GARDENDALE HOSPICE, LLC APPLICATION FOR EMPLOYMENT
It is this facility’s policy to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, or disability

* = Required Information
Yes No
Yes No
Full Time Part Time
Pool Part Time per visit
Day Evening Night W/E
Yes No
Yes No
Yes No
EDUCATIONAL HISTORY
Type of School Name and Location of School Last Year Attended Graduated Degree
High School
9 10 11 12
College
1 2 3 4
College
1 2 3 4
Other

WORK HISTORY
ATTACH AN ADDITIONAL SHEET LISTING OTHER WORK EXPERIENCE PERTINENT TO THE POSITION FOR WHICH YOU ARE APPLYING IF THE SPACE BELOW IS SUFFICIENT:


Company Name Complete Address incl. City/State/Zip Phone Number Supervisor’s Name
Date Started Type of Business Reason for Leaving Ok to contact Supervisor
Yes No
Date Left Salary
Full Time Part Time Per Visit

WORK HISTORY
ATTACH AN ADDITIONAL SHEET LISTING OTHER WORK EXPERIENCE PERTINENT TO THE POSITION FOR WHICH YOU ARE APPLYING IF THE SPACE BELOW IS SUFFICIENT:


Company Name Complete Address incl. City/State/Zip Phone Number Supervisor’s Name
Date Started Type of Business Reason for Leaving Ok to contact Supervisor
Yes No
Date Left Salary
Full Time Part Time Per Visit

WORK HISTORY
ATTACH AN ADDITIONAL SHEET LISTING OTHER WORK EXPERIENCE PERTINENT TO THE POSITION FOR WHICH YOU ARE APPLYING IF THE SPACE BELOW IS SUFFICIENT:


Company Name Complete Address incl. City/State/Zip Phone Number Supervisor’s Name
Date Started Type of Business Reason for Leaving Ok to contact Supervisor
Yes No
Date Left Salary
Full Time Part Time Per Visit


PERSONAL REFERENCES

PLEASE REVIEW AND SIGN

IN MAKING APPLICATION FOR EMPLOYMENT:

  • I CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS TRUE AND COMPLETE FOR ALL PRACTICAL PURPOSES. IT MAY BE VERIFIED BY THE FACILITY OR ANY AFFILIATE. SHOULD A POSITION BE OFFERED AND LATER IT IS FOUND THAT INFORMATION IS SIGNIFICANTLY UNTRUE, INCOMPLETE, OR MISREPRESENTED, I UNDERSTAND AND AGREE THAT THE FACILITY OR ITS AFFILIATES ARE RELIEVED OF ALL COMMITMENTS, FINANCIAL OR OTHERWISE PERTINENT TO EMPLOYMENT, AND THAT I AM SUBJECT TO IMMEDIATE DISCHARGE WITHOUT RECOURSE.
  • I UNDERSTAND THAT AN INVESTIGATIVE REPORT MAY BE MADE BY A CONSUMER REPORTING AGENCY TO INCLUDE INFORMATION AS TO MY CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS, AND MODE OF LIVING, WHICHEVER MAY BE APPLICABLE. IF SUCH AN INVESTIGATIVE REPORT IS MADE, I UNDERSTAND THAT I WILL RECEIVE NOTICE THAT SUCH A REPORT HAS BEEN REQUESTED, AND THAT I WILL HAVE THE RIGHT TO MAKE A WRITTEN REQUEST FOR A COMPLETE AND ACCURATE DISCLOSURE OF ADDITIONAL INFORMATION CONCERNING THE NATURE AND SCOPE OF THE INVESTIGATION.
  • I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.
  • I UNDERSTAND, IF I HAVE DIRECT PATIENT CONTACT WITH PATIENT RECORDS, THAT THE AGENCY WILL PERFORM A CRIMINAL HISTORY CHECK PER FEDERAL REGULATION, AS WELL AS CHECK OF THE NURSE AID REGISTRY AND EMPLOYEE MISCONDUCT REGISTRY FOR UNLICENSED EMPLOYEES. I UNDERSTAND THAT: 1) THE PURPOSE OF THE EMPLOYEE MISCONDUCT REGISTRY IS TO ENSURE THAT UNLICENSED PERSONNEL WHO COMMIT ACTS OF ABUSE, NEGLECT, EXPLOITATION, MISAPPROPRIATION, OR MISCONDUCT AGAINST RESIDENTS AND CONSUMERS ARE DENIED EMPLOYMENT IN DADS-REGULATED FACILITES AND AGENCIES; 2) THE STATE OF TEXAS MAINTAINS A REGISTRY OF ALL NURSE AIDES WHO ARE CERTIFIED TO PROVIDE SERVICES IN NURSING FACILITIES AND SKILLED NURSING FACIIETIES LICENSED BY THE TEXAS DEPARTMENT OF AGING AND DISABILITY SERVICES (DADS) AND THEY REVIEW AND INVESTIGATE ALLEGATIONS OF ABUSE, NEGLECT, OR MISAPPROPRIATION OF RESIDENT PROEPRTY BY NURESE AIDES AND IF THERE'S A FINDING OF AN ALLEGED ACT OF ABUSE, NEGLECT, OR MISAPPROPRIATION, THE NURSE AIDE MAY REQUEST BOTH AN INFORMAL RECONSIDERATION AND A FORMAL HEARING BEFORE THE FINDING IS PLACED ON THE REGISTRY: 3) ALL DADS-REGULATED FACILITES AND AGENCIES ARE REQURED TO CHECK THE EMPLOYEE MISCONDUCT REGISTRY AND NURSE AIDE REGISTRY BEFORE HIRE TO DETETMINE IF I AM LISTED IN EITHER REGISTRY AS HAVING COMMITTED AN ACT OF ABUSE, NEGELECT, EXPLITATION, MISAPPROPRIATION, OR MISCONDUCT AGAINST A RESIDENT OR CONSUMER AND AM THEREFORE, UNEMPLOYABLE.

