Employment Application Mountainview Home Health, LLC 409 N. Second Street Yakima, WA 98901 (509) 576-0800 scase@mountainviewhh.org Qualified applicants receive consideration for employment without discrimination based on age, creed, marital status, national origin, race, gender or sexual orientation, or the presence of any sensory, physical, or mental disability, veterans status, or any other basis prohibited by federal, state, or local laws. INSTRUCTIONS:Please complete all information requested on his form. Please type or print clearly. If you wish to supply additional education or work history information, attach a separate sheet. Submitting an application for employment does not guarantee an interview. A resume is optional and is not considered a substitute for any section of the application. First Name Middle Name Last Name Social Security Number Today's Date Street City State Zip Phone Birthdate for SSI Verification Message Phone How did you hear about this position? Ad Website MHH Employee Walk in Job Posting Other Have you any relatives employed here? Yes No If yes,indicate name Have you been previously employed here? Yes No Date Under what name Are you a U.S. citizen or legally authorized to work in the U.S.? Yes No Proof of identify and eligibility to work will be required if you are hired. If you read, write or speak a foreign language and would be willing to translate for patients/customers, please list the languages. Have you been debarred, excluded or are otherwise ineligible for participation in Medicare, Medicaid, or other government payor programs? Yes No Were you ever discharged for cause, dismissed during probation or have you resigned under pressure or unfavorable circumstances? Yes No Have you ever been convicted of a criminal offense or been released from prison? Yes No Job Information Position applied for Availability Full Time Part Time Per Diem Date Available Are you willing to work weekends Yes No On Call after hours (RN) Yes No Professional Registration Type of Registration or License State Number Expiration Date If you don’t have a required registration or license, have you applied for one Yes No If an examination is required, when are you scheduled to take the examination? If you are not licensed in Washington State, have you applied for reciprocity? Yes No Have you ever had a professional registration/license revoked, suspended or restricted? Yes No Education Information Type of School Name and Location of School Start Date End Date Academic Major Skill Type of School Name and Location of School Start Date End Date Graduated Yes/No Degree Received High School College Other Job Related Educ. Or Training In Military Service Skill Abilities Training List skills, training, or experience, which may qualify you for the position(s) desired. Include any special skills from Military service Equipment you can operate (computer software you are proficient in, word processing, point of care doc.) List patient care areas in which you have training and/or experience Job Performance Ability Given your knowledge, skills, education and experience are you able to perform all the essential functions of the position for which you are applying, with or without reasonable accommodation? Yes No Is there any reason you might be unable to meet our work attendance requirements? Yes No If yes, please explain Employment History Have you, within the last 12 month, been employed by an agency or organization which serves as a Medicare fiscal intermediary or carrier Yes No List all recent employers. List most recent employer first, include any job related military service assignments, volunteer activities, part-time jobs, former jobs and businesses of your own, for at least the last eight (8) years. Attach additional sheets if necessary. Please explain any gaps in employment Present Last Employer Address Phone Number Joining Date Leaving Date Name of Supervisor Reason for Leaving Other Comments. Job Title/Description Salary Expectations Ability and willingness to work overtime, various shifts Please explain Yes No With exceptions. Please explain Yes No Did you work for any of the above employers under a different name? lf so, please circle which ones(s): Yes No Give your previous name Professional References (other than relatives) Please give three references who have good knowledge of your work. Name position Address Phone Number of Years Known Name position Address Phone Number of Years Known Name position Address Phone Number of Years Known Professional References (other than relatives) I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I agree that if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time. I understand that my employment will be contingent upon proof of citizenship or alien registration, and upon the checking of references. In consideration of my employment, I agree to conform to the rules and regulations of Mountainview Home Health, LLC. I understand that my employment and compensation can be terminated with or without notice at anytime, at the option of either the company or myself. I understand that no manager or representative, other than the CEO or Governing Board, has any authority to enter into agreement contrary to this. Any agreement for employment for any specified period of time with the CEO or Governing Board must be in writing and signed. I consent and authorize Mountainview Home Health, LLC and its personnel to investigate all information concerning my previous employment, education and background including records of law enforcement, federal and state agencies. Iauthorize the Registrar/Placement Office of all educational institutions attended to release in official copy of my transcript, and, if available, faculty appraisals. I authorize any appropriate licensing board to release full information concerning my licensure status and licensure history. I authorize any prior employers to provide such information concerning my employment with them as may be requested. I therefore release all parties and persons connected with any request for information from all claims, liabilities and damages, for whatever reason arising out of furnishing said information. I understand that if offered a position with Mountainview Home Health, LLC, I will be required