* = Required Information

Personal Information

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Job Information

Regular Temporary
Weekdays Weekends
Morning Evening
Nights
Full Time Part Time On-Call
Monday Tuesday
Wednesday Thursday
Friday Saturday
Sunday
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Education

High School


College


Graduate


Other/Special Skills/Achievements

Professional Licenses and/or Certifications



How did you hear about our Agency

Employee School or Relative
Employment Agency State or Local Agency
Walk-In Newspaper/Publication
Internet Other

References (Business and Professional only)



Employment History (Most recent to oldest)

Voluntary Involuntary
Yes No

Voluntary Involuntary
Yes No

Voluntary Involuntary
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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.

Signature Disclaimer

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.

HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT

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:

  1. I will use and disclose confidential and protected health information only in connection with and for the purpose of performing my assigned duties.
  2. I will request, obtain or communicate confidential and protected health information only as necessary to perform my assigned duties and shall refrain from requesting, obtaining or communicating more confidential health information than is necessary to perform to accomplish my assigned duties.
  3. I will not disclose my personal password(s) to anyone without the written or verbal permission of my supervisor nor record or post it in an accessible location and will refrain from performing any tasks using another employee’s password.
I understand that as an employee of Careforce Homehealth Inc., a health care provider, the use and disclosure of patient information is governed by the rules and regulations established under HIPAA, the Health Insurance Portability and Accountability Act of 1996, and related policies and procedures of Careforce Homehealth Inc. Therefore, with regard to patient information, I commit to the following obligations:
  1. I will use and disclose confidential and protected health information solely in accordance with the federal, state laws as well as with Careforce Homehealth Inc. policies and procedures. I also agree to familiarize myself with any updates of changes to such policies in a timely manner.
  2. I will immediately report any unauthorized use or disclosure of confidential and protected health information that I become aware of to the appropriate supervisor.
I also understand and agree that my failure to fulfill any of the obligations set forth in this Agreement and/or violation of any terms of this Agreement shall result in my being subject to appropriate disciplinary action, up to and including termination of employment.

CONFIDENTIALITY AGREEMENT
I understand that during my employment with the Agency, I will have access to confidential patient/family, Agency and personnel information. I understand that all patient/family information is to be held confidential. I agree to hold that information confidential and use it only for the purpose of fulfilling my job responsibilities. I will not communicate information about my assigned clients from one client to another or to anyone not involved in their care. I further agree to not communicate in a negative manner about the agency or its employees to patients/families, news media, or other organizations. I understand that breach of this agreement may result in the termination of my employment or legal actions can be taken against me.
AGREEMENT
For and in consideration of employment of me by the Agency, I do hereby acknowledge and agree as follows: That, during the term of my employment with the Agency and for ninety (90) days after the date of termination, for any reason, of my employment with the Agency, I will not, directly or indirectly, become employed by any person to whom I provided services as employee of the Agency. That, in the event of my breach of this Agreement, I agree that the Agency shall be entitled to receive compensation from me as may be awarded by a court of law, plus all attorney’s fees, costs and expenses incurred by the Agency.
EMPLOYMENT-AT-WILL
Since I do not have a separate, individual written contract with the Agency for a specific, fixed term of employment, I understand that my employment with the Agency is as an Employee-At-Will and is for an indefinite period. I have read, understand and agree to fulfill the conditions of employment as stated above and in the agency’s policy and procedure manuals.

DECLINATION OF HEPATITIS B VACCINATION, WAIVER, RELEASE OF ALL CLAIMS AND INDEMNITY AGREEMENT
Please read carefully as this is a legally binding document. Please understand that in refusing vaccination and signing this document, you will be waiving and releasing on behalf of yourself, your spouse and your dependents all claims as a result of disease, death or for injuries, including but not limited to the aggravation of any pre-existing ailment or condition; disability and disfigurement, pain and suffering, medical care, treatment and services, lost of earnings, profits and salaries, lost earning capacity; the reasonable expense of necessary help in the home; as well any property damage that might be sustained arising directly or indirectly of your refusal to receive vaccination.
ACKNOWLEDGMENT OF RISK OF REFUSAL TO RECEIVE VACCINATION CLAUSE
I understand that due to occupational exposure to Blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B Vaccine when completing my pre-class medical work-up. 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. Appendix A to 29 CPR Part 1910.1030 Department of Labor OSHA Occupational Exposure to Blood Borne Pathogens
WAIVER OF CLAIM FOR INJURY CLAUSE
I do hereby fully release, hold harmless, discharge and defend Careforce Homehealth Inc., as well as any and all of its officers, agents, servants, employees, independent contractors and volunteers from any and all claims as a result of disease, death or from injuries, including, but not limited to the aggravation of any pre-existing ailment or condition; disability and disfigurement, pain and suffering, medical care, treatment and services; loss of earning capacity; the reasonable expense of necessary help I the home, as nay all property damage, my spouse or my dependents might sustain arising directly or indirectly out of my refusal to participate in the above captioned Hepatitis B Vaccination Program. I have read and fully understand the Waiver, Release of all claims and Indemnity Agreement. I understand that the terms hereof are contractual and are not a recital.

