Care Well of CLT CARE PROVIDER EMPLOYMENT APPLICATON

CARE PROVIDER APPLICATON
CWI Considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age disability. marital or veteran status or any other legally protected status.
Date

MonthDayYear
Date
Highest Education Level
1. Full Name (First, Middle, Last)
Place of Birth
Date of Birth

MonthDayYear
Date
Social Security #
2. Address
3. Email Address
example@example.com

4. Other Members of Household

	Name	Date of Birth	Relationship to Applicant	Place of Employment
1
2
3
4

5. Will you be able to provide a client with his/her private bathroom?
(This is a requirement for overnight placements)

CWI considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age disability, marital or veteran status or any other legally protected status.
6. List any health/medical limitations (CWI does not discriminate based on disabilities however, we will need to know if you have any limitations such as lifting, etc.)
***North Carolina requires an annual statement of good health from a doctor, are you able to provide a statement?

7. Do you have a valid North Carolina Drivers License?
We will also need a copy. (Drivers License #)
8. How did you learn about Care Well of Charlotte, Inc.?
9. Why do you want to become a Care provider?
10. What do you have to offer an individual with developmental disabilities?
11. Are you employed outside the home?
Working days and hours
Working Phone #
Can you be contacted at work by CWI if necessary?
12. Are you willing to have a physical and TB test?
(Required by North Carolina for employment as a care provider)
13. Have you ever been convicted of a felony or crime other than a misdemeanor?
(Police background check required prior to placement with a client)
14. Are you willing to participate in training sessions?

Current or Previous Employer(s)

	Current or Previous Emplyer	Address	Phone # and Contact Name	Dates of Employment	Job Title	Salary
1
2
3
4

FOR RESIDENTIAL PLACEMENT ONLY
Is your home currently licensed?
License expires

MonthDayYear
Date
Fire/Safety Inspection Date:

MonthDayYear
Date
Smoke detectors installed?
Fire Extinguisher?
Sanitation Inspection Date

MonthDayYear
Date
This information that I have provided is accurate and correct to the best of my knowledge. The undersigned hereby acknowledge that he / she is not an employee of Care Well of Charlotte, Inc. and that my status with the company is that of an independent agent. In acting as a caregiver, I acknowledge that all state and federal income taxes including federal social security taxes are my sole responsibility and not that of Care Well of Charlotte, Inc.
Signature

Clear
Date

MonthDayYear
Date

Assurance of Confidentiality

Care Well of Charlotte, Inc. is required to make known to all contractors, employees, students, volunteers and all other individuals with access to confidential information the provisions of the Federal Standards for Privacy of Individually Identifiable Health Information and the North Carolina Statues on Confidentiality (122C 51-56).

Care Well of Charlotte, Inc. is required by law maintain the privacy of protected health information.

Protected health information as defined by the Federal Standards is: all individually identifiable health information that transmitted or maintained in any form, including paper, oral and electronic records and communications.

Confidential information as defined by the Federal Standards is: all individually identifiable health information that is transmitted or maintained in any form, including paper, oral and electronic records and communications.

Confidential information as defined in the N.C. Statues “includes but it not limited to photographs, video tapes, audio tapes, client records, reimbursement records, verbal information relative to individuals served, client information shall take affirmative measures to safeguard such information.

Any release of confidential information:

∑ is authorized in writing by the individual and / or the legally responsible person.

∑ Is limited to specific information identified and is the minimum necessary to fulfill the request.

∑ has a time limitation not to exceed one year

∑ must allow for consent to be withdrawn at any time by the consenting individual

Once the authorization for release has been signed, only designated employees may approve the release of confidential information.

Examples: Information about an individual does not need to be discussed with individuals outside their team.

Contractor’s will only have access to the individuals’ information necessary to provide supports and services.

When a contractor leaves and goes to another agency, any knowledge of individuals supported remains confidential and is not to be used by the new agency for or against the individual.

All contractors shall indicate an understanding of the requirements governing privacy and confidentiality by signing a statement of understanding and compliance. These are signed upon employment and annually thereafter as required by funding source.

Confidentiality Statement

I understand and agree that all information, must be kept confidential from authorized persons.

In accordance with Federal Standards for Privacy and N. C. Statues on Confidentiality, I agree to hold confidential all information about applicants for placement, current and former individuals supported by Care Well of Charlotte, Inc. and other agencies to which I have access, Further, I agree not to divulge such information to any unauthorized persons. I understand that my failure to comply with the Federal Standards and the N. C. Statutes is a violation of client rights and may result in civil and / criminal penalties punishable by fine or imprisonment and / or results in disciplinary actions up to and including dismissal.

Receipt of Client Rights Policy and Procedures

I have received the required training of Care Well of Charlotte, Inc. Client Rights Policy and Procedures. I clearly understand the various types of violations that are covered by the Policy and Procedures and acknowledge that abuse can be physical, emotional or verbal and can include neglect or exploitation.

I understand that it is my responsibility as a contractor or employee to protect all individuals we support from any harm; physical, emotional or verbal abuse, neglect, indignity, sexual offense and any other personal infringement. I also understand that corporal punishment is strictly prohibited.

I agree to immediately reported any violations of any individual’s rights that I personally witness or become aware of to my supervisor or Program Director. If, for any reason, I do not feel comfortable reporting violations to the above-mentioned individuals, I understand that I can report incidents directly to the Department of Social Services. I understand that my failure to report any violation of the Client Rights Policy will result in my immediate termination.

