Apply at Flobega Health Careers

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Application for Employment

Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of Flobega Health LLC.

Position(s) applying for(Required)

Date of Application(Required)

Name(Required)

First Middle Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone #(Required)

Can you receive texts?(Required)

Secondary Phone #(Required)

Date of Birth(Required)

Social Security #(Required)

How did you hear about Home & Hospital?(Required)

Have you ever been employed here before?(Required)

Are you legally eligible for work in this country ?(Required)

Yes

What date are you available to start work?(Required)

Type of employment desired(Required)

Full Time

Part Time

Hours/Shifts/Days preferred(Required)

Are you able to meet the attendance requirements of this job?(Required)

Yes

Have you been convicted of a crime in the past seven years?(Required)

Yes

If yes, please explain(Required)

Conviction will not necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.

Employment History

Provide the following information for your past three employers, assignments, or volunteer activities, starting with the most recent.

From(Required)

To(Required)

Employer(Required)

Telephone(Required)

Job Title(Required)

Address

Immediate Supervisor & Title(Required)

Summarize the nature of work and job responsibilities(Required)

Reason for leaving(Required)

Hourly Rate/Salary(Required)

Starts $

Per

Final $

Per

Skills and Qualifications

Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Educational Background(Required)

Name & Location

Year Completed

Did you graduate?

Course of Study

High School

Year Completed

Did you graduate?

Course of Study

College

Year Completed

Major

Degree

Course of Study

Other

Year Completed

Did you graduate?

Course of Study

References(Required)

Name

Telephone #

Years Known

Emergency Contact(s)(Required)

Name

Relationship

Telephone #

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the Flobega Health LLC’s service, whenever it is discovered. I give Flobega Health LLC the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability Flobega Health LLC and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information. Flobega Health LLC does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law. The application is current for only 60 days. At the conclusion of this time, if I have not heard from Flobega Health LLC and would still like to be considered for employment, it will be necessary to fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice. Flobega Health reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as required by law. This application does not constitute an agreement or contract for employment for any specified period or duration. I understand that no representative of Flobega Health LLC other than an authorized officer has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand that it is this company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.(Required)

*Signature of Applicant(Required)

Date(Required)

Acknowledgment of Confidentiality of Information

The Health Insurance Portability and Accountability Act (HIPAA) ensures the client’s right to privacy of Protected Health Information (PHI)/ Electronic Protected Health Information (EPHI) to be maintained at all times. Any information related to the care of clients through Flobega Health LLC will be held as confidential. All information, written or verbal, will be disclosed only to appropriate health care personnel and appropriate staff, those with a “need to know basis” or to individuals the client requests.

Signature:(Required)

Date(Required)

Name (Please Print)(Required)

Hepatitis B Vaccination Declination Form

Declination (Statement of Non-Participation)

I understand that due to my occupational exposure to blood or other potentially infectious materials that I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine I 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 I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Employee Signature(Required)

Date(Required)

Conflict of Interest Disclosure Statement

I acknowledge I have read the policy and procedure regarding conflict of interest disclosure. I understand that if I have an outside relationship that is personal, professional, or otherwise, with a patient, vendor or potential business associate, I must disclose the nature of that relationship to the administrator. I acknowledge at this time, I have a potential personal, professional and/or financial relationship with:

Name(Required)

(Please Print) Signature

Date

TO BE COMPLETED BY APPLICANT:

APPLICANT NAME (PLEASE PRINT)(Required)

SOCIAL SECURITY NUMBER(Required)

NAME OF EMPLOYER(Required)

ADDRESS OF EMPLOYER(Required)

DATES OF EMPLOYMENT(Required)

POSITION(S) HELD(Required)

REASON FOR LEAVING(Required)

I have applied for a position with Flobega Health LLC. Please complete and return this evaluation for me. I hereby authorize you to disclose any and all information concerning my employment with your firm to Flobega Health LLC. I Understand this is in accordance with all Federal and State laws.

SIGNATURE OF APPLICANT(Required)

Date

TO BE COMPLETED BY FORMER EMPLOYER:

The applicant named above has applied for a position with Flobega Health LLC and has listed you as a previous employer. We would appreciate your assistance in verifying this applicant’s employment and in evaluating his/her job performance so we will be able to maintain our high standards. All information provided will be held in strictest confidence. Thank you.

1. Does the information above correspond with your records................................................…….......................

Yes

2. Position Held

Do Not Complete-To Be Complete By Flobega Secretary

3. Would you rehire this applicant................................................................................................................

Yes

4. Is there any reason, Medical/Other, that would interfere with this applicant performing his/her job....................................................................................................................

