PLEASE PRINT

06-30-2023

Date

153025435

Social Security Number


Employee #

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


Krier, Kristin

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
24J Reading Road
Apt. No.
City
Edison
State
New Jersey
ZIP Code
08817
Telephone Number
9082023737
Cell Telephone Number
9082023737
Alternate Number
Email Address
kristinkrier4@gmail.com
Languages Spoken
English
Other Names Used for Education or Employment Purposes
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:
Please identify the specific source (e.g., name of newspaper):
Indeed
EDUCATIONAL BACKGROUND
Name of School
Monmouth University
Address/City/State
400 Cedar Ave. West Long Branch, NJ 07764
Years Completed
4
Degree Received
BS in Health and Physical Education
Name of School
Emporia State University
Address/City/State
1 Kellogg Cir., Emporia, KS 66081
Years Completed
2
Degree Received
MS in Health, Physical Education, and Recreation
PROFESSIONAL LICENSURE, CERTIFICATION, OR TRAINING
License
State of Issue
License Number
Expiration Date
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
Regal Cinemas
Address
1000 Corporate Court
City
South Plainfield
State
New Jersey
ZIP Code
07080
Telephone Number
9086686943
Supervisor’s Name
Justin Richardson
Supervisor’s Telephone Number
7327639265
Position Held
Assistant Manager
Employment Dates
11-01-2021.to. 06-30-2023
Ending Pay (per hour)
20.50
Reason for Leaving
Going back into degree field
Type of Position
☑ Full-time ☐ Part-Time ☐ Per Diem
Name of Employer
The Chelsea @ Forsgate
Address
319 Forsgate Drive.
City
Monroe Township
State
New Jersey
ZIP Code
08831
Telephone Number
7326561000
Supervisor’s Name
Elizabeth Browne
Supervisor’s Telephone Number
7326197454
Position Held
Concierge
Employment Dates
05-01-2021.to.11-30-2021
Ending Pay (per hour)
16.50
Reason for Leaving
Offered better time and pay @ Regal Cinemas
Type of Position
☑ Full-time ☐ Part-Time ☐ Per Diem

This section continued on page 3

JBHC Employment Application - Page 3

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EMPLOYMENT INFORMATION
continued from page 2
Name of Employer
Jersey Physical Therapy
Address
3228 NJ-27
City
Kendall Park
State
New Jersey
ZIP Code
08824
Telephone Number
7322970032
Supervisor’s Name
Geoffrey Hunt
Supervisor’s Telephone Number
9082084770
Position Held
Physical Therapy Aide
Employment Dates
05-01-2019.to.05-31-2021
Ending Pay (per hour)
13.50
Reason for Leaving
got offered job at assisted living home
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:
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:
Are you willing and able to work in homes with smokers? ☐ Yes ☑ No
Comments:
Are you willing and able to work in homes with smokers?      
How many hours per day are you willing to work?      
Geographic Preferences:      
Other Work Preferences:      
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 #
250 Blackhorse Lane
Post Office Box
City
North Brunswick
State
New Jersey
ZIP Code
08902
How many years at this address?
25
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
Address
Applicant Policy Number

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?
☐ 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?
November 2021 - June 2023. Cash handling behind a register and creating deposits at the end of each night.
 ☑ 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:       Explanation under #4
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
07-03-2023

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)