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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) Personal Care Experience *

General Questions

1) How would your current/previous employer rate your attendance? *

2) Do you have reliable transportation? *

3) Do you understand the importance of showing up on time for your shift? *

4) PLEASE READ ALL STATEMENTS BELOW BEFORE SIGNING THIS APPLICATION: 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 this application SHALL BE GROUNDS FOR DISMISSAL I authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to 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 may result from furnishing the same to the Agency. This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested. 4 This Agency will perform a criminal history check including the National Sex Offender registry for any direct care position, or a position that has access to patient/client records. By signing this application, I acknowledge and agree to the Agency conducting a criminal history check if I am offered employment by the Agency. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time. *

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.