Welcome to Healthcare Plus Online Application
The information here will be used to autofill the paperback application. Please answer every question that shows an *
Employee Application
This section will Fill out the majority of the general information needed.
Name
*
First Name
Middle Name
Last Name
Device used to fill out Application
Phone
Tablet
Desktop/ Laptop
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Where did you hear about us?
*
Please Select
Walk In
Facebook
Applicant Pro
Indeed
Hiring Signs/ Marketing
Referral / Preferred Worker
Which Office/ Region are you applying for? (Addresses for locations at the bottom of the page)
*
Please Select
Diversey
Pilsen
North Riverside
Oak Lawn
South Holland
Aurora
Rockford
Freeport
Waukegan
Elgin
Sterling
Rolling Meadows
Position Applying for
Please Select
Caregiver
Floater
Year(s) of Related experience
Today's Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Apt
City
State / Province
Postal / Zip Code
Last 4 of SSN
*
Cell Phone
*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
*
example@example.com
Name of Emergency Contact Person
*
Phone Number of Emergency Contact
*
Please enter a valid phone number.
Are you 18 years of age or older?
*
Yes
No
Are you Currently authorized to work in the U.S.?
*
Yes
No
If selected for employment, are you willing to be fingerprinted?
*
Yes
No
Are you willing to work full-time at Healthcare Plus?
*
Yes
No
If "no", indicate the number of hours of your available time:
Have you ever been dismissed from employment?
*
Yes
No
If "yes", please explain.
Availability
*
Full-Time
Part-Time
Regular
Temporary
Highest Education Obtained
*
Please Select
Middle School
High School
College
GED
None of the above
Name of School
Address of School Attended
Did You Graduate?
*
Yes
No
Signature
*
Clear
Signature
*
Clear
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Staffing Questionnaire
This section will Fill out your Staffing Questionnaire section of your application and help us find the clients that work best with your schedule
What's your availability to work?
Mornings
Noon
Nights
Monday
Tuesday
Wednesday
Thrusday
Friday
Saturday
Sunday
How did you hear about Healthcare Plus?
Have you talked to one of our representatives? If yes, who?
Do you have a pending/potential client?
Yes
No
If Yes, Client name
What area are you interested in working in? (please provide zip codes or cities you might be interested in working in)
Do you smoke?
Yes
No
Can you work for someone who smokes?
Yes
No
What languages do you speak?
English
Spanish
Tagalog
Other
Are you pet friendly? ( Select all that apply)
Yes
No
Dogs
Cats
Other
Any allergies we should know about?
How would you like to be addressed?
Mr. / Sr.
Ms. / Srta.
Mrs. / Snra.
Non-binary / No binario
Preferred Name:
Do you drive your own car, or use public transport?
Have you ever received a dose of COVID-19 Vaccine?
Yes
No
Have you ever had a Positive test for COVID-19
Yes
No
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Policy & Procedures
This section will Fill out your Policy & Procedures section of your application
Signature
*
Clear
Record of Influenza Vaccination Date:
-
Month
-
Day
Year
Date
Declination of Vaccination
Declination of Vaccination Checkmark
Signature
*
Clear
UNIVERSAL COVID-19 SCREENING QUESTIONNAIRE Effective October 13, 2020*
Protecting seniors, vulnerable adults, and their caregivers while preventing the spread of COVID-19 is of paramount importance. Based on guidance from the Centers for Disease Control & Prevention (CDC, 2020), the Illinois Department on Aging (IDoA) recommends screening of staff, participants and other individuals who may be present when providing care and/or assistance to seniors. For additional information on timing of screening, documentation, and related issues please refer to specific provider guidance. Within the past 14 days:
1) Have you or someone you have had contact with been experiencing new onset of any of the following symptoms:
Fever or Chills
Muscle or Body Aches
Fatigue
New Loss of Taste/Smell
Diarrhea
Headache
Sore Throat
Cough
Congestion/Runny Nose
Nausea/Vomiting
Shortness of Breath or Difficulty Breathing
None
2) Have you or someone you have had contact with been tested positive for COVID-19?
