Legacy Home Healthcare Agency Inc

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

Applicant Name:
Have you ever used any other name or aliases? Yes    No
If yes, please list:
Physical Address:
Mailing Address:
Prof. Lic. #/ Exp. Date:  /   Social Security No.
Phone Number: Email Address:
Are you at least 18 years old?    Yes     No Were you referred for this position?    Yes     No
Are you authorized to work in the US?    Yes     No If yes, by whom were you referred?

EMPLOYMENT DESIRED

Position Applying for: Date Available Salary Desired:
Are you presently employed?    Yes     No Have you ever applied with this company before?    Yes     No
  If yes, when? What position?

EDUCATIONAL HISTORY

Type of School Name & Location of School(s) Circle Last Year Attended Graduated
(Yes or No)
Major/Degree
High School  9     10     11     12  Yes     No
College or University  1     2     3     4  Yes     No
Vocational / Technical School or Other From:
to:
 Yes     No

GENERAL INFORMATION

List all languages proficiencies:

List professional certifications or licenses you possess. Indicate type of license, number, and state.

List other skills applicable to the position for which you are applying: (For example: computer experience, typing speed, etc.)

Can you safely and effectively carry out the essential duties of the job, with or whitout accommodation?    Yes     No

Please explain:
Do you have adequate means of transportation?    Yes     No Comments:

Have you been convicted of a crime or felony within the past 7 years?    Yes     No    If Yes, give date, place, and nature of each such conviction.

PERSONAL REFERENCES

Name Phone Number Relationship

WORK HISTORY

Company Name
Complete Address include City/State/Zip
Phone Number
Supervisor
Date Started:

Date Ended:
 Full Time
 Part Time
 Per Visit
Position:

Salary:
Reason For leaving:
OK to Contact Supervisor?
 Yes     No
Company Name
Complete Address include City/State/Zip
Phone Number
Supervisor
Date Started:

Date Ended:
 Full Time
 Part Time
 Per Visit
Position:

Salary:
Reason For leaving:
OK to Contact Supervisor?
 Yes     No
Company Name
Complete Address include City/State/Zip
Phone Number
Supervisor
Date Started:

Date Ended:
 Full Time
 Part Time
 Per Visit
Position:

Salary:
Reason For leaving:
OK to Contact Supervisor?
 Yes     No

CONVICTIONS BARRING EMPLOYMENT
(Health and Safety Code §250.006)

  1. A person form whorm the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed below:
Abandoning or endangering a child Criminal homicide Medicaid Fraud
Aggravated assault Cruelty to livestock animals Money Laundering
Aggravated robbery Cruelty to non-livestock animals Obstruction or retaliation
Aggravated sexual assault Deadly conduct Online solicitation of a minor
Aggravated Promotion of Prostitution Improper photography or visual recording Possession or Promotion of Child Pornography
Agreement to abduct from custody Improper relationship between educator and student Promotion of Prostitution
Aiding suicide Indecency with a child Robbery
Arson Injury to a child, elderly or disabled individual Sale or purchase of a child
Continuous sexual abuse of young child or children Indecent exposure Sexual assault
Compelling Prostitution Kidnapping and unlawful restraint Terroristic Threat
Criminal Attempt of any offense listed as a bar Texas Controlled Substance Act: manufacture, delivery, intent to distribute or possess or produce, distribution to a minor, illegal expenditure or investment, transfer or receipt of chemical laboratory apparatus, punishable as a felony

* The same bar to employment applies to a conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing the elements that are substantially similar to the elements of an offense listed above; or an offense the Agency determines to be contraindicated to employment with the consumers the Agency serves.

  1. A person may not be employed in a position in which the duties involve direct contact with a patient in a facility before the fifth anniversary of the date the person in convicted of:
Assault punishable as a Class A misdemeanor or felony Misapplication of fiduciary property or property of a financial institution punishable as a Class A misdemeanor or felony Securing execution of a document by deception punishable as a Class A misdemeanor or felony
Burglary
Disorderly conduct False identification as a peace officer Theft punishable as a felony
  1. In addition to the prohibitions on employment prescribed in subsections (A) and (B), a nurse aide who is designated in the NAR or the EMR with a finding concerning abuse, neglect, or exploitation or mistreatment of a patient of an agency or a facility, or misappropriation of a patient’s property is not employable.

PLEASE READ CAREFULLY

Criminal History Checks, Nurse Aide Registry/Employee Misconduct Registry, US/Texas OIG Database:

The Texas Department of Human Services requires background checks on all non-licensed and licensed Home Health Care personnel.

The Agency will run a criminal history check, nurse aid registry, employee misconduct registry, and US/Texas OIG Database checks on all personnel. Employment is contingent upon the results of the investigation. If hired, the US/Texas OIG Database checks will be conducted on a monthlybasis, and the misconduct registry /nurse aid registry checks will be conducted annually. Employees will not be eligible to retain employmentif they do not clear all the required background checks.

Authorization:

I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and are made in good faith. I understand that any false or incomplete statement made herein may void this application and/or my result in temrination.

I authorize the Agency to make any reference checks and background checks relating to my employment. I also authorize all my prior employers to provide full details concerning my past employment and any pertinent information they may have, personal or otherwise, to the Agency. I release the company from all liability for any damage that may result from utilizing such information. I understand this aplication and all attachments are property of the Agency and that my employment is at will, which means either my employer r I can end the employment relationship at any time. I also understand and agree that no representative of this company has any authority to enterinto any agreement for employment for any specified period of time, or to make any agreements contrary to the foregoing, unless in writing and signed by an authorized company representative.

Assistance in Completing Hire Enrollment Forms Provided By:
 
 
Name of Applicant  Signature of Applicant  Date

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for emplyment with this Company depends solely on your qualifications.

Thank you for completing this application and for your interest in our business.