• Employment Application for Rooted ABA

    5302 S Florida Ave, Suite 202, Lakeland, FL 33813   Office:  863-937-8067   Fax:  863-607-6207    Website:  www.rootedaba.org 

  • Section 1: Personal Information

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  • Are you a citizen of the United States?*
  • Have you ever been convicted of a crime?*

  • Section 2: Hours and Service Area

  • Which position are you interested in applying for?*
  • Do you desire*
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  • Do you wish to be listed on our website?*

  • Section 3: Client Identifier Information

    Please provide any applicable information regarding certification and identification below

  • Section 4: Education and Training

  • Did you graduate?*
  • Did you graduate?
  • Did you graduate?
  • Completed

  • Section 5: References

    Please list 3 professional references
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  • Section 6: Previous Employment

    Please list your work experience for the past 5 years, beginning with most recent. If you were self-employed, give the firm name.
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  • Section 7: Disclosure Information

    If answering "YES" to any of the questions below, please provide an explanation in the space provided at the end of this section.
  • Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board?*
  • Has there been any challenge to your licensure or certification?*
  • Have any of your board certifications or eligibility ever been revoked?*
  • Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?*
  • Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicaid program, or in regard to other federal or state governmental health care plans or programs?*
  • Have you ever had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years?*
  • Have you ever been convicted of, pled guilty to, or pled no contest to any felony?*
  • In the past ten years have you been convicted of, pled guilty to, or pled no contest to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct?*
  • Do you use any chemical substances that would in any way impair or limit your ability to practice applied behavior analysis and perform the functions of your job with reasonable skill and safety?*
  • Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?*
  • Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable*

  • Section 8: Information Release, Disclaimer, and Signature

  • All employees require fingerprinting and background screening. In order for the stystem to be searched or a new screening initiated by our organization, you need give us permission, by returning the ACHA privcacy document below. This screening will only be initiated if you are selected to move forward with in-person interviews.

    When this process begins, we will contact you for the additional information required to initiate this Level 2 Fingerprinting and Background Check with the Department of Children and Family.

    Please review, sign, & upload this ACHA privacy document.  

    https://ahca.myflorida.com/MCHQ/Central_Services/Background_Screening/docs/Privacy_Policy.pdf

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  • In exchange for the consideration of my job application for Rooted ABA, I agree that: 


    Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Rooted ABA practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Rooted ABA, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the owner of Rooted ABA. Both the undersigned and Rooted ABA may end the employment relationship at any time, without specified notice or reason.   

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