Alafia Employment Application

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Please fill out this form completely. All required fields are marked with *. If you have any documents that you would like to upload, please do so in the file upload section at the end of this form.
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Today’s Date:* This field is required.
Date
Month
Day
Year
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Last Name:* This field is required.
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First Name: * This field is required.
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Middle Name
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SSN: Enter numbers without the dashes* This field is required.
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DOB:* This field is required.
Date
Year
Month
Day
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Home Address(Include Apt. No, Suite No., if any):* This field is required.
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City:* This field is required.
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State:* This field is required.
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Zip:* This field is required.
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Home Phone:
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Cell Phone:* This field is required.
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Email:* This field is required.
example@example.com
Email Verified
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Name of Emergency Contact:* This field is required.
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Relation:* This field is required.
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Emergency Contact Cell Number:* This field is required.
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Position (Job Class) Applying for:* This field is required.
RN
PT
LP/VN
CNA
PCA/PAS
PTA
Clerical
Other:
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Other:
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Date Available:* This field is required.
Date
Month
Day
Year
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Previous Facility Types Worked: Check All That Apply* This field is required.
Hospital
Hospice
Nursing Home
Rehab
Private Duty
Assisted Living/Residential Treatment
Other
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Language Skills: Other than English, please check any other languages you speak:
Spanish
French
German
Other
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Check the type of assignment you are available for:* This field is required.
Full-time
Part-time
Contract
Travel
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Check the days of the week you are available to work:* This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays available to work
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Holidays available to work
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Licenses & Certificates
License Type
License/Certification
State
Expiration Date
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
License Type
Row 0, Column 0
License/Certification
Row 0, Column 1
State
Row 0, Column 2
Expiration Date
Row 0, Column 3
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Has your professional license ever been suspended, revoked or under investigation?
Yes
No
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If yes, please explain:
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Certifications: Check all applicable certifications and enter expiration date:
Check all Applicable Certifications
Expiration Date
ACLS
Row 0, Column 0
Row 0, Column 1
BCLS
Row 1, Column 0
Row 1, Column 1
CPR
Row 2, Column 0
Row 2, Column 1
PALS
Row 3, Column 0
Row 3, Column 1
IV
Row 4, Column 0
Row 4, Column 1
NALS
Row 5, Column 0
Row 5, Column 1
Other
Row 6, Column 0
Row 6, Column 1
ACLS
BCLS
CPR
PALS
IV
NALS
Other
Check all Applicable Certifications
Row 0, Column 0
Expiration Date
Row 0, Column 1
Check all Applicable Certifications
Row 1, Column 0
Expiration Date
Row 1, Column 1
Check all Applicable Certifications
Row 2, Column 0
Expiration Date
Row 2, Column 1
Check all Applicable Certifications
Row 3, Column 0
Expiration Date
Row 3, Column 1
Check all Applicable Certifications
Row 4, Column 0
Expiration Date
Row 4, Column 1
Check all Applicable Certifications
Row 5, Column 0
Expiration Date
Row 5, Column 1
Check all Applicable Certifications
Row 6, Column 0
Expiration Date
Row 6, Column 1
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Facility/Employer Name * This field is required.
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Date Employed From* This field is required.
Date
Month
Day
Year
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To* This field is required.
Date
Month
Day
Year
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Address* This field is required.
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Suite/Unit
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City* This field is required.
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State* This field is required.
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Zip:* This field is required.
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Country* This field is required.
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Title* This field is required.
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Name of Current Immediate Supervisor* This field is required.
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Supervisor's Telephone:* This field is required.
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Describe duties and specialty areas:* This field is required.
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Pay Rate: Hourly OR Yearly
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May We Contact?* This field is required.
Yes
No
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If no, why?
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Reason for Leaving:
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If this was a travel assignment, name of agency:
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Are your employment records listed under another name?* This field is required.
Yes
No
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If yes, what name?
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Supervisory Experience:* This field is required.
Yes
No
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If yes, how often?
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Facility/Employer Name * This field is required.
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From:* This field is required.
Date
Month
Day
Year
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To:* This field is required.
Date
Month
Day
Year
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Address:* This field is required.
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Suite/Unit:
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City:* This field is required.
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State:* This field is required.
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Zip:* This field is required.
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Country:* This field is required.
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Title:* This field is required.
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Name of Current Immediate Supervisor
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Telephone:* This field is required.
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Describe duties and specialty areas:* This field is required.
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Pay Rate/Salary:Hourly OR Yearly
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May We Contact?* This field is required.
Yes
No
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If no, why?
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Reason for leaving:* This field is required.
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If this was a travel assignment, name of agency:
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Are your employment records listed under another name?* This field is required.
Yes
No
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If yes, what name?
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Supervisory Experience:* This field is required.
Yes
No
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If yes, how often?
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Please list any other work related information you think would be helpful to us in considering you for employment, Such as specialized training, certifications, additional work experience, etc.
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1. Are you legally authorized to work in the USA?* This field is required.
Yes
No
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2. Have you ever been convicted of a felony?* This field is required.
Yes
No
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3. Can you pass a pre-employment drug test?* This field is required.
Yes
No
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4. How were you referred to Incarnation Home Health Services, Inc.?
Newspaper
Trade Publication
Job Fair/Open House
Internet Site
Company Employee
Other
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Company Employee Name:
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* This field is required.
Yes I understand that I must report all accidents to my immediate supervisor and to Incarnation Home Health Services, Inc. NO MATTER HOW SLIGHT.
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* This field is required.
Yes I also understand that I must wear all required personal protection equipment PPE
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The penalty for not wearing PPE is disciplinary action, up to and including termination.
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Signature:* This field is required.
Clear
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Please read carefully and sign