Yes
No
3) Have you or someone you have had contact with been exposed to an individual with a positive COVID-19 diagnosis?
Yes
No
Employee Handbook
Initials
*
Signature
*
Clear
W-4 Forms
This section will Fill out your W-4 section of your application. This will fill out the required parts, to fill out a comprehensive W-4 parts that might not be included here, please fill out a paper application at your nearest office.
Social Security Number (SSN)
*
Filing Taxes as
*
Single or Married filing seperately
Married filing jointly or Qualifying Widow(er)
Head of Household (Check only if you're unmarried and pay more than half the cost of keeping up a home for yourself and a qualifying individual.)
Tax Withholding Estimator
https://www.irs.gov/individuals/tax-withholding-estimator
IRS Worksheet
https://www.irs.gov/pub/irs-pdf/fw4.pdf
2(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise more tax than necessary may be withheld
Check box if Applicable
Number of qualifying children under age 17
*
Multiply number of qualifying children under age 17 by $2,000 (Autofill)
Number of other dependents
*
Multiply the number of other dependents by $500 (Autofill)
Add the amount above and enter the total here (Autofill)
Step 4 (optional, Image above): Other Adjustments. Will you be Claiming other adjustments
*
Yes
No
4(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that wont have withholdings, enter the amount of other income here. This may include interest, dividends, and retirement income. . . . . .
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the deductions Worksheet on page 3 and enter the results here. . . .
4(c) Extra Withholding. Enter any additional tax you want withheld each Pay period. .
Signature
*
Clear
Will you be filling out Section 2(b) (Image above, optional)
*
Yes
No
1.
2a.
2b.
2c.
3.
4.
Will you be filling out Step 4(b) (Image above, optional)
*
Yes
No
1.
2.
3.
4.
5.
Write the total number of basic allowances that you are claiming
Check the box if you are exempt from federal and Illinois Income Tax withholding and sign and date the certificate
If applicable check box
Signature
*
Clear
I-9 & Background
This section will Fill out your !-9 & Background section of your application. Most of the information in this part has already been filled out using your information from step 1
Other Last Names Used (if any)
I attest, under penalty of perjury, that I am (check one of the following boxes):
*
A citizen of the United States
A noncitizen national of the United States
A lawful permanent resident(Alien Registration Number/USCIS Number):
An alien authorized to work until
Alien authorized to work until: (expiration date)
-
Month
-
Day
Year
Date
Alien Registration Number/ USCIS #
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
Signature
*
Clear
States Where You Have Lived?
Gender
*
Male
Female
Race
*
Please Select
A Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander
B Black or African American (Not Hispanic or Latino)
H Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin)
I American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition.
U Of undeterminable race. Of Untold mixture.
W Caucasian (not Hispanic or Latino)
Height
*
Weight (LB)
*
Hair Color
*
Eye Color
*
Place of Birth
*
Have you ever had an administrative finding of Abuse, Neglect or Theft?
*
Yes
No
If “Yes,” give full details and state.
*
Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated delinquent)
*
Yes
No
If “Yes,” give full details of each offense and the state in which convicted.
*
I certify that the above is true and correct and give my consent for my name to appear on Department’s Health Care Worker Registry with the results of my criminal history records check.
Signature
*
Clear
Please either copy and paste the link, or Scan the QR code, then input the code given below (Please open in a separate Tab, when complete do not press back https://tcs.adp.com/txcs-ui/screening/?cc=hcp
Required Documents
In this section you will submit the three required documents needed for your application.
Government Issued ID
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Social Security Card
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High School Diploma/ GED/ Letter of experience
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Covid-19 Vaccination Card (once employed, if fully vaccinated $50 bonus will be given)
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Choose a file
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Preview PDF
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