Stockdale Residence and Rehabilitation Center

Are you a citizen of the United States?

Have you ever worked for this company?

Have you ever been convicted of a felony?

Please list three professional references.

May we contact your previous supervisor for a reference?

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

This facility is an equal opportunity employer. Applicants are considered for all positions regardless of race, color, nationality, religion, gender, marital status, disability, age or military/veteran status in accordance with federal law. In addition, the Facility complies with applicable state and local laws governing nondiscrimination in employment in every jurisdiction in which it maintains facilities. The Facility also provides reasonable accommodation to qualified individuals with disabilities inaccordance with applicable laws. Consideration for employment depends solely on qualifications.

Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, the Facility will verify the status of every individual offered employment with the Company. In this regard, all offers of employment are subject to verification of the applicant’s identity and employment authorization.

The facility is committed to providing a safe and drug-free work environment for our employees. With this goal in mind, and because of the serious drug abuse problem in today’s workplace, we are establishing the following policy for our existing and future employees. Employees given an employment opportunity must consent to drug/alcohol testing based on the guidelines outlined below.

• The facility explicitly prohibits:
• The use, possession, solicitation for, or sale of narcotics or other illegal drugs, alcohol, or prescription medication without a prescription.
• Being impaired or under the influence of legal or illegal drugs or alcohol on premises, or away from the premises if such impairment or influence adversely affects to employee’s work performance, the safety of the employee or of others, or puts the Facility’s reputation at risk.
• The presence of any detectable amount of prohibited substances in the employee’s system while at work, while on the premises, or while on facility assignments. Prohibited substances include illegal drugs, alcohol, or prescription drugs not taken in accordance with a prescription.

• The company will conduct drug and/or alcohol testing under any of the following circumstances:
• Random Testing: Employees may be selected at random for drug and/or alcohol test at any time it feels that the employee may be under the influence of drugs or alcohol, including by not limited to the following circumstances: evidence of drugs or alcohol in the employee’s vicinity; unusual conduct on the employee’s part that suggests impairment or influence of drugs/alcohol; negative performance patterns; or excessive and unexplained absenteeism or tardiness.
• For-Cause Testing: The Facility may ask an employee to submit to a drug and/or alcohol test at any time it feels that the employee may be under the influence of drugs or alcohol, including but not limited to the following circumstances: evidence of drugs or alcohol in the employee’s vicinity; unusual conduct on the employee’s part that suggests impairment or influence of drugs/alcohol; negative performance patterns; or excessive and unexplained absenteeism or tardiness.
• Post-Accident Testing: Any employee involved in an on-the-job accident or injury under circumstances that suggest possible use or influence of drugs or alcohol in the accident or injury event may be asked to submit to a drug and/or alcohol test. “Involved in an on-the-job accident or injury” means not only the one who was or could have been injured, but also any employee who potentially contributed to the accident or injury event in any way.

If any employee is tested for drugs or alcohol outside of the employment context and the results indicate a violation of this policy, or if an employee refused a request to submit to testing under this policy, the employee may be subject to appropriate disciplinary action, up to an possibly including discharge from employment. In such a case, the employee will be given an opportunity to explain the circumstances prior to any final employment action becoming effective. If the employee is terminated due to positive drug and/or alcohol test, s/he will not be considered for employment at the Facility for 12 months, or at the discretion of the Administrator.

Employee Agreement to Consent to Drug and/or Alcohol Testing

I, hereby consent, upon a request made under the drug/alcohol testing policy of my employed Facility, to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under the Facility’s policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have the Facility and/or its physician send the specimen(s) collected to a laboratory for a screening test for the presence of any prohibited substances under the above policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Facility.

I understand that only duly-authorized Facility officers will have access to information furnished or obtained in connection with the test, that they will maintain and protect the confidentiality of such information to the greatest extent possible, and that they will share such information only to the extent necessary to make employment decision and to respond to inquiries or notices from government entities.

I will not seek legal action or hold accountable the Facility, physician, or testing laboratory the Facility might use, for any alleged harm to me that might result from such testing, including termination from employment or any other kind of adverse job action that might arise as a result of the drug/alcohol test. I will not seek legal action even if an employee at the facility or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

I have read and understand the above policy as well as this authorization form. I have been told that if I have any questions the test or the policy, they will be answered.

Consumer Reports/Criminal History Checks

Purpose of Background Checks The facility believes that hiring qualified individuals to fill positions contributes to our overall strategic success. Background checks serve as an important part of our selection process. The type of information that is collected is used as a means of promoting a safe work environment for current and future Facility employees. Background checks also help us obtain additional applicant-related information that helps determine the applicant’s overall employability, ensuring the protection of the current employees and residents, property, and information of the organization.

Background Check Policy The Facility will conduct a background investigation as part of its screening and hiring process, and is required to inform you of this based on the Fair Credit Reporting Act, therefore, you may be the subject of a “consumer report” and/or criminal history check, which may include information about your general reputation, mode of living, credit history, criminial history, social security verifcation, driving record, verification of edcuation or employment history, or other background checks. The primary objective of any investigation will strictly be for the purpose of verifying information you provided in connection with your application for employment. A consumer report/investigative consumer report may be obtained at any time during the application process or during your employment with the company, the extent permitted by law. If you submit a timely written request to the business office, we will provide you with the name, address, and phone number of the third party used to conduct these checks, and the nature and scope of any consumer report, if it is ordered. The Facility guarantees that all informaiton obtained from the reference and background check process will only be used as part of the employment process and will be kept strictly confidential.

I acknowledge the above disclosure regarding background investigation and criminal history checks, and certify that I have read and understood it. I hereby authorize the obtaining of consumer reports by the employer at any time after the receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize any law enforcement agency, administrator, state/federal agency, institution, information service bureau, employer, or ensure company to furnish any and all background information obtained.

On Wednesday, April 25, 2012, the U.S. Equal Employment Opportunity Commission approved guidance on employer use of criminial background checks. The EEOC guidance does not prohibit employers from considering criminal information during the hiring process.