HRA Employment Application

EMPLOYMENT DESIRED
What position are you applying for?*
What date can you start?*

MonthDayYear
Date
Hourly Rate/Salary desired*
Are you currently employed?*

YesNo
Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, explain.
Computer Skills (please describe)

REFERRAL SOURCE
How did you hear about us?*
Have you ever worked for this company before?*

YesNo
Explain:
Do you know anyone who works for our company?*

YesNo
If yes, who?

EDUCATION
High School
Number of years attended
Degree Received
Subjects Studied/Major
College / University
Number of years attended
Degree Received
Subjects Studied/Major
Trade, Business, or Correspondence School
Number of years attended
Degree Received
Subjects Studied/Major

References

Give the names of three persons not related to you, whom you have known at least three (3) years.
Name*
Contact Information (Address, Phone, Email)*
Company*
Years Acquainted*
Name*
Contact Information (Address, Phone, Email)*
Company*
Years Acquainted*
Name*
Contact Information (Address, Phone, Email)*
Company*
Years Acquainted*

Please mark that you have read and understand all:*

Equal Opportunity Employer – Helping Restore Ability is an equal opportunity employer. All applicants will be consideredregardless of race, color, religion, sex, national origin, age, marital or veteran status; medical condition, disability; or any other legallyprotected status. Equal access to the hiring process, services and employment is available to all persons. Applicants requiringaccommodations for the application and/or interview process should contact a representative of Helping Restore Ability’s HumanResources Department.Immigration Reform and Control Act – It is the policy of Helping Restore Ability to employ only those individuals who arelegally eligible for employment in the United States. The Immigration Reform and Control Act of 1986 requires that, should an offer ofemployment be extended, before you begin employment you will be required to submit to this agency certain documents for review andcopying which verify both your employment authorization and your identity. Copies of the documents you submit will be retained byHelping Restore Ability for the period of time prescribed by law. Also, before you begin employment you will be required to certify underpenalty of perjury that you are lawfully authorized for employment in the United States and the documents you have submitted to HelpingRestore Ability as evidence of your identity and employment authorization are genuine and relate to you. The certifications you sign andcopies of the documents you provide will be made available for inspections if requested by the United States Immigration andNaturalization services, the Department of Labor, the Office of Inspector General, and the Health and Human Services Commission.Drug Testing – Helping Restore Ability maintains a drug-free workplace with regard to possession, use, distribution and sale ofdrugs and alcohol. Helping Restore Ability may request a pre-employment drug test. In addition, Helping Restore Ability may performrandom drug testing on any employee.Workers Compensation - Helping Restore Ability is a non-subscriber to Workers Compensation Insurance.Criminal History Check - Helping Restore Ability performs Criminal History Checks on every applicant and all current employeesannually. Persons who have been convicted of certain Class “A” misdemeanors or felonies may be barred from employment (see“Convictions that are Automatic Bars to Employment” within this application for more information).At-Will Employment - Your employment with Helping Restore Ability is for an indefinite period of time and is subject totermination by you or Helping Restore Ability, with or without cause, with or without notice, and at any time.Previous Employer - I hereby authorize any and all prior employers to provide information concerning my employment withthem as may be requested.Education/Professional License Verification - I authorize the Registrar/Placement Office of any and all educationalinstitutions I have attended to release an official copy of my transcript and if available, faculty appraisals. I also authorize any and allappropriate licensing boards to release full information concerning my license history.Certification of True and Accurate Information - I certify that the information in my resume and throughout this application, including other related materials, is true, is complete and may be verified by Helping Restore Ability. I understand that consideration for employment and the continuation of subsequent employment depend on true, accurate and complete representation of these facts as stated or implied in all application-related materials. I authorize Helping Restore Ability to make inquiries regarding my education, work experience, references and criminal history/conviction. Should a position be offered, and later it is found that the information presented in this or any other application-related document is untrue, incomplete, or misrepresented; I understand and agree that Helping Restore Ability is relieved of all commitments, financial or otherwise pertinent to employment, and that am subject to immediate discharge without
Initials*

Clear

List all aliases and/or other married names (and dates they were used)*
Gender*

MaleFemale
Statement of Employability
By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check per TXH&SC 250.006. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. As required, I agree to a search of the Texas Health and Human Services Commission’s OIG List of Excluded Individual/Entities and the HHS - OIG Excluded Individuals/Entities Search Database prior to being hired and monthly thereafter. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253.

CRIMINAL HISTORY CHECK
I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check and that I may not have face-to-face patient/client contact until results are returned. I will be notified of results.

