HMG Employment Application

Application For Employment :
Qualified applicants receive consideration for employment without discrimination based on age, color, creed, marital status, national origin, race, sex, 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 this form. If you wish to supply additional education or work history information, attach a document with the information at the end of this form. A resume is optional and is not considered a substitute for any section of the application. Submitting an application for employment does not guarantee an interview.
Personal Information:
Full Name*

First NameMiddle NameLast Name
Social Security Number*
xxx-xx-xxxx
E-mail*
Phone Number*

Area CodePhone Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are You At Least 18 Years Old*

YesNo
How Did You Hear About This Position?*

AdWebsiteEmployee ReferralWalk-In / Job PostingOther
Referring Employee Name*
NA if not applicable.
Have You Any Relatives Employed Here?*

YesNo
Employee Name*
NA if not applicable.
Have You Been Previously Employed Here?*

YesNo
Dates*
Under What Name*
Are You a U.S. Citizen or legally authorized to work in the US?*

YesNo
Proof of identity 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.Type a question
Would you be willing to translate for patients/customers?

During normal work hours onlyVoluntarily during off duty hours
Have you been debarred, excluded or are otherwise ineligible for participation in Medicare, Medicaid, or other government payor programs?*

YesNo
If "Yes" Explain Fully*
NA if not applicable.
Employment Desired:
Position(s) Applied For:*
Date You Can Start*

MonthDayYear
Availability:*

Full-timePart-timeTemporaryDaysNightsEveningsPer Diem / On-call
Can You Rotate Shifts?*

YesNo
Are You Willing to Work Weekends?*

YesNo
Core Values

Harbor Regional Health Medical Group has developed 'Core Values' which guide all our interactions and decisions. These Core Values are:
- Respect: To value another person with consideration and thoughtfulness
- Integrity: Trust, honesty, wholeness, and commitment.
- Compassion: Caring deeply for all people.
- Excellence: Innovation, quality, and recognition.
Standards of performance

A set of performance standards has been developed to establish the specific behaviors that all employees are expected to practice while on duty. All applicants are required to read Harbor Regional Health Medical Group's 'Standards of Performance' and agree to comply with them when submitting an application/resume. The Standards of Performance are:

Communication
- Keep patients, families, and associates informed.
- When communicating with patients, families, and associates be patient, understanding, mannerly, kind, and positive.
- Use equipment supplied for communication properly and consistently.
Accountability
- Be positive role models and take responsibility for our own actions.
- Be dependable and take seriously our responsibility to perform our job with excellence in a timely manner.
- Give and receive constructive criticism gracefully.
- Use proper manners in every interaction.
Professionalism
- Practice self-control at all times, especially in stressful circumstances.
- Safeguard the privacy of all.
- Adhere to the hospital's Personal Appearance policy.
- Treat people equally, with dignity and respect, regardless of position.
Teamwork
- Help team members whenever possible and never say "It's not my job."
- Never downgrade, treat unfairly, gossip, or ostracize any member of the team.
- Support, understand, and be empathetic toward each member of the team.
Ownership
- Keep our hospital environment clean and submit repair work orders promptly.
- Be aware of the part we play individually and as a team that contributes to the fiscal health of the organization.
Safety
- Adhere to all safety policies and procedures, both hospital-wide and department-specific.
- Report and respond to unsafe situations, equipment, behaviors, accidents, and incidents immediately.
- Be prepared for any emergency.
Service
- Treat the people we serve as guests.
- All employees are responsible to respond to call lights.
- Anticipate and address predictable needs and concerns.
*Please sign and date only one of the two options below:
Agreement Verification:

I have read, understand and I agree to comply with and practice the Values and Standards of Performance described above. I understand that my application will be filed for 6 months and I will be considered for open positions as indicated on my application.I have read, understand and I choose not to agree nor comply with and practice the Values and Standards of Performance described above. I understand my application will be filed for 6 months however, I will not be considered for any positions based on my decision to not comply with the Values and Standards of Performance. I understand I may return and complete a new application and sign my agreement to comply with the Values and Standards at which time my application will be filed for 6 months and I will be considered for open positions as indicated on the new application.
Electronic Signature

First NameLast Name
Date

MonthDayYear
Date
Education:
High School*
Name of High School Attended
Location*
Graduated?*

YesNo
Degree Received
Diploma, GED, etc.
Dates Attended*
College
Name of College/University Attended
Location
Dates Attended
Area of Study/Major
Degree
AA, BA, BS...
Graduated?

YesNo
Graduate School
Name of Graduate School Attended
Location
Dates Attended
Area of Study/Major
Degree
MD, DO, MNS...
Graduated?

YesNo
Other Job Related Education or Training
Name of Trade/Technical/Other School Attended
Location
Dates Attended
Area of Study/Skill or Trade
Graduated/Completed?

YesNo
Employment History:
Have you, within the last 12 months, been employed by an agency or organization which serves as a Medicare fiscal intermediary or carrier?*

YesNo
If Yes, Pleas Indicate Name(s)
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 8 years.
Current or Last Employer*
Name of Current Employer or NONE if not Employed
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Supervisor*
Job Title and Description*
Reason for Leaving?*
Start Date*

MonthDayYear
End Date

MonthDayYear
Date
Previous Employer
Name of Previous Employer
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor
Job Title and Description
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Previous Employer
Name of Previous Employer
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor
Job Title and Description
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Previous Employer
Name of Previous Employer
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor
Job Title and Description
Reason for Leaving?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Did you work for any of the above employers under a different name? If so, please indicate which job and give your previous name(s)
Professional Registration
Type of Registration or License
State
Number
Expiration Date
2nd Type of Registration or License
State
Number
Expiration Date
If you do not have a required registration or license, have you applied for one?

YesNo
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?

YesNo
Have you ever had a professional registration/license revoked, suspended or restricted?

YesNo
If "Yes" Please Explain Fully
Skills/Abilities/Training:
Please list skills, training, or experience, which may qualify you for the position(s) desired. (Include any special skills from military service)*
Business machines and/or medical equipment you can operate (word processing, PBX, computer, x-ray, or other medical equipment, types of software you are proficient in)*
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?*

YesNo
Is there any reason you might be unable to meet our work attendance requirements?*

YesNo
If Yes, Please Explain
Professional References:

Please give 2 references, other than family, who have been your supervisor or close work peer.
Reference 1*
Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position*
Years Known*
Reference 2*
Name
Position*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Years Known*
Background
Were you ever discharged for cause, dismissed during probation or have you resigned under pressure or unfavorable circumstances?*

YesNo
If Yes, Please Explain*
NA if not applicable
Dismissal from prior employment will not necessarily bar applicant from employment.
Have you ever been convicted of a criminal offense or been released from prison?*

YesNo
A "yes" answer to this question will not necessarily bar applicant from employment.
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:
Aggravated murder*