RELEASE:

I HEREBY AUTHORIZE ANY PRIOR EMPLOYERS TO PROVIDE SUCH INFORMATION CONCERNING MY EMPLOYMENT WITH THEM AS MAY BE REQUESTED, AND ALSO AUTHORIZE THE REGISTRAR/PLACEMENT OFFICE OF ALL EDUCATION INSTITUTIONS ATTENDED TO RELEASE AN OFFICIAL COPY OF MY TRANSCRIPT AND, IF AVAILABLE, FACULTY APPRAISALS. I ALSO AUTHORIZE ANY APPROPRIATE LICENSING BOARD TO RELEASE FULL INFORMATION CONCERNING MY LICENSE STATUS AND MY LICENSE HISTORY.

INTERVIEWS REFERENCE CHECKS
INTERVIEWS
REFERENCE CHECKS

RVD 010115
HCL / CHAP EMPLOYMENT APPLICATION

STATEMENT OF EMPLOYABILITY

BY EXECUTION OF THIS DOCUMENT, I ACKNOWLEDGE THAT I HAVE BEEN INFORMED BY THE AGENCY AND AGREED THAT THE AGENCY MAY CONDUCT A STATE OF TEXAS CRIMINAL CHECK. I AGREE TO A SEARCH OF THE NURSE AIDE REGISTRY AND THE EMPLOYEE MISCONDUCT REGISTRY PRIOR TO EMPLOYMNETAND AT LEASET EVERY 12 MONTHS IF HIRED. I UNDERSTAND THAT THESE CHECKS WILL DETERMINE IF I HAVE A CRIMINAL CONVICTION OR HAVE COMMITTTED CERTAIN CONDUCT THAT WILL BAR ME FROM EMPLOYMENT WITH THIS AGENCY. I UNDERSTAND THAT I AM UNEMPLOYABLE IF LISTED AS UNEMPLOYABLE IN THE NAR OR EMR PER TAC SECTION 93.3 AND TX&H&SC CHAPTER 253; OR IF LISTED AS UNEMPLOYABLE IN THE OFFICE OF THE INSPECTOR GENERAL’S LIST OF EXCLUDED INDIVIDUALS AND ENTITIES (LEIE) PURSUANT TO SECTIONS 1128 AND 1156 OF THE SOCIAL SECURITY ACT.

CRIMINAL HISTORY CHECK

I HAVE INFORMED THIS AGENCY OF ALL NAMES (I.E., MAIDEN, ALIASES) THAT I HAVE USED IN THE PAST. I UNDERSTAND THAT MY EMPLOYMENT IS PENDING THE RESULTS OF THE CRIMINAL HISTORY CHECK, AND THAT I MAY NOT HAVE PATIENT CONTACT UNTIL RESULTS ARE RETURNED.


