Employment Application

Employment Application
Applicant Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Employment Desired
Position*
Date you can start*

MonthDayYear
Date
Desired Salary
Are you currently employed?*

YesNo
May we contact your current employer?

YesNo
Are you legally authorized to work in the United States?*

YesNo
Have you ever applied for a job with Dynamic before?

YesNo
When and where?
Education History
High School (Name and Graduation)
College/Trade School: Name and location
Graduation Year
Degree
College/Trade School: Name and location
Graduation Year
Degree
Specialized Skills and Training
Subjects of Special Study or Research Work
Special Training
Special Skills
Military Service and Rank
Former Employment
Employer Name*
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Started*

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Position*
Reason for Leaving
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Position
Reason for Leaving
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Position
Reason for Leaving

On the Job Injury
Policy:

An on the job injury will be reported immediately to the Administrator.

Procedure:
1. Notify the supervisor immediately following an on the job injury.
2. Write a full explanation of the injury, including, but not limited to the following:
  1. Date and time of injury.
  2. Place of injury.
  3. How the injury occurred.
  4. Injury or injuries sustained.
3. Submit to a drug screen, if requested by the Administrator.
4. Visit physician as appropriate. (i.e. Workers Comp)
5. Obtain written report from physician and give to the Supervisor.
6. Fill out release from Dynamic if choosing not to seek medical treatment for injury.
7. A copy of the incident report will be given to the administrator.
Workers' Compensation

Dynamic employees have coverage for work-related illnesses or injuries under Workers' Comp. All medical expenses incurred due to the work-related incident are paid in full along with partial salary payments for the duration of the employee's absent from work. Posted on the employee's bulletin board, is a Bill of Rights for the injured worker.
Employee Signature*

Clear
Signature Date*

MonthDayYear
Date

Affidavit of No Charges of Neglect or Abuse
Applicant Name*

First NameLast Name
I, blanks do not have a prior conviction nor have I pled no contest (nolo contendere) for child or adult abuse, neglect, or mistreatment.
Signature*

Clear

Harassment Policy
Policy:

It is the policy of Dynamic to ensure the maintenance of a workplace free of any form of employee harassment, including sexual harassment and intimidation. Dynamic expressly prohibits any form of unlawful employee harassment on race, color, religion, sex, national origin, age status, disability, or status as a veteran.

Procedure:

The company maintains a ZERO-TOLERANCE policy for improper interference with the ability of employees to perform their expected job duties.
1. Specifically, Dynamic prohibits:
  1. Unwelcome sexual advances.
  2. Requests for sexual favors.
  3. All other verbal or physical conduct of a sexual or otherwise offensive nature where:
    
    Submission to such conduct is made either explicitly or implicitly a term or condition of employment.
    
    Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting the individual, and
    
    Such conduct has the purpose or effect of creating an intimidating, hostile, or offensive working environment.
2. It is the responsibility of each member of management to create an atmosphere free of harassment, sexual or otherwise.
3. It is the responsibility of each employee to respect the rights of other employees or non-employees.
4. Dynamic does not tolerate the harassment of any employee or non-employee, supervisor, manager, or director for any reason.
5. Harassment of a sexual nature is a violation of various state and federal laws. This conduct may be subjected to the individual harassment policy for any such unlawful conduct.
6. Employees who become aware of sexual harassment or who believe that they have been subject to such harassment should report this to their supervisor or to Dynamic administration.
7. It is not necessary to file a formal complaint or formal grievance to complain of sexual harassment. All complaints will be taken seriously by Dynamic and will be kept confidential to the maximum extent possible.
Complaint Procedure:
1. If an employee experiences any job-related harassment, has a related complaint, or believes they have been treated in an unlawful, discriminatory manner, that employee will promptly report the matter.
2. On receipt of a complaint, the Administrator will undertake an investigation.
3. Should the investigation determine that na individual is guilty of harassing another employee, disciplinary action (up to and including discharge) will be taken against the offending employee.
4. Dynamic expressly prohibits any form of retaliatory action against any employee for a bona-fide complaint under this policy or for assisting in a complaint investigation.
5. If, after investing a complaint of harassment or unlawful discrimination, Dynamic finds that the complaint is not bona-fide, or that an employee has provided false information about the complaint, disciplinary action may be taken against the individual who filed the false complaint or whom gave the false information.
Signature*

Clear

Permission for Criminal Background Check
Applicant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Please list any previous names you have used.
Applicant Signature*

Clear
Date of Signature

MonthDayYear
Date

Confidentiality of Patient Information and Operational Data
As an employee/consultant of Dynamic, I agree to keep in confidence all information related to patient geographical data and health history unless requested by the Administrator or designee, to release information to appropriate health care regulatory agencies and/or health care providers.