CONVICTIONS BARRING EMPLOYMENT.
(A) A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:

· An offense under Chapter 19, Penal Code (criminal homicide);
· An offense under Chapter 20, Penal Code (kidnaping, unlawful restraint, and
smuggling of persons);

· An offense under Section 21.02, Penal Code (continuous sexual abuse of a
young child or children) or Section 21.11, Penal Code (indecency with achild);

· An offense under Section 22.011, Penal Code (sexual assault);
· An offense under Section 22.02, Penal Code (aggravated assault);
· An offense under Section 22.04, Penal Code (injury to a child, elderly individual,
or disabled individual);

· An offense under Section 22.041, Penal Code (abandoning or endangering a child);
· An offense under Section 22.08, Penal Code (aiding suicide);
· An offense under Section 25.031, Penal Code (agreement to abduct from custody);

· An offense under Section 25.08,
· An offense under Section 28.02,
· An offense under Section 29.02,
· An offense under Section 29.03,
· An offense under Section 21.08,
· An offense under Section 21.12,
between educator and student);

· An offense under Section 21.15,
recording);

· An offense under Section 22.05,
· An offense under Section 22.021, Penal Code (aggravated sexual assault);
· An offense under Section 22.07, Penal Code (terroristic threat);
· An offense under Section 32.53 Penal Code (exploitation of a child, elderly
individual, or disabled individual);

· An offense under Section 33.021, Penal Code (online solicitation of a minor);
· An offense under Section 34.02, Penal Code (money laundering); Penal Code (sale or purchase of a child); Penal Code (arson); Penal Code (robbery); Penal Code (aggravated robbery); Penal Code (indecent exposure); Penal Code (improper relationship); Penal Code (improper photography or visual); Penal Code (deadly conduct);
· An offense under Section 35A.02, Penal Code (Medicaid fraud);

· An offense under Section 36.06, Penal Code (obstruction or retaliation);

· An offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to nonlivestock animals); or

· A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.

· An offense the Agency determines to be contraindicated to employment with the consumers the Agency serves.

(B) A person may not be employed in a position the duties of which involve direct contact with a patient/client in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of:

· An offense under Section 22.01, Penal Code (assault), that is punishable as a ClassA misdemeanor or as a felony);

· An offense under Section 30.02, Penal Code (burglary);

· An offense under Chapter 31, Penal Code (theft) that is punishable as a felony);

· An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or

· An offense under Section 32.46, Penal Code (securing execution of a document by deception) that is punishable as a Class A misdemeanor or a felony. An offense under Section 37.12, Penal Code (false identification as a peace officer; misrepresentation of property); or

· An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).

(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:

· Of an offense under Section 30.02, Penal Code (burglary); or

· Under the laws of another state, federal law, or the Uniform Code of Military

(D) Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code. For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with, Article 42A.111 Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.
I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this Agency regarding any criminal history will remain confidential.*

I Acknowledge
I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.*

I Certify

Applicant Release*

I hereby release from all liability the company, agency or person completing this form and authorize them to release all information regarding my employment with them. I also release the requesting agency from all liability for any damages from the disclosure of this information.
Please read carefully before signing.

Helping Restore Ability is an equal opportunity employer. Helping Restore Ability does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex(including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Helping Restore ability to hire me. If I am hired, I understand that either Helping Restore Ability or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Helping RestoreAbility has the authority to make any assurance to the contrary. I attest with my signature below that I have given to Helping Restore Ability true and complete information on this application. No requested information has been concealed. I authorize HelpingRestore Ability to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
Type a question*

I Acknowledge

Summary of Rights Under FCRA
The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). Most CRAs are credit bureaus that gather and sell information about you such as if you pay your bills on time or have filed bankruptcy – to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. 1781-1681u, at the Federal Trade Commission’s website (http;//www.ftc.gov). The FCRA gives you specific rights, as outlines below. You may have additional rights under the state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.
You must be told information if your file has been used against you. Anyone who uses information from a CRA to take action against you – such as denying an application for credit, insurance, or employment – must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.
You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You are also entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise a CRA may charge you up to eight dollars.
You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs-- to which it has provided the data--of any error.) The CRA must give you a written report of the investigation and a copy of your report if the investigation results in any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies itsaccuracy
5. You can dispute inaccurate items with the source of the information. If you tell anyone-- such as a creditor who reports tothe CRA--that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you have notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.

6. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old, ten years for bankruptcies.

7. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA--usually to consider an application with a creditor, insurer, employer, landlord, or other business.

8. Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA maynot report medical information about you to creditors, insurers, or employers without your permission.

9. You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed fromfuture lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.

10. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court. The FCRA gives several different federal agencies authority to enforce the FCRA:

Prefill*
Final Signature (This signature will be used in place of "I acknowledge" and "I Certify" answers previously within the document)*

Clear
Should be Empty:

HRA Employment Application

PERSONAL INFORMATION

EMPLOYMENT DESIRED

REFERRAL SOURCE

EDUCATION

Employment History

References

DPS Computerized Criminal History CH Verification (AGENCY COPY)

Criminal History/Background Information

Statement of Employability

Please read carefully before signing.

Summary of Rights Under FCRA