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Incarnation Home Health Services, Inc. permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Incarnation Home Health Services, Inc.With regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Incarnation Home Health Services, Inc. May conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Incarnation Home Health Services, Inc. Its agents,and all affiliated entities, as well as any person or situation that provides any information about me, from all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Incarnation Home Health Services, Inc., I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Incarnation Home Health Services, Inc. Or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Incarnation Home Health Services, Inc. at any time, can constitute a contract of employment. No representative or agent of Incarnation Home Health Services, Inc., has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment, I agree that my continued employment may be contingent on the results.

I understand that Incarnation Home Health Services, Inc. is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Incarnation Home Health Services, Inc. against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.
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* This field is required.
I have read the above and fully understand it.
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Put your Initials in the box * This field is required.
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Applicant Signature:* This field is required.
Clear
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Date:* This field is required.
Date
Month
Day
Year
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Our agency is required to screen all employees and subcontractors in order to determine if those individuals and entities were excluded from participation in federal healthcare programs. The office manager prior will conduct the OIG screening to hiring and on before the fifth of every month. The OIG results will be obtain by searching both federal and Texas LEIE websites listed below. Texas Health and Human Service Commission- OIG list of Excluded individuals/
Entities online searchable database: Https://www.oig.hhsc.state.tx.us/exclusion/search.aspx
HHS-OIG Excluded Individuals/ Entities online searchable database: https://www.oig.hhs.gov/fraud/exclusion.asp.
All OIG results will be stored in one separate binder from personnel files and will be securely stored in a locked compartment.
Our office manage is aware that when a provider is excluded federal health care programs are generally prohibited from paying for any items furnished, ordered, or prescribed by excluded individuals or entities.
If the office manager becomes aware of anyone that are listed on the exclusion list, the office managers will
report any discovered information to HHSC-OIG using the self-report mechanism at: https://oig.hhsc.state.tx.us/
ProviderSelfReporting/SelfReporting.aspx.
https://e-verify.uscis.gov/web/Login.aspx.
The agency will maintain documentation for a minimum of six years. Documentation will included the following elements: Date of the federal and state database and searches; First and last names and date of birth of all employees and contractors subject to LEIE searchrequirements; Whether or not the employee/contractor appeared in the federal/state LEIE database; Date any excluded employee/contractor was self-reported to HHSC-OIG; Copy of self-report; and Printed name(s) and signature of staff responsible for completing the monthly searches. By signing below I am stating that I have been informed of the OIG search and am giving permission for Incarnation Home Health Services, Inc. to run the required OIG search prior to employment and on a monthly basis’s therefore after my employment.
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Signature of Employee/Subcontractor* This field is required.
Clear
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Date* This field is required.
Date
Month
Day
Year
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