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:

Sincerely,

Joy Bringers Home Care

Phone
9747978704
Date
06-15-2023

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WORK HISTORY INVESTIGATION-NJ

WORK HISTORY INVESTIGATION- NEW JERSEY
CONFIDENTIAL

Prospect’s Name:
Sam purushothaman
SSN :
#123456789
Employment Dates:
2023-06-01
to
2023-06-30
Employer:
Jithin S
Positon Held:
Developer
Street
Newyork
City/State/Zip
Brooklyn
Phone
718-123-5632
Fax
123-123-1234
Email (optional)
jithins.rv@gmail.com

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 thequestions 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.

Signature:
Date:
06-19-2023

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
06-30-2023
2.Position held
Text
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 inwhat specialty or capacity:
Date:
06-30-2023
Position:
Dev
5.Please place an X as applicable:
ACCEPTABLE NOT ACCEPTABLE
Reliability ☑ ☐
Attitude ☐ ☑
Cooperation ☑ ☐
Punctuality ☐ ☑
Quality of Work ☑ ☐
COMMENTS
test
6.Separation was: ☐ VOLUNTARY ☑ INVOLUNTARY ☐ STILL EMPLOYED
Reason:
test tst
7.Was employee ever counseled, warned, reprimanded, suspended or discharged? ☐ YES ☑ NO
Please explain:
test test1
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) ☐ YES ☑ NO
9. Would you rehire? Please circle: ☑ Yes ☐ No
N/A (if currently employed)
If NO please explain:
Test Test2356
10. How did you know this individual? Please circle: ☐ UPERVISOR ☑ PERSONNEL RECORDS
If NO please explain:
test test123

WORK HISTORY INVESTIGATION- NEW JERSEY
CONFIDENTIAL

Signature and Title
Phone # with Area Code
1425225222
Date:
06-19-2023

TELEPHONE VERIFICATION SECTION – for office use only

Spoke with:
test teest
Title:
test test
Date:
06-19-2023
Joy Bringers Home Care Office Employee Signature/Title