Clone of Application for Employment

Application for Employment

Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date Available to Start

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you legally eligible to work in the U.S.?
Have you ever worked for this employer?
If yes, write start and end dates
Are you willing to consent to a background check?
Have you ever been convicted of a felony?
If yes, please explain

Education:
High School:
City / State
Graduated?
College:
City / State
Graduated?
If yes, type of degree:

Previous Employment:
Employer 1:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Starting Pay:
Job Title:
Dates of Employment:
Job Responsibilities:
Reason for leaving:
Employer 2:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Starting Pay:
Job Title:
Dates of Employment:
Job Responsibilities:
Reason for leaving:

Personal References:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:

Applicant Certification, Authorization, and Equal Opportunity Statement

MMJ Home Care Solutions, Inc. is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all applicants and employees and do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other protected status under applicable federal, state, or local laws.

I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may result in the rejection of my application or termination of employment if discovered at a later date.

I understand that submitting this application does not constitute a contract or guarantee of employment. If hired, I understand that my employment will be at-will, meaning that either I or the company may terminate the employment relationship at any time, with or without cause or notice, as permitted by law.

I authorize MMJ Home Care Solutions, Inc. to verify the information provided in this application and to conduct lawful background checks, reference checks, and employment verification as necessary to evaluate my qualifications for employment.

By signing below, I acknowledge that I have read and understand the statements above.
Signature:

MMJ Home Care Solutions, Inc. Hepatitis B Vaccine Declination Form

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection.

I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Signature
Print Full Name

MMJ Home Care Solutions, Inc. Authorization to Contact References
I hereby authorize MMJ Home Care Solutions, Inc. to contact the references listed in my application, as well as previous employers, supervisors, and other individuals who may have knowledge of my work history, qualifications, and character.

I authorize these individuals and organizations to provide information concerning my previous employment, job performance, professional conduct, and qualifications for employment.

I release MMJ Home Care Solutions, Inc., its representatives, and all individuals or organizations providing information from any liability arising from the exchange of such information for the purpose of evaluating my application for employment.

I understand that this authorization will remain valid for the duration of the hiring process.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

MMJ Home Care Solutions, Inc. Background Check Disclosure and Authorization
DISCLOSURE REGARDING BACKGROUND INVESTIGATION MMJ Home Care Solutions, Inc. may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report,” which may include information about your character, general reputation, personal characteristics, criminal history, and employment history. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment for employment-related purposes as permitted by law.

AUTHORIZATION I authorize MMJ Home Care Solutions, Inc. to obtain consumer reports and/or investigative consumer reports about me for employment purposes. I understand that these reports may include criminal background information, verification of employment, reference checks, and other information relevant to my qualifications for employment. I authorize all persons, schools, employers, law enforcement authorities, and other organizations to release any information requested by the consumer reporting agency or MMJ Home Care Solutions, Inc. in connection with this investigation. I understand that my employment may be contingent upon satisfactory completion of the background screening.
Full Name:

FirstLast
Social Security Number:
Date of birth:
Driver's License Number:
Issuing State:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com

Direct Support Professional Description
MMJ Home Care Solutions, Inc.

DIRECT SUPPORT PROFESSIONAL (DSP)
Department: Direct Care Services
Reports To: Director of Training & Scheduling / Assigned Supervisor
Employment Status: Full-Time / Part-Time / PRN

Position Summary:

The Direct Support Professional (DSP) provides individualized, person-centered support to individuals receiving services through MMJ Home Care Solutions, Inc. The DSP assists individuals in maintaining independence, developing and strengthening daily living skills, participating in their communities, achieving personal goals, and maintaining their health, safety, dignity, and quality of life.

The DSP works directly with individuals in their homes and community settings and follows each individual’s Person-Centered Plan (PCP), Individual Support Plan (ISP), service plan, care plan, and applicable MMJ policies and procedures.

The DSP is expected to build respectful and professional relationships with individuals served while promoting choice, independence, self-determination, dignity, privacy, and community inclusion.