to submit to a background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with or any attempt to affect the results of this pre-employment check will result in withdrawal of any employment offer or termination of employment if already employed. By submitting the Application for Employment, I hereby consent to said check. If employed, I further agree that if Mountainview Home Health, LLC advances any paid leave before it has been accrued, or advances or loans me any money during the course of my employment, or I am indebted to the company at the time my employment ends, or if I lose, damage or fail to return any company property, I authorize the company to deduct from my wages sufficient funds to repay such loans, advances, indebtedness, or to replace its property in order to satisfy any unpaid obligations. Signature Clear Date This application for employment will be kept in an active file for six calendar months. During this period, an individual will be considered for the job in which he/she indicated an interest on this application, subject to existing vacancies. After the six calendar month period, all applications will be placed in an in-active file and will not be used for hiring purposes Any individual may continue to reapply at the company every six months to maintain his/her status in the active file. Disclosure Statement Pursuant to the requirements of RCW — 43.43.830-840, we must ask you to complete the following disclosure statement. This information will be kept confidential. Have you ever been convicted of any of the following crimes against children or other persons: Yes No Aggravated murder Arson First degree Assault First, Second or Third degree Assault Fourth degree (Simple Assault) Assault on a Child, First, Second, or Third degree Burglary First degree Child Abandonment Child Abuse or Neglect as defined in RCW 26.44.020 Child Buying or Selling Child Molestation First, Second or Third degree Communication with a Minor Crimes related to drugs as defined in RCW.43.43.830 Criminal Abandonment Criminal Mistreatment First or Second degree Custodial Assault Custodial Interference First or Second degree Extortion First, Second or third degree Felony Indecent Exposure Forgery Incest Indecent Liberties Kidnapping First or Second Degree Malicious Harassment Manslaughter First or Second degree Murder First or Second degree Patronizing a Juvenile Prostitute Promoting Pornography Promoting Prostitution First degree Prostitution Rape, Fést, Second or Third degree Child Rape, First, Second/Third degree Robbery First or Second degree selling or Distributing Erofic Material to a Minor Sexual Exploitation of Minors Sexual Misconduct with a Minor First Second degree Theft First, Second or Third Unlawful Imprisonment Vehicular Homicide (negligent homicide Violation of Child Abuse Violation of Restraining order Or any other of these crimes as they may have been renamed or that is equivalent in any State If your answer is "yes” to any of the above, please describe and provide the date(s) of the conviction(s) and the sentence(s) imposed. Dependency action to have neglected or sexually assaulted/abused or exploited any minor or adult person or to have physically abused any minor? Yes No Domestic relations proceeding to have sexually abused or exploited any minor or to have physically abused a minor? Yes No Disciplinary board final decision to have neglected or sexually or physically abused or exploited any minor or adult person? Yes No Court or State licensing board action to have neglected or sexually abused or exploited any minor or adult person? Yes No Discip1inary board final decision to have abused or financially exploited any person 60 years or older who has a functional, mental or physical inability to care for himself or who is a patient in a state hospital? Yes No Protection proceeding under Chapter 74.34 RCW to have abused or financially exploited a person 60 years of age or older who has a functional, mental or physical inability to care for himself or herself who is a patient in a state hospital? Yes No Has it been determined by any state agency or department that you have abused, neglected or Exploited anyone? Yes No Has a court issued any order of protection against you for abuse or exploitation? Yes No Have you ever had a license to care for children or adults denied, revoked or suspended? Yes No If your answer is “yes” to any of these questions, please describe and provide the date(s) of the findings(s) and the penalty(ies) imposed. Have you ever been convicted of any of the following crimes relating to financial exploitation of a person 60 years of age or older who has a functional, mental or physical inability to care for him or herself or who is a patient in a state hospital First, Second or third degree Extortion Yes No First, Second, or Third degree Theft Yes No First or Second degree Robbery Yes No Forgery Yes No Or any of these crimes as they may have been renamed Yes No If your answer if “yes” to any of the above, please describe and provide the date(s) of the conviction(s) and the sentence(s) imposed. UNDER PENALTY OF PERJURY, I certify that the above information is true, correct, and complete. I understand that ifI am hired, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if I am hired, my employment is conditioned on your receipt of a satisfactory report from the Washington State Patrol, lntellicorp & other states. Signature Clear Name Date We may request your fingerprints to obtain from the Washington State Patrol criminal identification system, a report of your record of criminal convictions for offenses against persons, civil adjudications of child abuse and disciplinary board final decisions. Intellicorp is used to verify your DMV record for our liability insurance. A driving standard of no more than two ticket in the past three years and no DWI, DUI or reckless driving convictions must be upheld. If you are hired before these reports are available. YOUR EMPLOYMENT WILL BE CONDITIONED UPON THE RECEIPT OF SATISFACTORY REPORTS. You will be notified of the State Patrol’s & Intellicorp’s responses within ten days after we receive the report. We will make a copy of the report available to you upon your request. If you are human, leave this field blank. Submit
