PLEASE PRINT
Date
Social Security Number
Employee #
Applicant (Last Name, First Name)
Committed to Excellent and Quality Care.
JBHC is committed to fair and equal
employment and access to home care services.
PLEASE PRINT
This section continued on page 3
PLEASE PRINT
If additional space is needed, please request a blank sheet of paper.
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 |
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?
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|
☐ 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 |
WITNESS
DATE
PLEASE PRINT
RATING KEY: 5 Very Much Above Standard 4 Above Standard 3 Meets Standard 2 Below Standard 1 Very Much Below Standard