This position requires sound judgment, reliability, professionalism, strong communication skills, and the ability to recognize and appropriately respond to changes in an individual’s physical, emotional, behavioral, or environmental condition.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Person-Centered Support

• Provide services and supports according to the individual’s authorized service plan and identified needs.
• Encourage individuals to make choices regarding their daily routines, activities, goals, and personal preferences.
• Promote independence rather than creating unnecessary dependence on staff.
• Assist individuals in identifying and working toward personal goals.
• Respect each individual’s rights, preferences, culture, values, privacy, and dignity.
• Maintain appropriate professional boundaries at all times.
• Encourage self-advocacy and participation in decisions affecting the individual’s life.

2. Activities of Daily Living and Independent Living Skills

Provide assistance, prompting, cueing, supervision, or hands-on support as authorized and appropriate, including:

•Personal hygiene and grooming
•Dressing and clothing selection
•Toileting
•Bathing
•Oral hygiene
•Eating and meal preparation
•Household organization and basic housekeeping
•Laundry
•Shopping and grocery planning
•Money-management and budgeting skills, when included in the individual’s service plan
•Medication reminders or medication assistance when permitted, authorized, and properly trained
•Mobility and transfers, when within the employee’s training and assigned responsibilities
•Development of independent living skills
Other daily living activities identified in the individual’s person-centered plan

3. Skill Development

• Teach, model, prompt, and reinforce skills that promote independence.
• Break tasks into manageable steps when appropriate.
• Encourage individuals to practice skills rather than completing tasks unnecessarily for them.
• Document progress toward identified goals.
• Reinforce positive behaviors and successful skill development.
• Communicate barriers or changes in progress to the appropriate supervisor.

4. Community Integration and Inclusion

• Support individuals in participating in meaningful community activities.
• Assist individuals with accessing community resources, recreational activities, appointments, educational opportunities, employment-related activities, and social events when authorized.
• Encourage development of appropriate social relationships and community connections.
• Support individuals in developing greater independence within their community.
• Provide transportation or accompany individuals in transportation arrangements when authorized and consistent with MMJ policy.

5. Health, Safety, and Wellness

• Monitor and report significant changes in an individual’s physical or emotional condition.
• Maintain a safe and supportive environment.
• Follow established emergency and safety procedures.
• Recognize potential health, safety, behavioral, or environmental risks.
• Follow approved crisis prevention and intervention procedures.
• Immediately report injuries, incidents, accidents, medication concerns, changes in condition, or other significant events according to MMJ policy.
• Follow infection-control and universal precaution practices as applicable.
• Assist individuals in maintaining healthy routines and wellness practices.

6. Behavioral and Crisis Support

• Implement approved interventions and strategies identified in the individual’s service plan.
• Recognize changes in behavior or environmental circumstances that may indicate an emerging crisis.
• Use de-escalation and crisis-prevention strategies for which the employee has been trained.
• Maintain a calm, respectful, and professional approach during challenging situations.
• Never use unauthorized physical, verbal, emotional, or punitive interventions.
• Report behavioral incidents and significant changes promptly to the appropriate supervisor.

7. Documentation and Service Records

• Complete all required service documentation accurately, objectively, and within required timeframes.
• Document services provided, activities completed, progress toward goals, significant observations, incidents, and changes in condition as required.
• Maintain accurate electronic visit verification (EVV) and/or electronic documentation when applicable.
• Never falsify, backdate, alter, or knowingly misrepresent service documentation.
• Ensure documentation reflects the services actually provided during the authorized service period.
• Maintain confidentiality of all individual records and information.

8. Rights, Confidentiality, and Abuse Prevention

The DSP is responsible for protecting the rights and welfare of every individual served.

Employees must:

-Maintain HIPAA and other applicable confidentiality requirements.
-Protect individual privacy.
-Respect the individual’s right to make choices.
-Never discriminate against an individual.
-Never engage in abuse, neglect, exploitation, intimidation, harassment, or retaliation.
-Report suspected abuse, neglect, exploitation, or other violations immediately through the appropriate reporting channels.
-Maintain professional boundaries with individuals and their families.
-Never borrow money from, lend money to, or engage in inappropriate financial arrangements with individuals served.

