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Professional / Personal References (Must Complete)

Persons who can furnish information about job performance or personal information about you.

Skill Questions

1) What languages do you speak? Please specify: *

2) Do you know CPR? *

General Questions

1) Have you ever applied for employment with this Agency? *

2) How many hours a week are you available for work? *

3) Are you legally eligible for employment in the United States? *

4) How did you learn of our organization? *

5) Are you willing to work *

6) Do you have a reliable mode of transportation? *

7) Are you a veteran? *

8) I authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons/entities listed on the application and give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. I understand and agree that, if hired, my employment is for not definite period and may, regardless of the date of payment of wages and salary, be terminated at any time for any lawful reason, without prior notice or without cause. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on the application SHALL BE GROUNDS FOR DISMISSAL. *

OIG/LEIE Background Checks

POLICY

We comply with licensure requirements regarding criminal history record checks, the OIG for employees, subcontractors, and volunteers.

PROCEDURE

1. Inform the individual who applies for employment that the agency is required to conduct a background check
2. Review the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General, and the LEIE maintained by the HHS Office of Inspector General:
   • before hiring an applicant for employment or contracting with a potential subcontractor; and
   • at least monthly, for each employee and subcontractor.
3. Not employ an applicant for employment or contract with a potential subcontractor to perform any duties that may be paid for directly or indirectly through a contract if the applicant or potential subcontractor is listed on LEIE.
4. Prohibit an employee or subcontractor listed on any LEIE from performing any duties that may be paid for directly or indirectly through a contract; and
5. if an employee or subcontractor is listed on either LEIE immediately report to the HHS Office of Inspector General, in accordance with the self-reporting protocol of the HHS Office of Inspector General:
   • the identity of an excluded employee or subcontractor; and
   • the amount paid by the contractor to the employee or subcontractor for services provided under a contract.