PLEASE PRINT

07-16-2023

Date

142621250

Social Security Number


Employee #

Desired Position: ☐ RN ☐ LPN ☑ HHA ☐ HMKR/Companion ☐ Live-In ☐ PT ☐ Other


Bullock, Lettitia

Applicant (Last Name, First Name)


Joy Bringers Home Care

(JBHC)

Providing meaningful work opportunities for home health
care professionals who are compassionate, pursue
excellence, and are reliable.

Committed to Excellent and Quality Care.

JBHC is committed to fair and equal
employment and access to home care services.

JBHC Employment Application - Page 2

PLEASE PRINT

PERSONAL INFORMATION
Street Address
200 Godwin Avenue
Apt. No.
Apt.13
City
Paterson
State
N.J.
ZIP Code
07501
Telephone Number
862-686-2511
Cell Telephone Number
863-686-2511
Alternate Number
Email Address
lettitiab@yahoo.com
Languages Spoken
English
Other Names Used for Education or Employment Purposes
N/A
Are you authorized to work in the United States?
☑ Yes ☐ No
Have you ever worked for JBHC?
☐ Yes ☑ No If yes, where?
How did you learn about JBHC?
☑ JBHC Employee ☐ Direct Mail ☐ Friend/Neighbor/Relative ☐ Internet ☐ Newspaper ☐ Radio ☐ School ☐ TV ☐ Yellow Pages ☐ Other:Employee
Please identify the specific source (e.g., name of newspaper):
N/A
EDUCATIONAL BACKGROUND
Name of School
Eastside High School
Address/City/State
Paterson, New Jersey 07501
Years Completed
4
Degree Received
GED
Name of School
AMG Medical Institute
Address/City/State
Paterson, New Jersey 07501
Years Completed
1
Degree Received
Diploma/Certificate
PROFESSIONAL LICENSURE, CERTIFICATION, OR TRAINING
License
Homemaker- CHHA
State of Issue
New Jersey
License Number
26NH01858200
Expiration Date
11/30/2025
License
State of Issue
License Number
Expiration Date
Certification
State of Issue
Certificate Number
Expiration Date

CPR Certified?
☑ Yes ☐ No
IV Certified?
☑ Yes ☐ No
Other:
Please specify:
Training
Type
☑ Yes ☐ No
Where Obtained
☑ Yes ☐ No
Length of Course
Please specify:........
EMPLOYMENT INFORMATION
Please provide information on all employers for the last 5 years, starting with the most recent.
Name of Employer
BrightStar Home Healthcare Agency
Address
601 Hamburg Turnpike
City
Wayne
State
N.J.
ZIP Code
07470
Telephone Number
862-686-2511
Supervisor’s Name
Daniell Lazcko
Supervisor’s Telephone Number
973-321=0010
Position Held
CHHA
Employment Dates
04-10-2023.to. 11-13-2023
Ending Pay (per hour)
Current pay rate $18.00 per hour
Reason for Leaving
Currently employed
Type of Position
☑ Full-time ☐ Part-Time ☐ Per Diem
Name of Employer
Center Laboratory
Address
85 Horse Hill Rd.
City
Cedar Knolls
State
New Jersey
ZIP Code
07927
Telephone Number
973-731-2900
Supervisor’s Name
Iliana
Supervisor’s Telephone Number
973-731-2900
Position Held
Specimen Processor
Employment Dates
09-20-2021.to.08-13-2022
Ending Pay (per hour)
$20.00
Reason for Leaving
Covid
Type of Position
☑ Full-time ☐ Part-Time ☐ Per Diem

This section continued on page 3

JBHC Employment Application - Page 3

PLEASE PRINT

EMPLOYMENT INFORMATION
continued from page 2
Name of Employer
PennReach Inc.
Address
1090 Broadway
City
West Long branch
State
N.J.
ZIP Code
07764
Telephone Number
732-759-8530
Supervisor’s Name
Mohammed
Supervisor’s Telephone Number
732-759-8530
Position Held
Program Manager
Employment Dates
10-13-2022.to.07-13-2023
Ending Pay (per hour)
salary $47,500.00
Reason for Leaving
Covid
Type of Position
☑ Full-time ☐ Part-Time ☐ Per Diem

If additional space is needed, please request a blank sheet of paper.

ASSIGNMENT PREFERENCES
Monday ☑ Day ☐ Evening ☐ Night
Tuesday ☑ Day ☐ Evening ☐ Night
Wednesday ☑ Day ☐ Evening ☐ Night
Thursday ☑ Day ☐ Evening ☐ Night
Friday ☑ Day ☐ Evening ☐ Night
Saturday ☑ Day ☐ Evening ☐ Night
Sunday ☑ Day ☐ Evening ☐ Night
Client Preference(s): ☐ Pediatric ☑ Adult ☐ Geriatric ☐ Rehab ☐ Terminally ill
Are you willing to cover call-outs? ☑ Yes ☐ No
Are you willing to work holidays? ☑ Yes ☐ No
Please list: Veterans, Columbus, Memorial, Thanksgiving
Are you able to work cases where public transportation may not be available? ☑ Yes ☐ No
Are you willing and able to work in homes with dogs? ☐ Yes ☐ No      Cats? ☑ Yes ☐ No
Comments:AS long as the animals are away from me. Not jumping all over me. I don't like the animal to be in my personal space.
Are you willing and able to work in homes with smokers? ☑ Yes ☐ No
Comments:As long as it is ventilation and/or I can go in another room
Are you willing and able to work in homes with smokers?       25 - 35 miles
How many hours per day are you willing to work?       8-12 hours
Geographic Preferences:      Passaic and Bergen Counties
Other Work Preferences:       Work schedule requesting Monday-Friday day shift 8-12 hours Sunday, Monday, Tuesday and Thursday 12 hours overnight shift
Please note: JBHC cannot guarantee work or give assurance that you will only be offered cases within the preferencesthat you have selected. This information will help us try to accommodate your requests.

