Catherine Doherty Foster Care, LLC.

Transcription

1 Application for Employment: 812 Waverly Street Eugene, Oregon Office: (541) Fax: (541) Directions for completing application for employment: 1. Please complete ALL aspects/sections of the application. 2. Part of the application process is initiating a background check. Once we have an application returned to us via , fax, or dropped off in person we will want to know that you have started that process. Background checks can take anywhere from a few days to a few weeks, so we like anyone who is serious about taking this job to have that started. We will contact all qualified individuals for an interview. To be considered for employment an applicant must have an approved background check. 3. How to initiate a background check: -Go downtown Eugene to 125 E. 8 th Ave between 10am and 3pm on Tuesday or Thursday (the cross street is Pearl). -Go down to the basement and enter the Developmental Disabilities office. -Inform them that you wish to complete a background check for Catherine Doherty and all associated foster homes. They will ask you to fill out paperwork and present them with valid identification. If you have lived out of state for more than 60 consecutive days in the last 5 years, they will instruct you to get finger prints done. -The main entrance of this building (where the metal detectors are) leading towards the court rooms is not the best way to locate the DDS office. We have found that entering on the Pearl Street side and using the stairs to the basement is a more direct path. If you need more directions or get lost, please call us at (541) or call the DDS office directly at (541) Please tear off and remove this page for your records prior to turning in your application. Page 1

2 OFFICE USE ONLY Background Check Status: 1 st call: 2 nd call: Date/time of interview: OIS: Foster Test: First/Aid/CPR: INTERVIEWERS Full Name (First, Middle, Last): Address: Apt #: City: State: Zip: Phone #: Alt Phone #: Date Available to Start: Are you at least 18 years of age? Yes No Have you ever applied to this company before? Yes No If yes, when? Have you ever worked for this company before? Yes No If yes, when? Position you are applying for: Caregiver Other (If other, please specify): Are you seeking a permanent position?: Yes No Type of Employment Desired: Full Part Temporary On-Call No Preference Shift Availability: Any Other (If other, please specify): Are you willing and available to work overtime? Yes No If employed, what needs do you have for time off from work? Are you able to perform the essential job functions of this position, with or without reasonable accommodation? Yes No Have you ever had a Protective Services Investigation (PSI) that resulted in a substantiated allegation of abuse of a child or adult? Yes No Page 2

3 Education Information: High School: Did you graduate? Yes No Diploma? Yes No Did you receive a GED? Yes No College: Years Completed: Did you graduate? Yes No Degree or certificate: Major/courses: Graduate School: Years Completed: Did you graduate? Yes No Degree or certificate: Military Information: Are you a veteran: Yes No Duty/Specialized Training: Skills & Qualifications: Have you ever been or are you currently CPR trained? Current In the past Never Have you ever been or are you currently OIS trained? Current In the past Never Other qualifications such as special skills, abilities, or honors that should be considered (including other languages or things related to this field you wish to bring to our attention such as past work with people with developmental disabilities and in emergency procedures): Questionnaire: 1. When supporting a person with a developmental disability, what do you think is key in establishing a positive working relationship? 2. What qualities do you believe to be most important and valued in the healthcare field? Page 3

4 References: References will be checked. Please provide only verifiable references. You must include 1 personal reference. Additionally, please list 2 professional references who are not related to you (professor, supervisor, co-worker, etc). We do not collect social security numbers. If any of your references require a social security number to confirm information, please call us with that information. Personal Reference Name: Phone #: How long have you known them? Occupation: Professional Reference Name: Phone #: Company: Work relationship (co-worker, supervisor, etc): Professional Reference Name: Phone #: Company: Work relationship (co-worker, supervisor, etc): Employment History: Please list the names of your present & previous employers in chronological order (with present or most recent employer listed first). You may also include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment. 1. Current/Most recent employer: Employer: Address: Type of Business: Phone #: Dates employed from : to Job Title: Supervisor s Name/Title: Starting wage: Final wage: Reason for leaving: What will this employer say was the reason your employment ended: You job duties and responsibilities: How much notice did you give when resigning? If none, explain: Do we have your permission to contact this previous employer? Yes No Page 4

5 2.Next previous employer: Employer: Address: Type of Business: Phone #: Dates employed from : to Job Title: Supervisor s Name/Title: Starting wage: Final wage: Reason for leaving: What will this employer say was the reason your employment ended: You job duties and responsibilities: How much notice did you give when resigning? If none, explain: Do we have your permission to contact this previous employer? Yes No Next previous employer: Employer: Address: Type of Business: Phone #: Dates employed from : to Job Title: Supervisor s Name/Title: Starting wage: Final wage: Reason for leaving: What will this employer say was the reason your employment ended: You job duties and responsibilities: How much notice did you give when resigning? If none, explain: Do we have your permission to contact this previous employer? Yes No Have you ever been disciplined or counseled at any previous job in the last 5 years for violating attendance requirements? Yes No If yes, please explain: Page 5

6 Employment Disclosure: I understand and agree that driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver s license for the state in which I reside. If I do not currently possess a driver s license, I understand that as a condition of my continued employment I will be required to actively seek to obtain a driver s license. I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or if employed disciplinary action up to and including immediate dismissal. I authorize the company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization form for the background investigation. I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above mentioned information. I hereby release, discharge and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the company and its representatives for seeking such information and all other person s corporations or organizations furnishing such information. If hired by the company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this company. I also understand that the company employs only individuals who are legally eligible to work in the United States. I certify that all of the information I have provided on this application is true, accurate, and complete. This company has my permission to contact references and previous employers as work references. Applicants will be required to complete a criminal history/background check to be considered for employment. I understand that no applicant will be considered until an approved background check is obtained and provided to hiring personnel of Catherine Doherty Foster Care. I also understand that background checks are conducted on a yearly basis as a term of employment with the company. If hired, schedules are not guaranteed. Homes are staffed 24 hours a day, 7 days a week, and schedules are determined based on the needs of the home. Catherine Doherty Foster Care is an equal opportunity employer. Consideration for hire, promotion and job status is done without regard to race, color, religion, creed, sexual orientation or identification, marital status, national origin, age, physical or mental disability. Applicant Signature Printed Name Date Page 6