Employment Application Step 1 of 10 10% Position applying for:*Volunteer CoordinatorRN Case ManagerCertified Home Health AideLocation:* OKC Metro Location:* Tulsa Location:* Oklahoma City Tulsa, Part-Time Location:* OKC Metro Tulsa Pryor Name* First Last Other Name:List any other name(s) you have previously worked under Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Cell Phone:Email: How did you hear about Physician's Choice Hospice? Newspaper ad Brochure Internet Presentation Phone Directory Bereavement Letter Personal Referral Other Which Newspaper?What website?When & Where was the presentation?Who referred you?You selected "Other". How exactly did you hear about us?If you are under 18 years of age, can you provide required proof of eligibility to work?N/AYesNoHave you applied with us before?YesNoWhen?Have you ever been employed by us?YesNoDates of previous employment: Are you currently employed?YesNoOn what date would you be available to work?Are you prevented from lawfully becoming employed in this country due to visa or immigration status? (proof of citizenship/immigration will be required upon employment)YesNoAre you on "lay-off" status and subject to recall?YesNoCan you travel if the position requires it?YesNo Employment HistoryList all employers, starting with the most recent position.Most Recent Employer #1May we contact this employer for references?*YesNoEmployer Name:* Phone*Dates employed:*Provide start and end datesSupervisor:Rate of pay:*Job duties and responsibilities:*Reason for leaving:* Next Recent Employer #2May we contact this employer for references?*YesNoEmployer Name:* Phone*Dates employed:*Provide start and end datesRate of pay:*Job duties and responsibilities:*Reason for leaving:*Would you like to list another employer?*YesNo Next Recent Employer #3May we contact this employer for references?*YesNoEmployer Name:* Phone*Dates employed:*Provide start and end datesRate of pay:*Job duties and responsibilities:*Reason for leaving:* CertificationIf you hold a current certification as a nurse aide (CNA), check the appropriate certification(s) below: Long Term Care (LTC) Home Health Aide (HHA) Adult Day Care (ADC) Residential Care Aide (RCA) Developmental Disability Aide (DDA) Certified Medication Aide (CMA) Certified Medication Aide - Gastrostomy (CMA-G) Certified Medication Aide - Glucose Monitoring (CMA-GM) Certified Medication Aide - Respiratory (CMA-R) Certified Medication Aide - Insulin Administration (CMA-IA) Other Information:Please list any employment history, education, special training, hobbies, interests or memberships in any club, organization, society, professional organizations or volunteer activities that you believe is related to hospice.Professional CredentialsPlease list any professional licenses, registrations and/or certificates held. Be sure to include the type of license, who it is issued by and the date issued for each.LanguageOther than English, do you communicate in any other languages?YesNoWhat language(s)?Restrictions & ConditionsPlease note any medical conditions or physical restrictions which need to be taken in to consideration when arranging assignments for you.Criminal History*Have you been convicted of a felony in the last 7 years? A yes response does not automatically disqualify your application.YesNo*Explain your conviction, giving nature, location and date(s) of conviction. Background InformationIf you answer YES to any of the questions below, explain in the space after the question. The explanation for a YES answer should include, but not be limited to: 1. State and/or jurisdiction 2. Nature of complaint/offense 3. Disposition of complaint and/or offense (e.g "dismissed insufficient evidence", "deferred sentence") 4. Date of disposition 5. Attach copy of any correspondence received by you, the applicant, regarding the complaint/offensea. Have you ever: 1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pled guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed?*YesNoExplanation a:*b. Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the practice of a health care profession?*YesNoExplanation b:*c. Are any disciplinary actions or allegations, pending or substantiated, against you or your CNA certification or health care professional license in any state or U.S. jurisdiction?*YesNoExplanation c:*d. Have you had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid, or in connection with, action by such authority?*YesNoExplanation d:*Applicant's Certification and AgreementPLEASE READ CAREFULLY - If you answer NO to any of the questions below, explain in the space after the question.e. I understand the employer has the right to proceed with any criminal background check.*YesNoExplanation e:*f. I understand as a part of the job selection process, I may be required to take a drug-screening test at the time of employment and if requested in accordance with the state and federal law at anytime during my employment. A test result that has been confirmed as positive will eliminate me from employment. If I refuse to sign this form and submit to drug testing, the employer will reject my application.*YesNoExplanation f:*g. I understand I may be required to have a physical examination and I hereby consent to take a physical examination and any future physical examinations as required by the employer.*YesNoExplanation g:*h. I understand if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986.*YesNoExplanation h:*i. I understand this form is not an employment contract.*YesNoExplanation i:* Personal Reference 1Use the fields Below to provide a personal reference.Name First Last PhoneRelationshipPersonal Reference 2Use the fields Below to provide a personal reference.Name First Last PhoneRelationshipEmergency ContactUse the fields below to provide information for your emergency contact.Name First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone Code of Ethics for Employees*As an employee, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me. I understand that any information that is disclosed to me while working is confidential. I expect to do my work according to the standards set forth in the employee policies and procedures. Information provided on this application is confidential and will only be considered in relation to positions to which this application pertains. By checking this box, I accept the code of ethics. Declaration*I hereby certify that the statements on this application are true and correct to the best of my knowledge. I understand that by submitting I authorize inquiries to be made concerning my employment, character and public records for the purpose of determining my suitability as an employee. I affirm that I have read the employee code of ethics and agree to abide by its regulations. I agree to respect the confidentiality of any client information I acquire in the course of my employment. I authorize Physician’s Choice Hospice to conduct a background check and drug screen on me according to their pre-employment background checks/drug screen policies. I understand that my employment may not begin until satisfactory background and drug screening information has been received. I also understand that Physician’s Choice Hospice will assume all costs of this background and drug screening research. I understand that Physician’s Choice Hospice reserves the right to accept or reject my application in its sole discretion and that the above statements made in this application are true to the best of my knowledge. By checking this box, I accept the declaration. This iframe contains the logic required to handle AJAX powered Gravity Forms.