JBHC Employment Application - Page 4

EMPLOYEE INTEGRITY INSURANCE COVERAGE SCREENING
How many years at your current address listed on page 2 of the application? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☑ 5+
Previous Address Street/Apt #
200 Godwin Avenue Apt.13
Post Office Box
City
Pateson
State
New Jersey
ZIP Code
07501
How many years at this address?
12 years
How many years have you lived in the state in which you are seeking employment? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☑ 5+
Malpractice Insurance   ☐ Yes ☑; No
Carrier name, if applicable
N/A
Address
N.A
Applicant Policy Number
N.A

Answer yes or no to the following questions (explain “yes” answers with the date(s) and detail(s) of each answer in the section below)

1.
Have you ever worked under a different name?
Lettitia Walker maiden name
 ☑ Yes ☐ No
2.
Have you ever been bonded in a previous position?
☐ Yes ☑ No
3.
Have you ever stolen?
☐ Yes ☑ No
4.
Have you ever worked in a capacity of handling cash or cash equivalents?
☑ Yes ☐ No
5.
Have you ever been reprimanded, suspended, or discharged from a job due to violent behavior at work?
☐ Yes ☑ No
6.
Have you ever been reprimanded, suspended, or discharged from a job due to abuse/neglect of clients or children?
☐ Yes ☑ No
7.
Have you ever been investigated for suspicion of abuse/neglect of clients or children by a government agency?
☐ Yes ☑ No
8.
Have you ever been involved in a lawsuit, either directly or through an employer, alleging negligence or malpractice?
☐ Yes ☑ No
9.
Have you ever been sanctioned or excluded from participation in federal or
state healthcare programs or surrendered/lost your professional license for an offense that could lead to sanction or exclusion?
☐ Yes ☑ No
10.
Have you ever had disciplinary action filed against your professional license or CNA/HHA certification in any state?
☐ Yes ☑ No
11.
Have you ever been reprimanded, suspended, or discharged from a job for any reason?
☐ Yes ☑ No
Explain:       N/A
Applicant statement: By signing below, I verify that all information provided about my background, education, licensure, employment history, and skills is true, complete, and correct. I authorize JBHC Home Health Care to independently verifyany information provided by me in the hiring process and if hired, throughout my employment. JBHC may specifically contactany reference, learning institution, current or previous employer of mine whether disclosed in my employment application or not. I understand that any offer of employment may be withdrawn or terminated if discrepancies are found.

WITNESS

APPLICANT SIGNATURE
11-09-2023

DATE

JBHC Employment Application - Insert

INTERVIEW EMPOLYMENT STANDARDS
INTERPRETATIVE GUIDELINES

Presence:

  • The Prospect is neat and clean (appropriate attire).
  • The Prospect is able to communicate effectively.
  • The Prospect is articulate.
  • The Prospect makes a good first impression.

Experience:

  • The Prospect has at least one year of verifiable work experience.
  • The Prospect has worked in home health care or has related health care experience (except trainingcandidates)
  • The Prospect can provide three professional work references.
  • The Prospect has proof of skill level and competence. (except training candidates)

Comprehension (subject to position level)::

  • The Prospect understands simple requests (brings documents needed for interview).
  • The Prospect follows directions.
  • The Prospect demonstrates intelligence.
  • The Prospect asks appropriate questions.

Attitude:

  • The Prospect’s conduct is professional.
  • The Prospect’s demeanor is pleasant.
  • The Prospect is open to discussion.
  • The Prospect is flexible.
  • The Prospect wants to be a JBHC Nurse.

Skills:

  • The Prospect has the appropriate skill level for the desired position.
  • The Prospect possesses core competencies.
  • The Prospect passed all written exams.
  • The Prospect passed all skills demonstrations.

Maturity:

  • The Prospect is reliable (makes and keeps commitments). TheProspect reported to the interview on time.
  • The Prospect believes in the mission and values of JBHC.
  • The Prospect demonstrates a caring devotion to home health care.

JBHC Employment Application - Insert

PLEASE PRINT

"
Date
Position

Employee #
Applicant Name
Pay Required
Please rate the applicant on the following (see reverse for interpretative guidelines):
Presence
Experience
Comprehension
Attitude
Skills
Maturity

RATING KEY: 5 Very Much Above Standard 4 Above Standard 3 Meets Standard 2 Below Standard 1 Very Much Below Standard

Evaluations
Be sure to evaluate prior work experience, test and skill results, and appropriateness for JBHC, and overall interview conclusions.
Prior Work Experience      
Test and Skill Results      
Appropriateness for JBHC Home Health Care      
Compassion      
Excellence      
Reliability      
Overall Interview Conclusions      
Interviewer (Signature and Title)
Date Interviewed
FOLLOW UP
☐ All paperwork reviewed and complete as perpolicy #0-994
☐ Lab skills competency complete as required for hiring decision
Director or Designee Approval for Hire Signature and Title Date
Approval for hire and to attend NHO (Must occur prior to NHO)