Employment Application

Notice: Qualified applicants will receive consideration for employment without discrimination because of age, color, race, marital status, national origin, religion, sex, or sexual orientation, or the presence a physical, mental, or sensory handicap.

AVAIL IS AN EQUAL OPPORTUNITY EMPLOYER

Cell phone( if applicable): Phone: EDUCATION

Name of School High School: Technical: University:

City/State

Years completed

Degree

Major

Other: Have you passed the G.E.D test in lieu of High School Graduation? Yes No If yes, please furnish proof. EMPLOYMENT RECORD Are you currently employed? Yes No When can you start? If you are currently employed, may we contact your present employer for a reference? Yes No If no, please state reason:

Avail Home Health, Inc. 4706 W. Nob Hill Blvd. Ave Yakima WA 98908

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PRESENT EMPLOYER: Name of employer: Address: Position/Title: Employment dates: From: Reason for leaving: Job Duties:
OFFICE USE ONLY / REFERENCE INFORMATION:

Telephone No.

Supervisor: To:

PREVIOUS EMPLOYER: Name of employer: Address: Position/Title: Employment dates: From: Reason for leaving: Job Duties:
OFFICE USE ONLY/ REFERENCE INFORMATION:

Telephone No.

Supervisor: To:

NEXT PREVIOUS EMPLOYER: Name of employer: Address: Position/Title: Employment dates: From: Reason for leaving: Job Duties:
OFFICE USE ONLY/ REFERENCE INFORMATION:

Telephone No.

Supervisor: To:

Avail Home Health, Inc. 4706 W. Nob Hill Blvd. Ave Yakima WA 98908

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Do you have any responsibilities, commitments, or obligations that could prevent you from meeting our work schedule? Yes No If yes, please explain: Have you ever been convicted of a crime or been released from prison within the last 7 years? Yes No If yes, please explain: If you are applying for a position that requires driving complete 1-3 and attach copies as requested. 1.) Do you have a car? Yes No 2.) Is it in good condition? Yes No 3.) Do you carry automobile insurance? Yes No Please attach proof of insurance. Do you have a valid drivers license or State issued ID card? Yes No Please attach copy of license or ID.

Do you have a current professional license or registration for the position for which you are applying? Yes No If yes, please attach copy of current license or registration. Has your license to practice ever been limited, suspended or revoked? Yes No If yes, please explain: _________________________________________________________________________ Please list your work objective and career goals: ____________________________________________________ ___________________________________________________________________________________________ Hobbies/Interests:_____________________________________________________________________________ REFERENCES Name:____________________________________ Relationship:_______________________________________ Address:_____________________________________________________________Phone:__________________ Name:____________________________________ Relationship:_______________________________________ Address:_____________________________________________________________Phone:__________________ Name:____________________________________ Relationship:_______________________________________ Address:_____________________________________________________________Phone:__________________ Washington State Patrol Identification and Criminal History Check Avail Home Health, Inc. conducts a background check using the WSP Identification and Criminal History Check Service. Please provide the following information: Alias/Maiden Name: __________________________________________________________________________ Date of Birth: _______________________________

Avail Home Health, Inc. 4706 W. Nob Hill Blvd. Ave Yakima WA 98908

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All agency, patient, and personnel information shall be treated as confidential. The employer expects all employees to use their best judgment in terms of sharing any information with other professionals directly involved in the patients care. Breach of confidentiality is considered a significant breach of AHH policy and is not treated lightly. Each applicant shall read and sign AHHs Confidentiality Oath below. This will be placed in the employees permanent personnel file. OATH OF CONFIDENTIALITY I understand that any personnel, personal patient/client, family, and medical information obtained through the application process, provision of care, observation of visits or team meetings, or review of patient/client and personnel records is confidential. Under no circumstances will I disclose patient/client, or personnel names or any other personal or medical information obtained in the course of my duties or contacts with Avail Home Health, Inc. to anyone unless I am authorized to do so. If authorized to release patient/client, agency or personnel information, I declare that I have read the confidentiality policies of AHH or a summary of them, and agree to follow such policies. If I am observing a home visit, team or staff meeting, or group session, I understand that I may be asked to leave at any time, and I agree to comply. PRE-EMPLOYMENT DRUG TESTING CONSENT I hereby agree to pre-employment drug testing, if so requested by AHH, to determine the presence of use of illegal drugs. Drug testing shall be conducted with accuracy and reliability. Specimen collections will conform to DHHS/DOT standards for all employees. As part of the pre-employment process, I further give my consent for the release of those test results to authorized management for appropriate review. I understand that specimen tampering, falsification of information on the chain of custody form, or refusal to submit a specimen may be grounds for disqualification from employment; that a positive test result may disqualify me from employment; that applicants who test positive without adequate explanation of the results may not be considered for an available position for twelve (12) months, and the proof of wellness may be required for further consideration. I also understand that refusal to sign below, refusal to submit to a drug test, or alteration of the test may cause me to be rejected from the employment process at AHH. I understand that I have a right to receive a copy of this authorization upon request.

Please check one option only: Consent to drug test Refusal to consent to drug test
STATEMENT OF AUTHORIZATION
The statements set forth in my application for employment are true and complete. I agree that any misstatement or omissions as to fact will constitute grounds for unfavorable consideration or dismissal from employment by the home health agency. I hereby authorize AVAIL to verify the information I have provided in the application. This verification may include former employers, educational institution and other sources. I also agree to hold the agency and those who are contacted harmless from any legal claim regarding the verification process. I agree to conform to AVAILs personnel policies, including the Oath of Confidentiality and Drug Consent agreement above, made known to me at the time of employment or any subsequent time. I understand that my employment shall be contingent upon results obtained from employment references and the Washington State Patrol Access to Criminal History, proof of identity and verification of eligibility for employment in the United States in accordance with the Immigration Reform and Control Act of 1986.

Signature of applicant:________________________________________________________Date:_________________
Avail Home Health, Inc. 4706 W. Nob Hill Blvd. Ave Yakima WA 98908 Employment Application Page 4 of 5

INTERVIEW ASSESSMENT SUMMARY Professional demeanor:

Strengths:

Weaknesses:

General Comments:

Recommended action:

Interviewer:

Date:

Ss1002
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