Careers – Reliable Health Care

Resume:

Professional License (RN, LPN, Therapy, HHA Certificate):

Current CPR Training:

Driver's License:

Voided Check (For Direct Deposit):

TB Screening Documentation within the past 1 year (If not available, we provide TB screening upon hire):

Employment Eligibility Documents* (Non-Expired)

(U.S. Social Card) OR (U.S. Passport ) OR ( U.S Birth Certificate) OR (Permanent Resident Card) OR (Employment Authorization Card)

Position Desired:

Full Time Part Time

Date Available for Work:

Temporary On-Call

First Name

Middle Name

Last Name

Address:

City/State

Zip Code

Cell Phone

Home Phone

Email Address

EMPLOYMENT HISTORY:

Begin with present or most recent employer first. Please fill out completely, listing all previous employers even if you provided a resume. Include self-employment, military service, summer, and part-time jobs. Please circle the name of any employer or supervisor who you do not want contacted at this time. If necessary, attach additional sheets following the same format.

Employer:

Address:

City/State

Zip Code

Phone Number

Position

Part Time Full Time

Supervisor's Name & Title

Dates of Employment

To: Month/Year

Specific job duties

Reason for leaving:

MEDICAL INFORMATION:

I am able to perform the essential functions of this job as stated on the job description with or without reasonable accommodation.

Yes No

Applicant's initials

Name of School

City/State

Did you graduate?

High School

Techincal School, College or University

Additional training, special achievement, certificates or license, or honors relevant to position applying for.

REFERENCES (3):

Name:

Occupation:

Address:

Telephone number:

Name:

Occupation:

Address:

Telephone number:

Name:

Occupation:

Address:

Telephone number:

Name

Address

Hire Date (if known)

Rate of Pay

Filing Status (married or single)

# of Dependents

Other deductions/tax withholdings

Bank Name

Routing Number

Account Number

1. It’s alright to discuss confidentiality information with people who know the residents.

TRUE FALSE

2. It’s alright to discuss confidential information with family members of the resident.

TRUE FALSE

3. Confidentiality is the responsibility of the doctors and nurses.

TRUE FALSE

4. Hipaa is a safety device for hip protection when people fall.

TRUE FALSE

5. Hipaa is to protect their Social Security number from identity theft.

TRUE FALSE

6. Residents should expect that their healthcare information will be protected.

TRUE FALSE

7. You should not leave resident information on a computer or kiosks in plain view if you are coming right back.

TRUE FALSE

8. It’s alright to give reports at the nurses’ station because the residents are usually hard to hear or confused.

TRUE FALSE

Name

Program

I have already received the Hepatitis B vaccination. (Documentation required)

Upload Documents

Dates:

Titer : (attach results if already done)

Signature of Agent/Agency providing

Date:

HEPATITIS B VACCINATION DECLINATION

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV) infection. I have been given the opportunity t be vaccinated with the Hepatitis B vaccine, at my expense. However, I decline the Hepatitis B vaccination at this time. I understand that by declining the Hepatitis B vaccine I continue to be at risk of acquiring Hepatitis B as 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 the Hepatitis B vaccine, I can receive the vaccination series at that time.

Signature:

Date: