JOB APPLICATION
  • Legal Consent
  • Personal Data
  • Applicant's Signature
  • Vaccine Consent
  • Finish
Date:
I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.
Consent Signature:
Personal Information
First Name:
Last Name:
Middle Initial:
Date of Birth:
Social Security Number:
Email:
Telephone No.:
Street Address:
City:
State:
Zip Code:
Driver License No:
State:
Expiration:
Position
Education
School or University:
Major/Degree:
Field of Study:
From:
To (Actual or Expected):
Emergency Contact
Name:
Relationship:
Telephone No.:
Work Experience
Job Title:
Company Name:
Location:
Date of Employment From:
Date of Employment To:
I currently work here
Role Description
General Questions

All fields are required.

Are you legally authorized to work in the United States for any employer?
Yes No
Have you ever been excluded, sanctioned, or otherwise restricted from participation in any federal or state health care program (including Medicare or Medicaid)? You have an affirmative duty as a condition of employment and/or staff privileges to immediately report any exclusion, sanction or other restriction (past, present, or future) from participation in any federal or state health care program (including Medicare or Medicaid) to the HR Department. Please note that any exclusion, sanction, or restriction will not necessarily disqualify an application for employment?
Yes No
Have you ever been the subject of any disciplinary or adverse action taken by a regulatory, licensing or government agency? You have an affirmative duty as a condition of employment and/or staff privileges to immediately report any disciplinary or adverse action taken (past, present, or future) by a regulatory, licensing and government agency to the HR Department. (Examples of regulatory, licensing and government agencies include, but are not limited to, Centers for Medicare and Medicaid Services (CMS), state Medicaid programs, Department of Health and Human Services (DHHS), Office of Inspector General (OIG), and any medical or nursing boards). Please note that disciplinary or adverse action will not necessarily disqualify an application for employment.
Yes No
Professional References
Name:
Company:
Telephone No.:
Name:
Company:
Telephone No.:
Resume
I hereby certify, under penalty of perjury, that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize the Agency to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Agency any and all letters, reports and other information related to my work records. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Agency. In addition, I expressly agree and understand that, if employed, my employment, having no specific term, is based upon mutual consent and may be terminated at will, with or without cause or notice, by either party (the company or me). I also understand that this aspect of my employment, which includes the Agency’s right to demote or otherwise discipline with or without cause or notice, may not be changed, modified, amended or rescinded except by an individual written agreement signed by both me and the administrator of the agency.
I understand that any offer of employment regarding certain job positions may be conditioned upon satisfactory completion of a medical examination and/or a drug and alcohol screen. I agree to sign a release of medical information authorization form and to submit to a medical examination and/or drug and alcohol screen should the Agency condition my offer of employment upon successful completion of such an examination or screening.
I understand that a consumer report or an investigative consumer report may be obtained from a Consumer Reporting Agency for the purpose of evaluating you for employment, promotion, reassignment or retention as an employee. This report may contain information bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living from public record sources or through personal interviews with your neighbors, friends or associates. You may also have a right to request additional disclosures regarding the nature and scope of the investigation.
I acknowledge that I have read all of the above statements and that I understand them. In addition, the statements above supersede and replace any prior understandings or discussions I have had with the Agency and set forth the complete agreement between me and the Agency regarding these matters.
Applicant Signature:
Hepatitis B
Hepatitis B virus causes inflammation of the liver. Symptoms may include jaundice (yellow skin), nausea, loss of appetite, fatigue and weakness. About 10% of infected people will develop chronic hepatitis, which can lead to cirrhosis and, infrequently, the acute illness can be fatal. The time from infection to symptoms is 2-5 months.
Hepatitis B virus is found in blood and many other body fluids. The infection is spread through sexual contact or by blood or other fluids of an infected person coming into contact with blood or mucous membranes (eyes and mouth) of another person.