YesNo
Arson First degree*

YesNo
Assault First, Second or Third degree*

YesNo
Assault Fourth degree (simple assault)*

YesNo
Assault of a child, First, Second or Third degree)*

YesNo
Burglary First degree*

YesNo
Child abandonment*

YesNo
Child abuse or neglect as defined in RCW 26.44.020*

YesNo
Child buying or selling*

YesNo
Child molestation First, Second or Third degree*

YesNo
Commercial sexual abuse of a minor*

YesNo
Commercial sexual abuse of a minor*

YesNo
Communication with a minor*

YesNo
Criminal abandonment*

YesNo
Criminal mistreatment First or Second degree*

YesNo
Custodial assault*

YesNo
Custodial interference First or Second degree*

YesNo
Custodial sexual misconduct First or Second degree*

YesNo
Endangerment with a controlled substance*

YesNo
Endangerment with a controlled substance*

YesNo
Extortion First or Second degree*

YesNo
Felony indecent exposure*

YesNo
Incest*

YesNo
Indecent liberties*

YesNo
Felony indecent exposure*

YesNo
Incest*

YesNo
Indecent liberties*

YesNo
Kidnapping First or Second degree*

YesNo
Malicious harassment*

YesNo
Manslaughter First or Second degree*

YesNo
Murder First or Second degree*

YesNo
Promoting pornography*

YesNo
Promoting prostitution First degree*

YesNo
Prostitution*

YesNo
Rape First, Second or Third degree*

YesNo
Rape of a child First, Second or Third degree*

YesNo
Robbery First or Second degree*

YesNo
Selling or distributing erotic material to a minor*

YesNo
Sexual exploitation of minors*

YesNo
Sexual misconduct with a minor First or Second degree*

YesNo
Unlawful imprisonment*

YesNo
Vehicular homicide (negligent homicide)*

YesNo
Violation of child abuse restraining order*

YesNo
Or any of these crimes as they may be renamed in the future, or that is equivalent in any state*

YesNo
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.
1. Have you ever been found in a:
(a) Dependency action to have neglected or sexually assulted/abused or exploited any minor or adult person or to have physically abused any minor?*

YesNo
(b) Domestic relations proceeding to have sexually abused or exploited any minor or to have physically abused any minor?*

YesNo
(c) Disciplinary board final decision to have neglected or sexually or physically abused or exploited any minor or adult person?*

YesNo
(d) Court or state licensing board action to have neglected or sexually abused or exploited any minor or adult person?*

YesNo
(e) Disciplinary board final decision to have abused or financially expoloited any person 60 years or older who has a functional, mental or physical inability to care for himself or herself or who is a patiet in a state hospital?*

YesNo
(f) 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?*

YesNo
2. Has it been determined by any state agency or department that you have abused, neglected or exploited anyone?*

YesNo
3. Has a court issued any order of protection against you for abuse or exploitation?*

YesNo
4. Have you ever had a license to care for children or adults denied, revoked or suspended?*

YesNo
If your answer is "yes" to any questions of 1 through 4 previous, please describe and provide the date(s) of the finding(s) and the penalty(ies) imposed.
Have you ever been convicted of any of the following crimes related to drugs:
Manufacture of a controlled substance*

YesNo
Delivery of a controlled substance*

YesNo
Possession with intent to manufacture or deliver a controlled substance*

YesNo
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 himself or herself or who is a patient in a state hospital:
First, Second or Third degree extortion*

YesNo
First or Second degree robbery*

YesNo
First, Second or Third degree theft*

YesNo
Forgery*

YesNo
Or any of these crimes as they may be renamed in the future*

YesNo
If your answer is "yes" to any of the above, please describe and provie 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 if I 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 and other states.
Electronic Signature*

First NameLast Name
Date*

MonthDayYear
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. If you are hired before that report is available, your employment will be conditioned upon the receipt of a satisfactory report.

You will be notified of the State Patrol's response within 10 days after we receive the report. We will make a copy of the report available to you upon your request.
Please read the following carefully before signing
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 Harbor Regional Health Medical Group's. I understand that my employment and compensation can be terminated with or without notice at any time, at the option of either the Hospital or myself.

I understand that no manager or representative, other than the CEO or Board of Directors, has any authority to enter into an agreement contrary to this. Any agreement for employment for any specified period of time with the CEO or the Board of Directors must be in writing and signed.

I consent and authorize the Hospital and its personnel to investigate all information concerning my previous employment, education, and background including records of law enforcement, federal and state agencies. I authorize the Registrar/Placement Office of all educational institutions attended to release an 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 reque3sted. 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 Harbor Regional Health Medical Group, I will be required to submit to a pre-employment drug screening and 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 these pre-employment tests and checks 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 tests.

If employed, I further agree that if Harbor Regional Health Medical Group 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 Hospital at the time my employment ends, or if I lose, damage or fail to return any Hospital property, I authorize the Harbor Regional Health Medical Group 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.
Electronic Signature*

First NameLast Name
Date*

MonthDayYear
Date
Cover Letter & Resume (Optional):
Cover Letter

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Resume

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License/Credentials

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Application For Employment :

Personal Information:

Employment Desired:

Education:

Employment History:

Professional Registration

Skills/Abilities/Training:

Job Performance Ability

Professional References:

Background

Disclosure Statement

Please read the following carefully before signing

Cover Letter & Resume (Optional):

Send Application: