PLEASE PRINT

06-19-2023

Date

155515415

Social Security Number

JSR

Employee #

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


JOHN Hani

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
fdgfd
Apt. No.
gfd
City
gfd
State
gfd
ZIP Code
gfd
Telephone Number
gfd
Cell Telephone Number
gfd
Alternate Number
fdg
Email Address
gfdggfd
Languages Spoken
gfd
Other Names Used for Education or Employment Purposes
tyyt
Are you authorized to work in the United States?
☐ Yes ☑ No
Have you ever worked for JBHC?
☐ Yes ☑ No If yes, where? sgddh
How did you learn about JBHC?
☐ JBHC Employee ☐ Direct Mail ☐ Friend/Neighbor/Relative ☐ Internet ☐ Newspaper ☐ Radio ☑ School ☐ TV ☐ Yellow Pages ☐ Other:yty
Please identify the specific source (e.g., name of newspaper):
ytyt
EDUCATIONAL BACKGROUND
Name of School
yty
Address/City/State
yt
Years Completed
yt
Degree Received
yt
Name of School
yt
Address/City/State
yt
Years Completed
yt
Degree Received
yt
PROFESSIONAL LICENSURE, CERTIFICATION, OR TRAINING
License
yt
State of Issue
yt
License Number
yt
Expiration Date
yt
License
yt
State of Issue
yt
License Number
yt
Expiration Date
yt
Certification
ytytytytnyytuytu yuytutuyt
State of Issue
uytuyt
Certificate Number
uyuut
Expiration Date
uytuytuyt

CPR Certified?
☐ Yes ☑ No
IV Certified?
☐ Yes ☑ No
Other:
Please specify: ytutuytu
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
8698
Address
686868
City
687867
State
7686
ZIP Code
7866
Telephone Number
7866
Supervisor’s Name
6786
Supervisor’s Telephone Number
67866
Position Held
6876
Employment Dates
06-29-2023.to. 06-22-2023
Ending Pay (per hour)
6868886
Reason for Leaving
677867786
Type of Position
☐ Full-time ☑ Part-Time ☐ Per Diem
Name of Employer
67867
Address
6787
City
6686
State
678766
ZIP Code
686
Telephone Number
6876
Supervisor’s Name
6786
Supervisor’s Telephone Number
6786
Position Held
7677
Employment Dates
06-28-2023.to.06-28-2023
Ending Pay (per hour)
7866
Reason for Leaving
6786
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
7866
Address
67876
City
767
State
6786
ZIP Code
67867
Telephone Number
67867
Supervisor’s Name
76786
Supervisor’s Telephone Number
67
Position Held
768767
Employment Dates
06-28-2023.to.07-06-2023
Ending Pay (per hour)
68768
Reason for Leaving
6786787
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: 6786778
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:67667878
Are you willing and able to work in homes with smokers? ☑ Yes ☐ No
Comments:786676786787
Are you willing and able to work in homes with smokers?       78666
How many hours per day are you willing to work?       76786678
Geographic Preferences:      676786786
Other Work Preferences:       678678687
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 #
7866
Post Office Box
78678687687
City
6786
State
7678
ZIP Code
7678
How many years at this address?
6786
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
67867687678
Address
678678667866786
Applicant Policy Number
786767867867

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?
fdf
☐ 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:       877676786786786786786
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.
67867678678

WITNESS

APPLICANT SIGNATURE
06-17-2023

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
06-20-2023
Position
hfhfj

Employee #
kyukykyuk
Applicant Name
kuykkuy
Pay Required
kyukk
Please rate the applicant on the following (see reverse for interpretative guidelines):
1
Presence
2
Experience
3
Comprehension
4
Attitude
5
Skills
6
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       yrtytryrryrtyrtyr yytyt yrty ryrt yty rttytr ytr yrt
Test and Skill Results       ytyyrt rtrtyt rtyrttjyuuluiluilioi ukyuiyuiyuiyuiyuiyu yiyuiyuiyuiyu
Appropriateness for JBHC Home Health Care       iyuiyui yuyyuiuyiyu yu iyuiyuiyuiyu yiy
Compassion       iyuiuyiyuiyu yuiyuiyuiyuiyu ufuyukyu
Excellence       uytuytiytiyuiyu uiuyiyuiyuiyu
Reliability       iyuiyuiyuiuyyuiyui yuiioyuiyui
Overall Interview Conclusions       iyuiyuiyuiyuyiyu yui yuiyuiyu
Interviewer (Signature and Title)
Date Interviewed
06-07-2023
FOLLOW UP
ytuiytiyiuyiuyi
☑ 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)

06-19-2023