Receipt of Information Regarding the NC Health Care Personnel Registry Law

I understand that in accordance with the Registry Law Care Well of Charlotte, Inc. is required to report individuals with allegations of abuse, neglect, misappropriation of individual or facility property, fraud against the individual or facility and diversion of individuals or facility drugs occurring in facilities. The registry contains a listing of unlicensed personnel who have been found to have caused harm to an individual or facility. Information from the Registry is available to the public and all health care providers.

The information and reporting requirements regarding the law have been reviewed and explained to me. I have received the following: overview of Health Care Personnel Registry, Examples of Allegations and Suggestions for Employees.
Signature

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date

I First Name Last Name duly affirm that I do not have a Criminal record in North Carolina or any other state where I have resided. I understand that should I be found to have convictions or otherwise a record, I must disclose this information to Care Well of Charlotte, Inc immediately. I understand that the administrative staff at Care Well of Charlotte, Inc. will review the nature of the crime and I may be terminated or suspended from my duties as determined by the review.
CRIMINAL RECORDS DISCLOSURE
Signature

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date

Professional Reference Form
Applicant Name blanks
Position Applied   Type a label
Business Reference Name   Type a label
Business Reference Contact Number   Type a label
Date of Employment From   Date     to    Date
Working relationship to Candidate   Type a label
Date

MonthDayYear
Date
Personal Reference Form
Applicant Name First Name Last Name
Personal Reference Name First Name Last Name Phone Number Area Code Phone Number

Emergency Information
In case of emergency a person working at Care Well of Charlotte, Inc. should complete this form. This includes ALL staff, full time, part time, temporary staff, volunteer, etc.

Note: For keeping our personnel records up to date, staff is required to report any changes in their personal status to the Personnel office within 72 hours of said change.

(Care Well's "Policies and Procedures" Handbook).

PLEASE COMPLETE ALL OF THE FOLLOWING EMERGENCY INFORMATION

Contractor's Name   First Name   Last Name
Social Security #     Type a label
Street address   Street Address   Address Line 2   City   State   Zip
Home Telephone #   Area Code   Phone Number
Cell phone#   Area Code   Phone Number

IN CASE OF EMERGENCY, PLEASE CONTACT THE FOLLOWING

Name   First Name   Last Name
Relationship to applicant   Type a label
Telephone #   Area Code   Phone Number

DISCLOSURE FORM TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES
Please Read Carefully Before Signing the Authorization Disclosure

In considering you as a contractor and if you are employed as a contractor, in considering you for subsequent promotion, assignment, reassignment retention, or discipline, Care Well of Charlotte, Inc. may request and rely upon one or more consumer reports or investigative consumer reportsabout you that we obtain from a consumer reporting agency. such as Intellicorp Records, Inc.

IntellCorp Records, Inc. can be contacted by mail at 3000 Aubum Dr. Suite 410; Beachwood, OH 44122; or phone: 1-888-946-8355; or website: www.intellicorp.net

For explanation purposes: A "Consumer Report" is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing. credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information criminal history reports, or driving records. An "Investigative Consumer Report is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers. neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information In the event an investigative consumer report is requested about you, youare entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act ("FCRA"

Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for contract purposes, we must have your written authorization Before we take adverse action on the basis, in whole or in part. of information in that report. you will be provided a copy of that report. the name, address and the telephone number of the consumer reporting agency and a summary of your rights under the FCRA. IAUTHORIZE CARE WELL OF CHARLOTTE. INC. to obtain and rely upon consumer reports or investigative consumer reports concerning me obtained from IntelliCorp Records, Inc.

By my signature below, authorize the Company to obtain any such reports and to share the information received with any person involvedin their decision about me.
I also consent to have any legally required notices sent electronically.
I do do notauthorize you to contact throughIntelliCorp Records Inc. my current employer for Employment and Reference Verifications. (Checking "I do' will authorize inquiries to the Human Resources Department and to any listed supervisors)
Printed Name
Applicant Signature

Clear
Date

MonthDayYear
Date
Parent or Legal Guardian Signature (for searches conducted on minors under the Age of 18)

Clear
Date

MonthDayYear
Date

CARE PROVIDER APPLICATON
Contractor Personal Data
Name

First NameMiddle NameLast Name
Current Address, City, State, Zip code
Dates Lived Here

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Other Names Used (including maiden name)
Years Used
Social Security Number #
Driver's License #
DL State
Email address (may be used for official correspondence) Email
I have the right to make a request to Intellicorp Records, Inc. upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information and the recipients of any reports on me which IntelliCorp Records, Inc. has previously furnished within the two-year period preceding my request. I certify that all elements of the personal data I have provided are true, accurate and complete.
Printed Name
Applicant Signature

Clear
Date

MonthDayYear
Date

Should be Empty:

	Yes	No	Don't Know
1. Do you have close contact with anyone who has tuberculosis?
2. Do you have any of the following conditions
a) History of TB
b) HIV Infection
c) Diabetes mellitus
d) High doses of Steroids/Immunosuppressive Therapy
e) Chronic Renal Failure
f) Leukemia/lymphoma
g) Severely underweight
3. Close contact with anyone who has arrived within 5 years from Africa, Asia, Latin America or Middle East
4. Close contact with anyone who is:
a) HIV positive
b) Homeless
c) An IV drug user
d) A migrant worker
e) Employed by or resides at a correctional facility, homeless shelter, long term facility

CARE PROVIDER APPLICATON

DISCLOSURE FORM TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES

CARE PROVIDER APPLICATON