Employment Appilcation

Gablink Home Health Care

Employment Application
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
Applicant Full Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Date Of Birth *

MonthDayYear
D.O.B.
Are You at Least 18 Years Old?*

YesNo
Do You Have a Reliable Means of Transportation?*

YesNo
Are You Authorized to Work in The U.S.?*

YesNo
What positions will you be applying for?*

Full-TimePart-TimePer Diem
Salary Requirements
Which Position Will You Be Applying For?*

CaregiverRN (PRN)LVN (PRN)CNAAdministrationPsych Tech
Schedule Availability (Select all that apply)*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
List professional licenses you possess. Indicate type of license number and state.*
Earliest Start Date*

MonthDayYear
Upload a front/back copy of your most recent drivers license.*

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Upload a front/back copy of your social security.*

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Educational History
Levels of education completed (select all that apply)*

GEDHigh SchoolBachelorsMastersAssociates
List the city/state of all education completed, the graduation year, and the degree type.*
List professional licenses you possess. Indicate type of license, number and state:*
List any memberships in professional organizations honors or activities which you feel would enhance your application excluding those that would indicate race color religion sex national origin disability status protected veteran status or any other characteristic protected by law.
List Languages Spoken Other Than English*
List Other Skills Applicable to The Position For Which You are Applying Including Computer Experience, Typing Speed, etc.
Work History
Company Name*
Supervisor's Name
Phone Number*
Please enter a valid phone number.
Do we have permission to contact previous supervisor?*

YesNo
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Job Responsibilities
Reason For Leaving
Company Name*
Supervisor's Name
Phone Number*
Please enter a valid phone number.
Do we have permission to contact previous supervisor?*

YesNo
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Job Responsibilities
Reason For Leaving
Company Name*
Supervisor's Name
Phone Number*
Do We Have Permission to Contact Previous Supervisor(s)?*

YesNo
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Job Responsibilities
Reason For Leaving
Upload a Copy of Your Most Recent Resume.

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Emergency Contact*
Relationship*
Phone*
Address
Out of state contact if possible
Relationship
Phone
Address
Please review and sign In making application for employment:

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the Agency or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the Agency or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand and agree that if I am offered employment by the Agency, my employment will be for no definite term and that either I, or the Agency will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the Agency.
I understand, if I have direct patient contact that the Agency will perform a background check, including criminal history check, OIG exclusion list check (if applicable), and any additional checks as required by accrediting body standards or State Regulations. I further understand, if I am an unlicensed person, the Agency will perform a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Health and Human Services (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All HHS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable. I understand that a refusal to authorize the criminal background check may result in adverse employment action, such as rejection of the application or termination of employment.

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
Applicant Signature

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Date

MonthDayYear
Date
Signature

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TB FACT SHEET/RISK AND SYMPTOM SCREEN

Tuberculosis (TB)
Mycobacterium Tuberculosis is transmitted by air, carried in droplets that are created when a person with respiratory TB coughs, sneezes or shouts. TB Infection occurs when someone inhales the droplet particles containing the Mycobacterium. A person may have no symptoms, but still have latent TB infection (LTBI) and may develop TB disease at some point in their lives. TB skin tests may become positive in 2 to 12 weeks after the exposure.
Which high risk group, if any, do you belong to? (check all that apply)

Low income/medically under served populationsResidents or employees of congregate living facilities such as homeless shelters, long-term care facilities and correctional facilitiesInfants, children or adolescents who are exposed to adults in high-risk categoriesForeign-born persons recently arrived (within 5 years) from areas with a high incidence of TB, such as Asia, Africa, Eastern Europe, Latin America and Russia, or those who frequently travel to areas with a high incidence of TBClose contacts with individuals with pulmonary TB persons who inject illicit drugs or other locally identified high-risk substance users (e.g., crack cocaine users)Individuals with HIV infection, silicosis, diabetes, chronic renal failure, and those more than 10% below normal body weight, hematologic disorders (e.g., leukemias and lymphomas), other specific malignancies (e.g., carcinoma of the head or neck),Those receiving some medical treatments that may increase risks, such as prolonged corticosteroid use, or other immunosuppressive treatments, bone marrow or organ transplant, intestinal bypass or gastrectomyPersons with a history of untreated or inadequately treated TB disease
Signs and Symptoms of TB (check any symptoms you may be expierencing)
I understand if I am experiencing any of the above symptoms, followup will be required. I understand if I have any of the above symptoms at any time in the future, I am to report to management immediately and follow-up will be required at that time.
Signature

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Date

MonthDayYear
Date
Employee Name

First NameLast Name
Applicant Signature

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Date

MonthDayYear
Date
For Nurses Only
Upload a clear picture of your valid liscence/certification(s)

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Should be Empty:

Gablink Home Health Care

Educational History

Work History

TB FACT SHEET/RISK AND SYMPTOM SCREEN

For Nurses Only