Please be prepared to upload your credentials at the end of the application. (TXDL,SS card, CPR card, Auto Insurance, Professional Liability Insurance, TB test/results)For confidentiality if you prefer, you may bring your original copies to the in-person office interview.

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Applicants Name( Last, First, M.): *  Email: Email
Present Address:     *  
City/State/ Zip: * 
Home Phone (N/A):  *  Mobile Phone: *   DOB:*   
Are You at Least 18 Years Old? Yes    No   
Full Time    Part-Time*  
 If you are not a US Citizen, do you have the legal right to remain permanently in the US?Yes    No*  
Salary Requirements: * Date Available:  *   
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?     Yes   No*   
Educational History
High School:*   Graduated *  Degree:    
Circle Last Year Attended 9   10   11   12*   
College:   Graduated 
Degree:   *   Circle Last Year Attended  1   2    3    4    
List professional licenses you possess. Indicate type of license, number and state:
*   

List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law: *   

List languages spoken other than English: * 

List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:  *   
Work History
Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient:
Company Name: * Complete Address including City/State/Zip  *Phone Number:  * Supervisor's Name:  *     
Date Started:*  Date Left: *  Reason For Leaving *   

Describe your job title, responsibilities and accomplishments: *   
OK to contact supervisor?Yes   No*   

Please list your preferred service areas: (Zip Codes or areas) *   

PERSONAL REFERENCES: (Name, Phone, Relationship) *   
Emergency Contact/Relationship/ Phone Number/ Address:*

Please review and sign
In making application for employment:

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the Agency or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the Agency or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
I understand and agree that if I am offered employment by the Agency, my employment will be for no definite term and that either I, or the Agency will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the Agency.
I understand, if I have direct patient contact that the Agency will perform a background check, including criminal history check, OIG exclusion list check (if applicable), and any additional checks as required by accrediting body standards or State Regulations. I further understand, if I am an unlicensed person, the Agency will perform a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Health and Human Services (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All HHS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable. I understand that a refusal to authorize the criminal background check may result in adverse employment action, such as rejection of the application or termination of employment. 
I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
Applicant Signature: Signature* Date:  Date*   

Reference Request
Name of person giving reference from previous employer:  * Company/Facility: *  
The individual named below is applying for a position as *  and has given you as a reference. As we place great importance on the thorough screening of all our applicants, we would appreciate a prompt and thoughtful response.    
Applicant Release
Position Held in previous employer:* Social Security #  *   Dates Employed: From  *  To: *   I hereby release from all liability the company or person completing this form, and authorize them to release all information regarding my employment with them. I understand that this information may be released to clients of the requesting company and other requesting third parties on a need to know basis. I also release the requesting company from all liability for any damages from the disclosure of this information.   Signature*   

STATEMENT OF EMPLOYABILITY
By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check per TXH&SC 250.006. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. As required, I agree to a search of the Texas Health and Human Services Commission’s OIG List of Excluded Individual/Entities, prior to being hired and monthly thereafter, the HHS - OIG Excluded Individuals/Entities Search Database and SAM Exclusion List. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253.
CRIMINAL HISTORY CHECK
I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check and that I may not have face-to-face patient/client contact until results are returned. I will be notified of results. 
I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this Agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.   Signature*   

CONFIDENTIALITY OF PATIENT/CLIENT INFORMATION
I plan to utilize electronic documentation of patient care.
I will ensure confidentiality and security of patient information by password protecting the device or program utilized.
I agree to change the password at least quarterly or following a breach of security.
I will not provide my password to anyone.
I will use an electronic signature, if acceptable to payor source. Authentication will be available if requested by the Agency.
I have been informed of the Agency’s Confidentiality Policy and Safeguarding of Medical Records Policy and I agree to abide by these policies.
Signature*   

ORIENTATION CHECKLIST FOR CONTRACT STAFF
Confidentiality: Due to the nature of our work, each contract staff will gain, directly or indirectly, sensitive and confidential information on patient/client and staff members. The health care professional safeguards the patient’s/client’s right to privacy by judiciously protecting information of a confidential nature including medical treatment information, diagnosis, medical records, personal patient/client information, etc. This information should be shared only with those persons who, due to their position, have a need to know. Sensitive or confidential information must never be used as the basis for social conversation or gossip. If in doubt as to whether or not certain information may be shared, s/he should consult with their supervisor.
I acknowledge that I have read, understand and will comply with all applicable Agency policies.   Signature*   

Consent to check OIG/LEIE Exclusionary List
I,   Name*    have been informed that the Agency will verify my eligibility to work with a community service provider by verifying if I am excluded in participating in the Medicaid/Medicare programs. The Agency will perform this verification initially prior to hiring and monthly thereafter, if at any time the Agency finds my name/company on the exclusionary list, my employment/contract/appointment will be terminated immediately. 
“All Community Service Providers must search the state and federal online databases for excluded individuals and entities prior to hiring or hiring or contracting and on a monthly basis.” 
The websites below will be used to perform the search. Each website allows searches by entering names or by downloading databases.    Signature*   

DPS Computerized Criminal History (CCH) Verification
I, acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F. Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search. In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company.
Once this process is completed the information on my fingerprint criminal history record may be discussed with me.     Signature*   

HEPATITIS B VACCINATION
Due to your occupational exposure to blood or other potentially infectious materials, you may be at risk for acquiring hepatitis B viral (HBV) infection. The vaccination series is available, at no cost, to you. Please indicate below your declination or acceptance to receive the vaccine.
Hepatitis B is a blood borne virus which can cause a range of symptoms from mild to serious, and possibly result in fatal liver damage to health care workers who become infected. The virus can be transmitted through contact with infectious fluids of a patient who has hepatitis B virus. You have been taught the concepts of Universal Precautions concerning safe patient care and the use of equipment to avoid unnecessary exposure.
Synthetic hepatitis B vaccine is derived from yeast cells. It is not composed of human blood or plasma. It is given as a series of three injections into the arm muscle at prescribed intervals (initial shot, one month later, and six months later). It has proven to be over 80-90% effective in protecting against the disease. There may be hypersensitivity to the vaccine, and there may be soreness and swelling of the injection arm. Other side effects may occur at an incidence of under 3% of injections.
Declination: X I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge myself. I decline the vaccination series. I understand that by declining this vaccine, I continue to be at risk for acquiring hepatitis B. If I continue to have occupational exposure to blood or other potentially infectious material (OPIM) and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Signature*