1a | HCIS Personnel – Student Please enable JavaScript in your browser to complete this form.General - Step 1 of 10**IMPORTANT**Please have these items handy and ready, so the onboarding process is fast and easy.For all applicants Application/Resume License Copy/Verification Diploma/Degree or Transcripts Social Security Card Agency Form For clinic staff and interns ONLY CPR Card Driver's License Auto Insurance TB Clearance Health Screening Application For ServicesAll prospective staff will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential. This applies to: Volunteers, Contractual, Consultants, or Any Other Type of Contracted/Agreement Individual. Name *FirstMiddleLastDate *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome/Cell Phone *Business PhoneSocial Security #Emergency Contact Name *Emergency Contact Phone *NextHave you ever applied for employment or volunteered with this agency? *YesNoHow many hours a week are you available to work? *Are you legally eligible for employment in the United States? *YesNoHow did you learn of our organization? *Newspaper AdAgency RepresentativeOtherIf other, please indicate: *Are you willing to work:EveningsWeekendsPosition applying for: *StudentM.A.LVNRNTherapist (specify below)NPPAMDPlease specify therapy specialty (if applicable) *Are you currently employed? *YesNoDo you have reliable transportation? *YesNoBackNextProfessional ReferencesPersons who can furnish information about job performance 1. Name *Telephone *Fax2. Name *Telephone *Fax3. Name *Telephone *FaxWas your last name different from your present name during the above listed jobs? *YesNoIf yes, what was your name? *BackNextHave you been convicted of a crime in the past 5 years, barring employment in a Health Facility and Community Support Agency? *YesNoConviction will not necessarily disqualify an applicant from employment or volunteering. If yes, describe in full: *Are you capable of performing the job outlined in the job description? *YesNoIf no, which job requirement are you not able to meet? *BackNextAcceptance Statement I have read, understood, and agreed to the terms specified in this job description for the position I presently hold. A copy of this job description has been given to me. I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy. Name *FirstMiddleLastDate *Signature * Clear Signature Date *BackNextConfidentiality and Non-Competition Agreement The Agency requires that the staff avoid disclosure of confidential information to anyone outside the Agency and refrain from engaging in unfair competition. The Staff agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding staff, clients, and the Agency business. The Staff will have access to information not generally made available to the public, such as the identity of clients, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purposes other than for the Agency’s own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to agency administration and/or projects, or outside investigations of the Agency. The Staff is Prohibited from disclosing any defaming information regarding Agency personal and/or personnel incidents related to any violations of the personnel policies. During the course of service and for a twelve-month period thereafter, the Staff is prohibited from engaging in any of the following: induce any volunteers or staff of the agency to resign, encourage any client or entity to discontinue any relationship with the Agency, solicit any client of the Agency (current and within the past twelve month period), enter into competitive employment or seek to provide competitive services within twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source. Upon termination of services or at the request of the Agency, the staff is required to return all of the Agency’s property, including keys, client records, forms, manuals, beeper, etc. to the Agency and will not retain copies. Failure to return a key will result in a $25.00 charge, and failure to return a beeper will result in a $50.00 charge deducted from the paycheck, or billed to you if you are a volunteer. Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, costs of replacing and training staff improperly solicited for competitive employment, etc., suffered by the Agency. You will be required to reimburse the Agency for all legal fees, costs, and other expenses. This agreement is in effect during the Staff’s service and for twelve months thereafter. It does not modify the right of Staff to resign at any time of the Agency to terminate services without prior cause, notice, or liability and does not modify any other Agency policy. Signature * Clear Signature Date *BackNextPolicies and Procedures I understand that copies of policy and procedure manuals are available and it is my responsibility to read, understand, and conform to all applicable Agency policies, including personnel policies. It is also my responsibility to comply with periodic changes and revisions as staff, consult, contractor, or volunteer. I have read the Agency’s Policies and Procedures on Abuse, Neglect, and Exploitation and agree to comply with and be bound by the Policy. I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its representatives, nor is it an expression of my terms of agreement. I affirm that I have auto insurance coverage as required by this state and the Agency, and I agree to keep it fully in force on any vehicle I use during the conduction of Agency business during the term of my agreement. The Agency has the right to request proof of insurance at any time during the term of the agreement, and I am required to follow all Agency requirements and state and local laws. I understand that only the Agency has the authority to admit clients and will supervise with appropriate personnel all services provided. As a Provider, I will carry out the plan of treatment, submit time