Yes

5. Reason for termination (This Part Not For You)______________________________________________________________________________________

EVALUATION →

EXCELLENT

GOOD

AVERAGE

POOR

ATTENDANCE →

EXCELLENT

GOOD

AVERAGE

POOR

PUNCTUALITY →

EXCELLENT

GOOD

AVERAGE

POOR

DEPENDABILITY →

EXCELLENT

GOOD

AVERAGE

POOR

QUALITY OF WORK→

EXCELLENT

GOOD

AVERAGE

POOR

JOB KNOWLEDGE →

EXCELLENT

GOOD

AVERAGE

POOR

ACCEPTS SUPERVISION→

EXCELLENT

GOOD

AVERAGE

POOR

PERSONAL APPEARANCE→

EXCELLENT

GOOD

AVERAGE

POOR

CONDUCT→

EXCELLENT

GOOD

AVERAGE

POOR

Information Supplied by

Title

Date

EMPLOYEE REFERENCE REQUEST- EDUCATIONAL

TO:(Required)

Date(Required)

Fax:

The applicant below has applied for a position with Flobega Health LLC and has indicated you as an educational reference. We would appreciate your assistance in verifying this applicant’s attendance and in evaluating his/her performance. All information provided will be held in the strictest of confidence. Thank you.

TO BE COMPLETED BY THE APPLICANT- Please print

Applicant Name(Required)

Social Security #_(Required)

School Name

Street Address

City/State

Zip Code

Dates of attendance

Program(s) attended

I, (print)(Required)

hereby authorize Flobega Health LLC to request and receive from all prior employers within one year of the date of the application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I further authorize Flobega Health LLC to request and receive information about my work, education and personal history. I authorize all individuals, schools, firms, organizations named therein to provide any information requested about me, and I release them from all liability for damages in providing this information. I have given Flobega Health LLC my permission to contact you in relation to my employment application.

Signature(Required)

Date(Required)

Evaluation→

Excellent

Good

Fair

Poor

Attendance→

Excellent

Good

Fair

Poor

Punctuality→

Excellent

Good

Fair

Poor

Dependability→

Excellent

Good

Fair

Poor

Job knowledge→

Excellent

Good

Fair

Poor

Quality of work→

Excellent

Good

Fair

Poor

Accepts supervision→

Excellent

Good

Fair

Poor

Personal appearance→

Excellent

Good

Fair

Poor

Attitude→

Excellent

Good

Fair

Poor

1. Are the dates of attendance correct?(Required)

Yes

If no, please give correct information:(Required)

2. Does the information below correspond with your own records?(Required)

Yes

If no, please give correct information(Required)

3.Would you recommend this person for employment with our company?(Required)

Yes

If no, please explain:(Required)

4. Comments:

Signature/title/relationship(Required)

Date(Required)

For documentation of a verbal reference (also request above information):

Name of person giving the reference:

Title/Relationship:

Content of the reference:

Signature/title of Flobega Health LLC staff who obtained reference

Date of the call

Employee Availability

Name:

Title:

Date:

Day(s) of the week that you can work:

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

Monday

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

Tuesday

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

Wednesday

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

Thursday

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

Friday

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

Saturday

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

Sunday

Days (From - To)

Evenings/Nights (From - To)

Overnight (From - To)

How many hours per week would you like to work?

Minimum:

Maximum:

How far are you willing to travel from home? (Miles)(Required)

Geographic area you are willing to work in:(Required)

Client Preference:(Required)

Geriatric

Pediatric

Adult

Other (specify)

Are you available on Holidays?(Required)

Yes

Which holidays are you unable to work?(Required)

Thank you!

Signature:(Required)

Date(Required)

EMPLOYEE W-4 INFORMATION FORM

Employee Name(Required)

Address(Required)

Email Address

Home #

Cell #

Date of Birth

Social Security #

Marital Status

Dependents

Date of Hire

Rate of Pay

Additional Withholdings

ALL EMPLOYEES WILL BE USING DIRECT DEPOSIT……..FILL OUT BELOW

Bank Name

Bank Account Number

Bank Routing Number

Employment Eligibility Verification

Please read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins

Print Name(Required)

Last First Midle

Address(Required)

Street Name And Number City State / Province / Region ZIP / Postal Code Apt#

Maiden Name

Date Of Birth

Social Security

I am aware that federal law provides for Imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following):

A citizen or m1tionc1I of the United States

A Lawful Permanent Resident (Alien#) A

An alien authorized to work until (Alien # or Admission #)

Employee's Signature(Required)

Date(Required)

Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Preparer's/Translator's Signature

Print Name

Address (Street Name and Number, City, State. Zip Code)(Required)

Date (month/day/year)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of the document(s).

Document title:(Required)

List A

List B

List C

Issuing authority:(Required)

List A

List B

List C

Document#:(Required)

List A

List B

List C

Expiration Date (if any):(Required)

List A

List B

List C

Document#:(Required)

List A

List B

List C

Expiration Date (if any):(Required)

Name

Phone(Required)

Email(Required)

License Number(Required)

Nursing Level(Required)

Copy of Nursing License(Required)

Max. file size: 1 GB.

Copy of CHHA or Nursing License(Required)

Max. file size: 1 GB.

Copy of Work Permit or US Passport(Required)

Max. file size: 1 GB.

Copy of Driver’s License(Required)

Max. file size: 1 GB.

Resume(Required)

Max. file size: 1 GB.

Additional Comments

This field is for validation purposes and should be left unchanged.