Healthcare Staff Application

HEALTHCARE STAFF APPLICATION

Application Date:    Position Applied For:

Applicant Information

Date of Birth:    Gender:

Primary phone:    Alternate phone:

Emergency Contact

Relationship:    Phone:

Position & Availability

Department/Unit:    Employment type: Full-time Part-time PRN/Per diem

Desired start date:    Shift preference:

Education and Professional Training

Licensure & Certifications

Professional license type:    License number:

Issuing state:    Expiration date:

Employment History (Last 10 Years)

Job title:    Supervisor:

Dates employed: From to

Job title:    Supervisor:

Dates employed: From to

References

Relationship:    Phone:

Relationship:    Phone:

Criminal, Disciplinary & Compliance History

Have you ever been convicted of a felony or misdemeanor related to the practice of healthcare? Yes No

Have you ever had a professional license disciplined, suspended or revoked? Yes No

Health Screening and Immunizations

TB test (date):   Result:

MMR:    Hepatitis B:

Authorization & Certification

By signing below, I certify that all information provided in this application is true, correct and complete to the best of my knowledge. I understand that any omission, false statement, or misrepresentation may be grounds for denying employment or for immediate termination of employment if discovered at a later date. I authorize the use of this application to verify my education, employment history, licensure, credentials, and other information provided by me.

I expressly authorize current and former employers, educational institutions, licensing authorities, references, and other entities to release information about my employment, education, licensure, and professional conduct to the employer. I release those entities from liability for providing such information. I also authorize the employer to obtain criminal background checks, worker's compensation records, substance abuse screening results, and other pre-employment screening as required by facility policy or law. I understand that employment is contingent upon satisfactory completion of required background checks, licensure verification, and health screening including immunizations and drug testing where applicable.

I acknowledge my obligation to comply with facility policies regarding patient privacy, confidentiality, and all applicable federal and state privacy laws. I understand that any breach of confidentiality may result in disciplinary action, up to and including termination and reporting to licensing authorities.

Initial to indicate acceptance:

Acknowledgment of Confidentiality / HIPAA

I acknowledge that, as an applicant and employee candidate, I may be granted access to protected health information. I agree to abide by all confidentiality requirements and facility policies that govern the use, disclosure, transmission, storage and disposal of protected health information. I understand that unauthorized use or disclosure of patient information may result in civil and criminal penalties and may be grounds for disciplinary action.

Additional Information

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