All information that I may encounter in my line of work related to patient volume, patient referral sources, payroll and salaries, billing/accounts payable/receivable must be maintained in strict confidence and only provided to employees designated by the administrator.

I understand that all codes used for billing and patient registration must be kept confidential.

I understand that breach of confidentiality of information related to patients and Dynamic Hospice and Palliative Care operational procedures will lead to disciplinary actions up to and including termination.

I understand that no patient files, billing information, payroll information, or any other records, forms or data such as Open Packs, Revisit Notes, Policy Manuals obtained at Dynamic is to be loaned, reviewed, or sold to other hospice agencies. This violation will lead to immediate termination and legal action by Dynamic.
Employee Signature*

Clear
Date Signed*

MonthDayYear
Date
Administrator Signature

Clear

Emergency Contact Information
Applicant Name*

First NameLast Name
Date

MonthDayYear
Date
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.

Agreement for Conditions of Employment
Applicant Name*

First NameLast Name
This agreement is made and entered into on Dateby and between Dynamic (hereinafter referred to as the AGENCY) and First Name Last Name, (hereinafter referred to as EMPLOYEE).
You will be fully informed about our work policies and procedures during an orientation session. In the meantime, the following information should be useful to you:
1. We will do our best to find suitable job assignments that will take full advantage of your qualifications and experience. However, we cannot guarantee employment.
2. If you are unhappy with your assignment, contact us, and we will make every effort to try to find another assignment for you. We expect full cooperation regarding your availability to provide patient care.
3. Your wages will be calculated from activity logs you submit to us.
4. IMPORTANT: If activity logs are late or incorrect, your paycheck may be delayed or incorrect.
5. Processing of your activity logs may be delayed if service reports, progress notes, or other required documentation of patient care is not submitted correctly and on time.
6. The rate of overtime pay you receive will be based on the employment laws of Georgia.
7. You must provide services according to duties outlined in your job description and agency policy. If your work performance falls below Dynamic’s standards, you will be subject to discipline and possibly termination. Unacceptable work performance includes excessive cancellations and tardiness as well as “no shows”.
  1. Remember that you must contact Dynamic’s office as soon as you are aware of a change in your availability.
8. You must provide us with copies of current licenses, physical examinations, and other documentation required by relevant federal, state, and contracting agencies.
9. You are not permitted to accept or hold money or other valuable property for any client.
10. If you are a paraprofessional, you must regularly attend in-service educational programs to maintain your employment with Dynamic. You will be informed as to the exact number of service hours and topics required each year, as well as the dates, locations, and times of service sessions.
11. You will be provided with a Dynamic identification card, which must be worn on your person while you are on all assignments. There is no charge for your initial ID card. However, if your card is lost or damaged, you may be required to pay a replacement fee.
12. You are not permitted to drive patients in their car, family member’s car, or your own car.
13. You must abide by HIPAA policies related to patient confidentiality. (Refer to HIPAA policy)
14. You must avoid discussing Dynamic business, problems with patients, and problems with Dynamic employees or any situation involving them with a patient or client.
15. You are not permitted to use any information regarding Dynamic clients, accounts, or operational procedures to benefit yourself or others without permission of Dynamic administration.
16. You are considered an employee of Dynamic and not an employee of the client.
17. Employment will be terminated when it is substantiated that an employee requested payment for services that were not rendered.
18. Dynamic and the employee assures that it will comply with title VI of the Civil Rights Act.
19. Dynamic shall pay bi-weekly for services rendered pursuant to this agreement at a rate of $ visit rate/visit and $assessment rate/assessment or $hourly rate/hour. Dynamic shall keep records and show computation of charges.
20. I understand that my employment mat be terminated by Dynamic at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination.
Indicate below by your signature and date that you fully understand and intend to adhere to all Dynamic policies and procedures indicated in this form.
Employee Signature*

Clear
Dynamic Signature

Clear
Should be Empty:

Employment Desired

Education History

Specialized Skills and Training

Former Employment

Confidential Reference Inquiry

On the Job Injury

Affidavit of No Charges of Neglect or Abuse

Harassment Policy

Permission for Criminal Background Check

Confidentiality of Patient Information and Operational Data

Emergency Contact Information

Agreement for Conditions of Employment