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Personal Details
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Employer #1

Employer #2

Employer #3

Reference Letter

The undersigned, having applied for a position with our organization, herby authorizes you to release any information to and do hereby unconditionally release your organization from all liability for damage whatsoever that might result from furnishing this information.

SECTION I: Applicant to complete.

I acknowledge filing an application with

and authorize release of information from my former employer.

Sworn Disclosure Statement

To the Applicant:

Sections 32.1-162.9; 32.1-126.01 of the Code of Maryland require that any person desiring work at a licensed Staffing organization or nursing home provide the hiring facility with a sworn disclosure or affirmation disclosing any criminal convictions or pending criminal charges, whether within or outside the Commonwealth of Virginia. The laws prohibits licensed homes for adults and licensed health care organizations and licensed nursing homes from hiring any individuals convicted of the following: murder, abduction or immoral purposes, assaults and bodily wounding, robbery, sexual assault, arson, pandering, crimes against nature involving children, taking indecent liberties with children, abuse and neglect of children, failure to secure medical attention for an injured child, obscenity offenses or abuse or neglect of an incapacitated adult. However, applicants convicted of one (1) misdemeanor crime not involving abuse or neglect or moral turpitude may be hired provided five (5) years has clasped since the conviction. Any person making a false statement on this form regarding any criminal offense shall be guilty upon conviction of a Class 1 misdemeanor. Further dissemination of the information provided on this form is prohibited other than a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.

  1. Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday which were finally adjudicated in a juvenile court or under a youth offender law?

  2. Are you the subject of any pending criminal charges?

  3. I hereby affirm that the information provided on this form is true and correct, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment offered by this facility. I understand that all information on this form is subject to verification. I authorize:
    to make an investigation to verify this information.
Availability Form

What times are you available? (Please specify if AM or PM)

Employee Verification Requirements

Paperwork List Requirements

A copy of the following documents should be sent with your application. All forms must be signed and dated.
Documents required:

  1. Proof of active professional license from verification site
  2. CPR
  3. Car Insurance
  4. Social Security
  5. Driver's License
  6. Passport or naturalization certification or green card/work permit
  7. TB Test or chest X-Ray certification
Employee Health Self-Assessment
Have you had or do you have any of the following?

To the best of my knowledge and belief

I,

, the undersigned certify the above answers are true, and give the examining Physician permission to submit a report to

Hepatitis B Vaccine Notification

I understand that due to my occupational exposure to blood or other potentially infectious materials that it is strongly suggested that I am vaccinated for the Hepatitis B Virus (HBV). I understand that I may refuse the vaccination. I also understand that not being vaccinated may leave me susceptible to the HBV.

has explained to me that I continue to be at risk for HBV until such time that I am immunized, and that if I wish to be immunized I need to see my physician for the series of shots.

Declination of Mantoux

I,

, have submitted documentation of PPD test results of said test.

If an employee has a known history of having had a positive Tuberculin test by Mantoux method, he/she may decline the Mantoux test. He/ she must agree to give the Agency documentation of the negative chest X-Ray within the past twelve months.

Confidentiality Agreement

Any information exchanged about

either written or verbal, is to be kept confidential by all
employees and contracted staff. This applies but is not limited to contract, proposals, regulatory information, forms, paperwork, correspondence, and proceedings of meetings.

Any employee who does not comply with this policy will be terminated immediately.
Upon hire all employees are required to sign a Confidentiality Statement as follows:

I,

, hereby agree to treat and keep all personal medical information on
services and or its patients and or clients confidential. Furthermore, I will agree not to release any information to any outside organization or agency without the approval of the patient and or client, or as required by law or third-party payment contract. Any employee that does not comply with this policy will be terminated immediately.

Acknowledgment of Policies and Procedures

I acknowledge that I have received, read and understand the following policies and procedures and documents for

.

  • Criminal Records-Employment Barrier of Crimes stating which criminal convictions for offenses involving abuse or neglect may disqualify me from employment with Prospect Staffing.
  • HIPPA Policy and procedure regarding the privacy of individually identifiable protected health information (PHI), as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the state of Virginia.
  • Sexual Abuse Policy and Procedure
    • I understand that
      will not tolerate any employee, volunteer, board member or third party who commits sexual abuse. Disciplinary actions will be taken against those who are found to have committed sexual abuse.
    • I understand that it is my responsibility to abide by all rules contained in the policy. I also understand how to report incidents of sexual abuse as set forth in the abuse policy, including retaliating against any employee/volunteer exercising his or her rights under the policy
  • Documentation (paper or electronic) is required to be submitted from the current week by Friday no later than 5:00 PM.
  • Universal Precautions OSHA Blood borne Pathogens Policy and procedure stating you understand you are at risk of exposure to blood or other potentially infectious materials; therefore, have been given proper instruction on OSHA Regulation and Requirements
  • Rules governing employees' visits in a client' s home.
  • Inservice requirements stating each employee or independent contractor needs to complete a minimum of twelve (12) in-service hours per year
  • HIV Confidentiality stating you have received training in the regulations concerning HIV confidentiality
  • tatement of nonhabituation stating that you are not using or habituated of addicted to depressants, stimulants, narcotic, alcohol or other drugs and is fully able to perform the duties of your field you are employed in.