Immunization
Hepatitis B vaccine is recommended for all persons who are at increased risk of infection with Hepatitis B virus, including health care workers who may be exposed to blood or body substances. Hepatitis B vaccine does not contain human serum and cannot transmit any infection. One cannot develop hepatitis, AIDS or any other viral illness from receiving the vaccine. After a series of 3 doses of the vaccine injected into the upper arm over 6 months, about 90% of healthy adults develop antibodies which protect against development of Hepatitis B. This protection is long lasting so boosters are not routinely recommended.
Side Effects
Among recipients of Hepatitis B virus vaccine, soreness and redness at the injection site have occasionally been seen. Flu-like symptoms and low grade fever are rare. Other side effects have been reported; however, they do not occur at a rate higher than in the general, unvaccinated population. Hypersensitivity has not been reported. Safety of the vaccine for the developing fetus is not known, but because it is non-infectious, the risk to the fetus from the vaccine should be negligible. However, Hepatitis B infection (which can be prevented by this vaccination) in a pregnant woman may result in severe disease for the newborn. If you are pregnant, we recommend discussing all vaccines and medications with your health provider.
Procedure
After signing the consent below, you will be scheduled to receive the immunization in three doses (dose 1 - now, dose 2 - one month from now, dose 3 -six months from now). After the immunization series is completed, you will have a blood test for antibody to Hepatitis B virus. This blood test and the immunization injections are done without charge to you. If the blood test indicates you are not yet immune, additional doses may be given. If you will not be employed at this institution for the next 6 months, it is recommended that you complete the vaccine elsewhere
I ACCEPT THE HEPATITIS B VACCINATION
I have been informed of the biological hazards that exist in my workplace, and I understand the risks of exposure to blood or other potentially infectious materials involved with my job. I understand that I may be at risk of acquiring hepatitis B virus (HBV) infection. I acknowledge that I have been provided information on the hepatitis B vaccine, including information on its effectiveness, safety, method of administration and the benefits of being vaccinated. I have been given the opportunity to be vaccinated with the hepatitis B vaccine at no charge to myself.
I understand that I am responsible for scheduling and keeping my appointments to receive the Hepatitis B vaccine in accordance with the recommended series (three vaccination series; second vaccine one month after first vaccine; and third vaccine within five months of second vaccine
I DECLINE THE HEPATITIS B VACCINATION
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B (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
Applicant Signature:
Personal Information
First Name:
Last Name:
Middle Initial:
Date of Birth:
Social Security Number:
Email:
Telephone No.:
Street Address:
City:
State:
Zip Code:
Driver License No:
State:
Expiration:
Position
Education
School or University:
Major/Degree:
Field of Study:
From:
To (Actual or Expected):
Emergency Contact
Name:
Relationship:
Telephone No.:
Work Experience
Job Title:
Company Name:
Location:
Date of Employment From:
Date of Employment To:
Role Description
General Questions
Are you legally authorized to work in the United States for any employer?
Have you ever been excluded, sanctioned, or otherwise restricted from participation in any federal or state health care program (including Medicare or Medicaid)? You have an affirmative duty as a condition of employment and/or staff privileges to immediately report any exclusion, sanction or other restriction (past, present, or future) from participation in any federal or state health care program (including Medicare or Medicaid) to the HR Department. Please note that any exclusion, sanction, or restriction will not necessarily disqualify an application for employment?
Have you ever been the subject of any disciplinary or adverse action taken by a regulatory, licensing or government agency? You have an affirmative duty as a condition of employment and/or staff privileges to immediately report any disciplinary or adverse action taken (past, present, or future) by a regulatory, licensing and government agency to the HR Department. (Examples of regulatory, licensing and government agencies include, but are not limited to, Centers for Medicare and Medicaid Services (CMS), state Medicaid programs, Department of Health and Human Services (DHHS), Office of Inspector General (OIG), and any medical or nursing boards). Please note that disciplinary or adverse action will not necessarily disqualify an application for employment.

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