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Gracious Hearts Home Care

Caregiver

Overview Application

Personal Information


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Professional / Personal References (Must Complete)

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

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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) Position applying for *


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.

DISCALIMER AND SIGNATURE



I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

AS PART OF CONSIDERATION FOR EMPLOYMENT, I HEREBY AUTHORIZE COMPANY HOME CARE TO
INVESTIGATE MY CHARACTER, CONDUCT, EMPLOYMENT RECORDS, AND TO KEEP AND PRESERVE
SUCH RECORDS. I AGREE THAT FAILURE TO REVEAL ANY PRIOR EMPLOYER OR GIVING OF ANY FALSE OR MISLEADING INFORMATION WILL BE GROUNDS FOR TERMINATION OF EMPLOYMENT.


Applicant Signature: __________________
Date: July 16, 2025

AUTHORIZATION TO PERFORM A BACKGROUND CHECK



It is the policy of COMPANY upon consent to conduct background checks on all employees and/or contractors before the state of employment and periodically thereafter. Every applicant will be screened for a criminal background utilizing the NC State Bureau of Investigations, Division of Criminal Justice (SBI).

I, ____________________, authorize COMPANY, to perform a NC State Bureau of Investigation Criminal Background Check and a Department of Motor Vehicle Check.


Applicant Signature: __________________
Date: July 16, 2025

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