Work History Investigation

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WORK HISTORY INVESTIGATION- NEW JERSEY


CONFIDENTIAL

Dear :

Joy Bringers Home Care (JBHC) needs your help in order to hire good people. Please take a few minutes to complete the questionnaire located on the back of this letter as it relates to the employee’s job performance and the Health Care Professional Responsibility and Reporting Act (HCPRREA).

The Health Care Professional Responsibility and Reporting Enhancement Act (HCPRREA) require that reference requests from another health care entity must:

  • Disclose whether any notice about the individual to the Division within the seven (7) years precedingthe inquiry has been made.
  • Provide information about a current or former employee’s job performance as it relates to patient care.
  • For a former employee, provide the reason for the employee’s separation. Also providing the inquiringhealth care entity with a copy of the form of notification and any form of documentation provided with it.

JBHC specializes solely in caring for people in their own homes. We employ a staff of experienced RNs, LPNs,Home Health Aides and Live-In Companions. JBHC is proud of the service we provide.

In order to maintain our high standards, JBHC must rely on your assistance. We are committed to a very thoroughscreening process which includes work history investigation.

Please note that the applicant has given their authorization for the release of job performance information on the reverse side of this letter. It includes the following provision: “I agree to release you from any liability for damages of whatever nature arising from the requested information.”

All information received will be kept strictly confidential.

Sincerely,

Joy Bringers Home Care

For additional information or questions, please call:

WORK HISTORY INVESTIGATION-NJ

WORK HISTORY INVESTIGATION- NEW JERSEY


CONFIDENTIAL

to

I hereby authorize you to release any and all information that pertains to my job performance while in your employ. I understand that your response will be kept confidential and will not be disclosed to me. I request that you specifically provide JBHC with full, complete and honest answers to the questions below to help determine my suitability to work with elderly, disabled, technology dependent clients in an unsupervised environment. I agree to release you from any liability for damages of whatever nature arising from the requested information.


FORMER/CURRENT EMPLOYER’S SECTION YOUR COMMENTS WILL NOT BE RELEASED TO PROSPECT!

1. Are employment dates correct? Please circle: Yes No      If No, give correct dates

2. Position held     3. Please circle: FULL TIME PART TIME AS NEEDED

4. If the position was per diem, part time or as needed, please list when the employee last worked and in what specialty or capacity:

5. Please place an X as applicable:

ACCEPTABLENOT ACCEPTABLE
Reliability
Attitude
Cooperation
Punctuality
Quality of Work
COMMENTS

6. Separation was: VOLUNTARY INVOLUNTARY STILL EMPLOYED

Reason:

7. Was employee ever counseled, warned, reprimanded, suspended or discharged? Please circle: Yes No

Please explain::

8. Was employee ever counseled, warned, reprimanded, suspended or discharged due to impairment, incompetency, professional misconduct which related adversely to patient care or safety (required to be answered per HCPRREA) Please circle: Yes No

9. Would you rehire? Please circle: Yes No       N/A (if currently employed)

If NO please explain::

10. How did you know this individual? Please circle: SUPERVISOR PERSONNEL RECORDS

If NO please explain::


TELEPHONE VERIFICATION SECTION – for office use only

Office Address

6 Auer Ct, Unit G, East Brunswick, NJ 08816

Email

info@joybringersofnj.com

Phone Number

732-253-7822

Fax Number

732-317-3250

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