9. Communication and Team Collaboration

• Maintain professional communication with supervisors, care coordinators, families/support systems, and other members of the individual’s support team as permitted.
• Communicate changes, concerns, incidents, and barriers promptly.
• Participate in required staff meetings, supervision, training, and care-plan-related activities.
• Follow instructions provided by authorized supervisory personnel.
• Maintain respectful communication with coworkers and individuals served.

10. Compliance and Professional Conduct

• Follow applicable federal, state, and local laws and regulations.
• Follow applicable NC Medicaid requirements and program-specific service requirements.
• Maintain required certifications, screenings, and training.
• Protect the integrity of MMJ’s services and reputation.
• Report suspected fraud, waste, abuse, or compliance violations through appropriate channels.
• Remain awake, alert, attentive, and engaged throughout assigned working hours.
• Perform other duties as assigned within the scope of the position and employee’s training.

REQUIRED QUALIFICATIONS

• Must be at least 18 years of age.
• High school diploma or GED preferred/required according to program requirements.
• Previous experience working with individuals with disabilities, older adults, behavioral health needs, or other populations requiring direct support is preferred.
• Must successfully complete required background checks and screenings.
• Must successfully complete required onboarding and competency-based training.
• Must demonstrate the ability to communicate effectively in verbal and written form.
• Must demonstrate professionalism, reliability, patience, compassion, and sound judgment.
• Must be able to maintain confidentiality.
• Must be able to work independently while following an individual’s authorized service plan.
• Must be willing to work varying schedules, including evenings, weekends, holidays, and/or overnight shifts when assigned.
• Valid driver’s license and reliable transportation may be required for positions involving community transportation.

PHYSICAL REQUIREMENTS

The DSP must be physically capable of performing the essential functions of the position, with or without reasonable accommodation.

Depending upon the individual’s authorized needs, duties may include:

- Standing and walking for extended periods
- Bending, stooping, reaching, kneeling, and crouching
- Assisting with mobility
- Assisting with transfers when trained and authorized
- Providing personal care
- Lifting or moving items within applicable safety guidelines
- Responding appropriately to emergencies
- Maintaining adequate visual, auditory, and cognitive awareness to safely perform assigned duties

CONFIDENTIALITY

The DSP is required to maintain strict confidentiality regarding all individual, family, employee, business, medical, financial, and organizational information obtained during employment.

Unauthorized disclosure of confidential information may result in disciplinary action, up to and including termination of employment.

MANDATED REPORTING

DSPs are responsible for immediately reporting suspected abuse, neglect, exploitation, or other circumstances that may place an individual at risk, in accordance with applicable law, program requirements, and MMJ policies.

Job Description Acknowledgment

I acknowledge that I have received, read, and understand the job description for the position of Direct Support Professional (DSP) with MMJ Home Care Solutions, Inc. I understand that I will perform my duties under the direction, instruction, and supervision of the Service Supervisor and in accordance with the client’s plan of care and agency policies.

I understand that this job description is not intended to be a complete list of all responsibilities and that additional duties may be assigned as necessary to meet the needs of clients and the agency.
Full Name

First Last
Signature

Identification Requirement

Please upload two (2) forms of identification as part of your application.

Required documents include:

• A clear photo of the front and back of your Driver’s License or State Identification Card

• A clear photo of your Social Security Card

Please upload all professional documentation related to this position, including applicable certifications, training certificates, licenses, credentials, or other relevant documentation.

All images must be clear, legible, and show the entire document. Blurry, cropped, or incomplete images may delay the review of your application.
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Application for Employment

Education:

Previous Employment:

Personal References:

MMJ Home Care Solutions, Inc. Authorization to Contact References

MMJ Home Care Solutions, Inc. Background Check Disclosure and Authorization

Direct Support Professional Description