CONVICTIONS BARRING EMPLOYMENT

(A)

A PERSON FOR WHOM 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 IN THIS SUBSECTION:

  • AN OFFENSE UNDER CHAPTER 19, PENAL CODE (CRIMINAL HOMICIDE)
  • AN OFFENSE UNDER CHAPTER 20, PENAL CODE (KIDNAPING AND UNLAWFUL RESTRAINT)
  • AN OFFENSE UNDER SECTION 21.02, PENAL CODE (CONTINUOUS SEXUAL ABUSE OF A YOUNG CHILD OR CHILDREN)
  • AN OFFENSE UNDER SECTION 21.08, PENAL CODE (INDECENT EXPOSURE)
  • AN OFFENSE UNDER SECTION 21.11, PENAL CODE (INDECENCY WITH A CHILD)
  • AN OFFENSE UNDER SECTION 21.12, PENAL CODE (IMPROPER RELATIONSHIP BETWEEN EDUCATOR AND STUDENT)
  • AN OFFENSE UNDER SECTION 21.15, PENAL CODE (IMPROPER PHOTOGRAPHY OR VISUAL RECORDING)
  • AN OFFENSE UNDER SECTION 22.011, PENAL CODE (SEXUAL ASSAULT)
  • AN OFFENSE UNDER SECTION 22.02, PENAL CODE (AGGRAVATED ASSAULT)
  • AN OFFENSE UNDER SECTION 22.021, PENAL CODE (AGGRAVATED SEXUAL ASSAULT)
  • AN OFFENSE UNDER SECTION 22.04, PENAL CODE (INJURTY TO A CHILD, ELDERLY INDIVIDUAL, OR A DISABLED INDIVIDUAL)
  • AN OFFENSE UNDER SECTION 22.041, PENAL CODE (ABANDONING OR ENDANGERING A CHILD)
  • AN OFFENSE UNDER SECTION 22.05, PENAL CODE (DEADLY CONDUCT)
  • AN OFFENSE UNDER SECTION 22.07, PENAL CODE (TERRORISTIC THREAT)
  • AN OFFENSE UNDER SECTION 22.08, PENAL CODE (AIDING SUICIDE)
  • AN OFFENSE UNDER SECTION 25.031, PENAL CODE (AGREEMENT TO ABDUCT FROM CUSTODY)
  • AN OFFENSE UNDER SECTION 25.08, PENAL CODE (SALE OR PURCHASE OF A CHILD)
  • AN OFFENSE UNDER SECTION 28.02, PENAL CODE (ARSON)
  • AN OFFENSE UNDER SECTION 29.02, PENAL CODE (ROBBERY)
  • AN OFFENSE UNDER SECTION 29.03, PENDAL CODE (AGGRAVATED ROBBERY)
  • AN OFFENSE UNDER SECTION 32.53 PENAL CODE (EXPLOITATION OF A CHILD, ELDERLY INDIVIDUAL, OR DISABLED INDIVIDUAL)
  • AN OFFENSE UNDER SECTION 33.021, PENAL CODE (ONLINE SOLICITATION OF A MINOR)
  • AN OFFENSE UNDER SECTION 34.02, PENAL CODE (MONEY LAUNDERING)
  • AN OFFENSE UNDER SECTION 35A.02, PENAL CODE (MEDICAID FRAUD)
  • AN OFFENSE UNDER SECTION 36.06, PENAL CODE (OBSTRUCTION OR RETALIATION)
  • AN OFFENSE UNDER SECTION 42.09, PENAL CODE (CRUELTY TO LIVESTOCK ANIMALS) OR
  • AN OFFENSE UNDER SECTION 42.092, PENAL CODE (CRUELTY TO NONLIVESTOCK ANIMALS) OR
  • A CONVICTION UNDER THE LAWS OF ANOTHER STATE, FEDERAL LAW, OR THE UNIFORM CODE OF MILITARY JUSTICE FOR AN OFFENSE CONTAINING ELEMENTS THAT ARE SUBSTANTIALLY SIMILAR TO THE ELEMENTS OF AN OFFENSE LISTED BY THIS SUBSECTION
  • AN OFFENSE THE AGENCY DETERMINES TO BE CONTRAINDICTED TO EMPLOYMENT WITH THE CONSUMERS THE AGENCY SERVES

(B)

CONVICTED OF ANY OF THE FOLLOWING CRIMES WITHIN THE PAST 5 YEARS:

  • AN OFFENSE UNDER SECTION 22.01, PENAL CODE (ASSAULT PUNISHABLE AS A CLASS A MISDEMEANOR OR AS A FELONY)
  • AN OFFENSE UNDER SECTION 30.02, PENAL CODE (BURGLARY)
  • AN OFFENSE UNDER CHAPTER 31, PENAL CODE (THEFT THAT IS PUNISHABLE AS A FELONY)
  • AN OFFENSE UNDER SECTION 32.45, PENAL CODE (MISAPPLICATION OF FIDUCIARY PROPERTY OR PROPERTY OF A FINANCIAL INSTITUTIION), THAT IS PUNISHABLE AS A CLASS A MISDEMEANOR OR A FELONY)
  • AN OFFENSE UNDER SECTION 32.46, PENAL CODE (SECURING EXECUTION OF A DOCUMENT BY DECEPTION PUNISHABLE AS A CLASS A MISDEMEANOR OR A FELONY)
  • AN OFFENSE UNDER SECTION 37.12, PENAL CODE (FALSE IDENTIFICATION AS A PEACE OFFICER)
  • AN OFFENSE UNDER SECTION 42.01 (A) (7) , (8), OR (9), PENAL CODE (DISORDERLY CONDUCT)

