Professional Licenses and/or Certifications
How did you hear about our Agency
References (Business and Professional only)
Employment History (Most recent to oldest)
This application is considered current for sixty (60) days only.
Careforce Homehealth, Inc. and its subsidiaries, affiliates, other related entities, successors and/or assigns (“Company”) will provide equal employment opportunities to all applicants without regard to an applicant’s race, color, religion, sex, gender, genetic information, national origin, age, veteran status, disability, or any other status protected by federal or state law. Company will provide reasonable accommodations to allow an applicant to participate in the hiring process (e.g. accommodations for a test or job interview) if so requested. When completing this application, you may exclude information that would disclose or otherwise your reference your race, religion, age, sex, genetic, veteran status, disability or any other status protected by federal or state law. This application is considered current for sixty (60) days only. At the end of this period, if you are still interested in employment, it will be necessary for you to reapply by completing a new application.
I certify that all information provided 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 employment being terminated.
I acknowledge that during the course of performing my assigned duties at Careforce Homehealth Inc., I may have access to, use, or disclose confidential and protected health information. I hereby agree to handle such information in a confidential manner at all times during and after my employment and commit to the following obligations:
As a consideration and as a condition precedent to continued employment with Careforce Homehealth Inc. (“Careforce”), the undersigned, hereinafter referred to as “Employee” agrees to be bound as follows
Applicant should complete all relevant information and sign and date the form.
I, , hereby authorize Careforce Homehealth Inc. and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, adult criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for service now and if applicable, during the tenure of my employment or service with Careforce Homehealth Inc.
I release Careforce Homehealth Inc., and its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name and all information is true and correct to the best of my knowledge:
*NOTE: The above information is required for identification purposes only, and is in no manner used as qualifications for employment, internship, or service as a volunteer. Careforce Homehealth Inc. abides all applicable state and federal employment laws.
Consent for drug/Alcohol Testing
I, , have been fully informed by my potential employer of the reasons for this urine test for drug or alcohol. I understand what I am being tested for, the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my potential employer and become part of my record.
If this test result is positive and for this reason I am not hired, I understand that I will be given the opportunity to explain the results of this test.
I hereby authorize these test results to be released to:
Employee Tuberculin Screening Acknowledgement
If you have tested positive for the PPD/Mantoux test, then we require that you submit a chest x-ray.
If the results of the chest x-ray are negative, then we will require you to complete this Employee Tuberculin Screening Acknowledgement every year. On the 5th consecutive year of employment, you will be required to submit a current chest x-ray.
If you have any of the above signs of symptoms, you are required to notify the Agency Supervisor immediately.
I hereby acknowledge that my tuberculin skin test has been tested positive. Further, I take full responsibility for reporting any of the early signs and symptoms of tuberculosis to the Agency Supervisor immediately.
I have also received information about the causes, treatment and prevention of tuberculosis, along with a reminder to report any of the above signs and symptoms to the Agency Supervisor.
Sections I, II, and III must be completed by employee
I. Personal Information
II. Please indicate with an (X) if you have any of the following
III. Medical History (Past Five Years)
I hereby give my permission to release the result of any test and/or information regarding my health status to Careforce Homehealth Inc. and I understand that I must have a biennial PPD to retain active employment.
IV. Must be completed by Health Examiner/Physician
I certify that the above person is free from symptoms/indications of the presence of infectious disease and does not have any conditions, which would interfere with the performance of his/her duties.