ADDENDUM TO EMPLOYMENT AGREEMENT

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

Covenant of Noncompetition
At all times during the Employee’s employment and for one (1) year after termination of employment with Careforce, Employee agrees not to directly or indirectly, in one or a series of transactions, own, manage, operate, control, invest or acquire an interest in, or otherwise engage or participate in the business of, whether as a proprietor, partner, director, officer, joint venture, investor, lessor, representative, lender, guarantor, or other participant for, any business, individual or entity engaged in the providing of home health care/home care or any other service for which Careforce provides, including any entity employing personnel in any similarly situated position as that held by the Employee with the Careforce within fifty (50) miles of any Corporate or Branch Office of Careforce.
Covenant of Disclosure
Employee agreed that to the extent that he or she, directly or indirectly, including through any relationship with the employee’s spouse, parent or children, in one of a series of transactions, owns, manages, operates, controls, invests or acquires any interest in, or otherwise engages or participates in the business of, whether as a proprietor, partner, director, officer, employee, joint venture, independent contractor, consultant, investor, lessor, agent, representative, lender, guarantor, or other participant in (collectively referred to as “relationship”), any business, individual or entity engaged in the providing of home health care/home care or any other service for which Careforce provides, including any entity employing personnel in any similarly situated position as that held by the Employee with the Careforce, agrees to disclose the relationship, within five (5) business days to disclose to the Officers of Carefoce. Disclosure of such relationship does not waive any right of Careforce.
Covenant of Nonsolicitation
At all times during the Employee’s employment and for one (1) years after termination of employment with Careforce, Employee agrees that he or she will not engage in solicitation of Careforce’s clients or patients, whether past or present clientele or patients, and further agrees to not solicit or recruit, directly or indirectly, any employees of Careforce in the employ of the Careforce and its parents, subsidiaries or affiliations within fifty (50) miles of any Corporate or Branch Office of the Careforce, whichever is closer, nor encourage Employee in the employment of Careforce to breach the terms of their agreement with the Careforce.
Covenant of Nondisclosure
The term “confidential information” as used in the agreement includes, but is not limited to, records, lists and knowledge of Careforce’s customers, suppliers, methods of operation, processes, trade secrets, methods of determination of prices, business plans, budgets, financial condition, profits, sales, net income, and indebtedness, as the same may exist from time to time in any form, media or format. Employee agrees that he or she shall not, at any time from and after the date hereof, in any manner, either directly or indirectly, divulge, disclose, or communicate to any person, firm, corporation, or other entity, or use for his or her own benefit or for the benefit of any person, firm, corporation, or other entity, and not for the benefit of Careforce, any confidential information of Careforce, without the express prior written consent of an authorized officer of Careforce. The Employee further agrees to disclose to the Careforce within two (2) business days the existence of all Careforce data, in any form, that is stored on his or her personal computer or other equipment, including cellular phones, personal data assistants, USB drives, CD/DVD or other media. Following disclosure, upon request of the Careforce, the Employee agrees to immediately irrevocably destroy and secure from any method of restoration, all Careforce data as requested be destroyed by the Careforce.
Covenant of Nondisparagement
At all times during the Employee’s employment and after termination of employment with Careforce, Employee further agrees that he/she shall not, at any time, make, directly or indirectly, any oral or written public statements that are disparaging of, or are intended to disparage, discredit or injure Careforce, any products or services Careforce offers, or any of its shareholders, partners, affiliates, successors, assigns, including any of its present or former officers, directors, partners, agents or, employees. The Employee further agrees that he/she will not make any statements or engage in any conduct that would in any manner harm Careforce or its shareholders, board of directors, officers, employees or other assigns reputation, relationships and goodwill with its customers, suppliers, employees or others having business dealings with Careforce during Employee’s employment and after termination of employment with Careforce.
Use of Careforce Equipment/Property
The Employee agrees to not, directly or indirectly, copy, take, or remove from Careforce premise(s), any of Careforce’s books, records, customer lists, or any other documents, data or materials. The Employee understands that all equipment issued for use by its employees, either directly or indirectly, is and irrevocably remains the sole and exclusive property of Careforce. The Employee agrees to not use personal computer, electronic equipment or media including USD drives, CD/DVDs or hard drives in conjunction with Careforce equipment. Employee agrees not to install any unauthorized computer programs upon Careforce computers, and agrees not to use Careforce equipment to surf, download, navigate or peruse the Internet for any personal purpose, without express permission of Careforce. As a condition of employment, upon termination of employment, the Employee agrees to return all equipment and property of Careforce, including but not limited to computer equipment, cellular phones, global positioning systems, books, records, customer lists or any other document or material to Careforce within two (2) days of termination of employment. The Employee also agrees to be liable to Careforce for any equipment and property that is not returned to Careforce.
BACKGROUND SCREENING CONSENT

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.

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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

Severe Headaches TB/ any Communicable Disease High Blood Pressure Venereal Disease
Vision Impairment Chronic Coughing Low Blood Pressure Arthritis/Bone Problems
Hearing Difficulties Chest Pain/Pressure Back Problems Heart Problems
Fainting/Dizzy Spells Allergy/Wheezing/Asthma Varicose Veins Skin Allergies/Diseases
Speech Impairment Hepatitis Stomach Ulcer Alcoholism/Drug Addiction
Frequent Colds Bowel Problems/Hernia Nervous Breakdown Diabetes
Menstrual Difficulties Kidney Problems/Diseases

III. Medical History (Past Five Years)

Yes No
Yes No
Yes No
Yes No
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Yes No

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.