(C)

IN ADDITION TO THE PROHIBITIONS ON EMPLOYMENT PRESCRIBED BY SUBSECTIONS (A) AND (B), A PERSON FOR WHOM A FACILITY LICENSED UNDER CHAPTER 242 OR 247 IS ENTITLED TO OBTAIN CRIMINAL HISOTRY RECORD INFORMATION MAY NOT BE EMPLOYED IN A FACILITY LICENSED UNDER CHAPTER 242 OR 247 IF THE PERSON HAS BEEN CONVICTED:

  • OF AN OFFENSE UNDER SECTION 30.02, PENAL CODE (BURGLARY), OR
  • UNDER THE LAWS OF ANOTHER STATE, FEDERAL LAW, OR THE UNIFORM CODE OF MILITARY JUSTICE FOR AN OFFENSE CONTAINING ELEMENTS THAT ARE SUBSTANTIALLY SIMILAR TO THE ELEMENTS OF AN OFFENSE UNDER SECTION 30.02, PENAL CODE

(D)

IN ADDITION TO THE PROHIBITIONS ON EMPLOYMENT PRESCRIBED BY SUBSECTIONS (A), (B) AND (C), A NURSE AIDE LISTED AS UNEMPLOYABLE PER AMENDMENT TO TAC 40, §94.10(1) AND §94.11(C)(D) AND IS LISTED ON THE NAR OR EMR STATING A FINDING OF ABUSE, NEGLECT OR MISAPPROPRIATION WILL NOT BE RECERTIFIED THEREFORE, IS UNEMPLOYABLE

(E)

FOR PURPOSES OF THIS SECTION, A PERSON WHO IS PLACED ON DEFERRED ADJUDICATION COMMUNITY SUPERVISION FOR AN OFFENSE LSITED IN THIS ECTION, SUCCESSFULLY COMPLETES THE PERIOD OF DEFERRED ADJUDICATION COMMUNITY SUPERVISION, AND RECIEVES A DISMISSAL AND DISCHARGE IN ACCORDANCE WITH SECTION 5(C), ARTICLE 42.12, CODE OF CRIMNAL PROCEDURE, IS NOT CONSIDERED CONVICTED OF THE OFFENSE FOR WHICH THE PERSON RECEIVED DEFERRED ADJUDICATION COMMUNITY SUPERVISION.


I ACKNOWLEDGE THAT IF I AM FOUND TO HAVE BEEN CONVICTED OF ANY OTHER OFFENSE(S), THAT THESE OFFENSES MAY ALSO BAR MY EMPLOYMENT. I UNDERSTAND THAT ALL INFORMATION OBTAINED BY THIS AGENCY REGARDING ANY CRIMINAL HISTORY WILL REMAIN CONFIDENTIAL. I CERTIFY THAT THE INFORMATION ON THIS FORM CONTAINS NO WILLFUL MISREPRESENTATION AND THAT THE INFORMATION GIVEN IS TRUE AND OCMPLETE TO THE BEST OF MY KNOWLEDGE.


Yes No

FOR AGENCY USE ONLY: CRIMINAL HISTORY, EMPLOYEE MISCONDUCT REGISTRY (EMR), AND NURSE AIDE REGISTRY (NAR) CHECKS COMPLETED:

CRIMINAL HISTORY CHECK COMPLETED ON-LINE
EMR CHECKED BY TELEPHONE (800) 452-3934
EMR
CHECKED BY TELEPHONE (800) 452-3934
CHECKED ONLINE AT WWW.DADS.STATE.TX.US/PROVIDERS/EMPLOYABILITY/ESEARCH.CFM
NAR CHECKED BY TELEPHONE (800) 452-3934
NAR
CHECKED BY TELEPHONE (800) 452-3934
CHEKCED ONLINE AT WWW.DADS.STATE.TX.US/PROVDERS/EMPLOYABILITY/ESEARCH.CFM
OTHER CONVICTIONS IDENTIFIED ON CRIMINAL HISTORY (DOCUMENT REASON HIRING )


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