sheets, clinical and progress notes, and EHR as appropriate, and, at a minimum, on a daily basis. I will participate in developing and reviewing plans of care, periodic client evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend required staff meetings and in-service training. Providers are required to have 12-hour incentive training annually. I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided even if I am a volunteer staff. I understand all information, both written and verbal, regarding client and staff health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease; testing; results or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, and drug or alcohol abuse is protected under specific law. All information in connection with the examination, care, or provision of services to any client will not be disclosed without the individual's written consent, except as may be necessary to provide services as required by law. Information may be used in statistical or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of client/staff confidentiality is subject to civil and criminal penalties. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will, even if I am a Volunteer staff. Signature * Clear Signature Date *BackNextTB Targeted Medical QuestionnaireTo be completed by the provider: *Print nameDate *Have you ever had a positive TB skin test or a history of TB infection? *Select oneYesNoHave you ever had the BCG vaccine? *Select oneYesNoDo you have prolonged or recurrent fever? *Select oneYesNoHave you recently lost weight? *Select oneYesNoDo you have a chronic cough? *Select oneYesNoDo you cough up blood? *Select oneYesNoDo you sweat at night? *Select oneYesNoDo you have any of the following risk factors that may substantially increase the risk of tuberculosis?Silicosis (Lung Disease)GastrectomyIntestinal BypassWeight 10% or more below ideal body weight?Chronic Renal DiseaseDiabetes MellitusProlonged high-dose corticosteroid therapy or other Immunosuppressive therapyHematologic Disorder l.e. Leukemia or lymphomaExposure to HIV or AIDSOther malignanciesSignature * Clear Signature Date *BackNextWelcome! This Agency requires adherence to the following Standards and Procedures: 1. All persons are expected to dress in a manner appropriate to the healthcare environment or as directed by the patient/client/family. This includes personal hygiene, jewelry, hair, and makeup. 2. Please do not smoke in the presence of a patient/client. 3. Always wear your ID badge. This must be easily visible on your uniform. Licensed personnel must always carry their current license and CPR card while on assignment or on any campus. 4. You are expected to arrive on time for all assignments that you accepted. However, if an emergency or any situation should cause you to be five minutes late or more, or to be totally absent from the assignment, you must notify the Agency immediately. PLEASE DO NOT CALL YOUR PATIENT DIRECTLY. You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment. A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION UNLESS YOU CAN PROVE YOU HAD AN EMERGENCY! 5. If you have any problem, incident, or accident on the job, do not discuss it with the patient/client, but call the Agency immediately at any campus or home visit. 6. If the patient/client asks you to stay longer than your assignment or to leave earlier, you must call the Agency first for approval. 7. Paraprofessional personnel (i.e. Aides) hereby acknowledge that they WILL NOT, UNDER ANY CONDITION, DISPENSE, OR ADMINISTER ANY MEDICATION. Initial *8. UNDER NO CIRCUMSTANCES are you to ask for, or accept any money from your patient/client, take home property that belongs to the patient/client, or remove any items from any school campus or client's home. 9. There shall not be any involvement with the patient/client’s financial affairs (i.e., check writing) 10. You are expected to honor the confidentiality of any patient-client information which is obtained in the regular course of your service. 11. No personal telephone calls should be made or received by you while on assignment. 12. Please do not discuss your or any personal affairs with the patient/client/family. 13. As a representative of this Agency, you are not authorized to accept any direct employment that may be offered to you by your patient/client/family. If you are requested to do so, please have the patient/client contact us. 14. It is imperative that all signed notes and documents, including Daily Logs, be filled out properly and returned to the office as per our schedule and entered into EHR. If the patient/client is unable to sign your note, a family member or responsible party may sign. 15. During the course of service, this Agency’s proprietary materials (i.e., forms and medical records) will be used only in connection with your service and will not be disclosed to anyone without authorization from the agency. 16. Never leave your patient/client unattended. Report all incidents on campus immediately. Dial 911 only in imminent occurrences (life or death). Signature * Clear Signature Date *BackNextDefinition Property rights of an owner of proprietary information that may be protected under the law. In contracting, this term refers to the data belonging to the contractor, and may include financial information, intellectual property (concepts, designs, techniques), technical documentation, artwork, and the like. I, _____________________________, employee/contractor at Health Care Integrated Services, understand and will comply with the Data Security Policy. At no time will I remove, copy, falsify, alter, or destroy any documentation of Health Care Integrated Services both paper and/or electronic copies. I understand that if I do so, it will result in a misdemeanor and/or criminal charges being filed against me. Name *Date *Signature * Clear Signature Date *Submit
