Date Application Completed
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MM
DD
YYYY
Name
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First Name
Last Name
Email
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Home Phone
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(###)
###
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Pager/ Cellular Number
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(###)
###
####
Other Number
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(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Length of Residence
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Position Applying For:
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How were you referred to us?
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Date available for worK?
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Anticipated wage?
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Please check the specialty area(s) that best match your experience/ education and interests:
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Work Status
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Please indicate your availability or interests
Shifts Available
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Please indicate your availability or interests
Days Available
Please select all days of availability
Select your highest level of education completed:
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Some High School
High School
GED
Some College
Associates Degree
Bachelors Degree
Masters Degree
Doctorate
DODD Initial DSP Training Expiration Date
MM
DD
YYYY
DODD Annual DSP Training Expiration Date
MM
DD
YYYY
Medication Administration (Med 1, Med 2, Med 3) Expiration Date
MM
DD
YYYY
CPR Expiration Date
MM
DD
YYYY
Drivers License Expiration Date
MM
DD
YYYY
Any restrictions on Drivers License?
Have you ever been convicted of a felony or misdemeanor crime?
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This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.
If yes, state the basis for each conviction and the date of each conviction.
Have you ever been employed by this agency or one of its subsidaries?
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Yes
No
If yes, give locations and dates
Work History
Please list the Company Name, Employment Dates, Company Address (including city, state, and zip), Describe your responsibilities and duties, Your Compensation, Supervisor's Name, Supervisor's Telephone Number, Can we contact them?, and your Reason for Leaving
Work History
Please list the Company Name, Employment Dates, Company Address (including city, state, and zip), Describe your responsibilities and duties, Your Compensation, Supervisor's Name, Supervisor's Telephone Number, Can we contact them?, and your Reason for Leaving
Work History
Please list the Company Name, Employment Dates, Company Address (including city, state, and zip), Describe your responsibilities and duties, Your Compensation, Supervisor's Name, Supervisor's Telephone Number, Can we contact them?, and your Reason for Leaving
Work History
Please list the Company Name, Employment Dates, Company Address (including city, state, and zip), Describe your responsibilities and duties, Your Compensation, Supervisor's Name, Supervisor's Telephone Number, Can we contact them?, and your Reason for Leaving
In accordance with Title VI of the Civil Rights Act of 1964 and its implementing regulation, Good Samaritan Home Health Care is an EQUAL OPPORTUNITY EMPLOYER and WILL NOTDISCRIMINATE AGAINST RACE, COLOR, SEX, CREED, NATIONAL ORIGIN ORCOMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI. In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation Good Samaritan Home Health Care WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP. In accordance with the Age Discrimination Act of 1975 and its implementing regulation Good Samaritan Home Health Care WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision of services, unless age is a factor necessary to the normal operation or the achievement of any statutory objective. In accordance with the Americans with Disabilities Act of 1992 (42 USC §12101) and it’s implementing regulations, (private employers with more than 25 agency personnel), Good Samaritan Home Health Care WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment that substantially limits a major life activity, or for which there is a record of impairment or which causes the individual to be regarded as impaired.
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This information that I have given is true and accurate to the best of my knowledge. (Sign your name below and list the date)
ADDENDUM TO EMPLOYMENT APPLICATION: The Ohio Administrative Code (5123:2-.05) requires that home health companies ascertain from applicants for employment that have not been convicted or plead guilty to the offenses listed below. Your signature below indicates that you have not committed nor plead guilty of: Aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, failing to provide for a functionally impaired person, aggravated menacing, patient abuse and neglect, kidnapping, abducting, criminal child enticement, rape, sexual battery, unlawful sexual conduct, with a minor, gross sexual imposition, importuning, voyeurism, public indecency, compelling prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually oriented materials involving a minor, illegal use of a minor in nudity- oriented material or performance, aggravated robbery, robbery, aggravated burglary, burglary, unlawful abortion, endangering children, contributing to the unruliness or delinquency of a child, domestic violence, carrying a concealed weapon, having weapons while under disability, improperly discharging a fire arm at or into a habitation of school, corrupting others with drugs, trafficking in drugs, illegal manufacture of drugs or cultivation of marijuana, funding of drugs or marijuana trafficking, illegal administration or distribution of anabolic steroids, placing harmful objects in food or confection, child stealing, possession of drugs, felonious sexual penetration.
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I (Applicant) have read the contents of this addendum to
my application for employment with Good Samaritan Home Health Care. I also understand that I
am required by law to notify Good Samaritan Home Health Care, within 14 (fourteen) days if I
receive formal charges, convictions, or make a guilty plea to any one of the disqualifying offenses listed above. (Sign below and give date of signing)
