (19.99) Driver Safety Report (14.98) Finger Print ($18)By signing below, I understand and agree to the above policy.PRINT NAME:DATE: REFERENCE REQUEST Please send my reference request to: Company Name:Supervisor: Address: City:State: Zip Code:Country: Phone:For:Applicant's Name:Job Title: I hereby authorize the employer named above to provide any requested information to Cooks Health Care and release them from all liabilities in responding to inquiries in connection with my application.(Applicants do not fill out this portion.) TO BE COMPLETED BY EMPLOYERDate of Employment:From:To: Position Held:Reason for leaving:Would you re-hire?If no please explain:Title:SIGNATURE:DATE:In placing an application with us for the position of the above applicant has given you as a reference. It would be appreciated if you will complete this form and return it to us in the enclosed self addressed envelope. Thank you for your help. AUTHORITY FOR RELEASE OF INFORMATION I authorize Reach Adult Recreational Service to perform a criminal history record information check in connection with my work, and to share the information with any / all facilities where I will accept work when required. Last Name:First Name: Social Security Number:Date of Birth: Current State of Residence:County: Sex:Race: I hereby release said agency and persons from any and all liability, which may be incurred as a result of furnishing such information needed to criminal background check me (applicant).PRINT NAME:DATE: DISCLAIMER In the signing of this document, I acknowledge and agree that I am contracted to facilities by Reach Adult Recreational Service. I also understand that I am not an employee of the facility and that I have no legal rights to any benefits provided by the facility to its employees. I further agree that I will not make any claims against said facilities for any wages or benefits including Worker's Compensation claims. I understand and agree that in order to file a claim as an Independent Contractor; I am self-employed and must carry my own Worker's Compensation Insurance. PRINT NAME:DATE: Certification By submitting this application, and as an applicant for employment, I understand and certify the following: • The information given by me in this application is complete and true in all respects. Any omission, misrepresentation or falsification will preclude my application from further consideration. If employed, the subsequent disclosure of any omission, misrepresentation or falsification of information will result in the termination of my employment. • Nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Reach Adult Recreational Services and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promises or guarantees are binding upon Reach Adult Recreational Services unless made in writing. • If I am offered employment by Reach Adult Recreational Services, my employment will be for no definite term and that either I or Reach Adult Recreational Services will have the right to terminate the employment relationship at any time, without cause and with or without notice. I also understand that this status can only be altered by a written contract that is specific as to all material terms and is signed by me and the CEO of Reach Adult Recreational Services. • Reach Adult Recreational Services will make all necessary and appropriate investigations to verify the information contained herein. I authorize and consent to my current and former employers, educational institutions and/or persons or organizations named in this application to release information to Reach Adult Recreational Services that may be required to make an employment decision. • If I am offered employment, an investigative consumer report will be completed for employment purposes as appropriate to the position and upon my written authorization. I will have the right to make a written request for a complete and accurate disclosure. • If I am offered employment, my employment is conditioned on the provision of satisfactory proof of my identity and legal authority to work in the United States • Any employee handbook or other personnel policies maintained by Reach Adult Recreational Services do not constitute an employment contract, but are merely gratuitous statements of Reach Adult Recreational Services' current policies. This application will remain active for a period of 90 days. It is the policy of Reach Adult Recreational Services to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability or any other legally protected status as required by federal or state law. I further understand, that any offer of, or continued employment is contingent upon: • Successful completion of a health assessment and drug test. • Satisfactory completion of reference checks with past employers and/ or personal references; and • Verification of current status with applicable licensing and certification authorities, when necessary. • Successful completion of criminal background check. I certify that the information on this application is accurate and subject to verification. I understand that any misleading or incorrect statements may render this application void. This iframe contains the logic required to handle Ajax powered Gravity Forms.