JM STAFFING PRELIM APPLICANT QUESTIONNAIRE

Transcription

1 PRELIM APPLICANT QUESTIONNAIRE It s about partnership. It s about people. It s about success. Applicant Name City, State Address 1. Are you telephone accessible? Yes No Cell Phone: Home Phone: 2. Do you have reliable transportation? Yes No a. If the assignment you re applying for involves driving a motor vehicle: Will you release your driving record (MVR) to us for review? Yes No (please attach your drivers license) b. (If for a driving assignment) Do you have your own vehicle? Yes No c. (If the answer to b is yes) Will you provide us your personal automobile insurance policy identification card? Yes No 3. Do you have your I-9 (work status) information? Yes No 4. How did you hear about us or where did we see your resume? 5. What job(s) are you applying for? 6. What areas are you willing to work? 7. For what pay? 8. Do you have current, valid credentials, licenses, and permits (as necessary) to fill the positions for which you are applying (question 4)? Yes No a. (If answer to #7 is yes) Will you authorize us to verify your credentials with the appropriate authorities? Yes No 9. Are you willing to take a drug test according to our policy? Yes No 9. Can you pass a Federal background check; no misdemeanors, felonies, including DUIs? Yes No If No, please explain 10. Will you release your background information inclusive of criminal records? Yes No Applicant Signature Date

2 554 E. Foothill Blvd., Suite 117 San Dimas, CA Fax It s about partnership. It s about people. It s about success. APPLICANT INFORMATION Last Name First Name M.I. Date Street Address City State Zip Phone # Cell # Date Available Social Security # Driver s License # Position applying for: Desired Pay Range: (Hourly/Salary) Type of Work Experience: Pharmacist Physician s Assistant Dietician/Diet Technician Radiology Technician Phlebotomist Registered Nurse Licensed Vocational Nurse Registered Dental Assistant Laboratory Technician Medical Records Technician Other: EDUCATION Medical Education Colleges attended, dates, degrees Medical School Degree Phone/Address Date Internships Types, hospitals, addresses, and dates of service Hospital Type Phone/Address Date Equal Opportunity Employer Page 1 of 10

3 Residencies and other Graduate Training Types, hospitals, clinics, correctional facilities Hospital Type Phone/Address Date LICENSURE License(s) Type State Date Received Last Renewal Number Exam/Reciprocity If certified, give name of Board and date of certification: If not certified, do you contemplate certification? Yes No When do you believe you will be eligible? Give name of Board of your choice: If a graduate of a foreign medical school, have you taken the examination of the Education Council for Foreign Medical Graduates? Yes No Date and Result? If not taken, do you plan to? Yes No When? Temporary ECFMG Certificate #: Date: Regular ECFMG Certificate #: Date: Hospital Appointments (List chronologically appointments to hospital staffs, showing name of hospital, type of appointment: active, courtesy, etc, dates of services and privileges Type and Privilege Hospital Phone/Address Date Teaching Appointments Name Subject Phone/Address Date Equal Opportunity Employer Page 2 of 10

4 Solo Practice and/or Group Practice (list types of practice, location, and dates of practice in addition to training appointments already listed: Name and describe your present position if in other than solo or group practice: Have you ever had a license refused, revoked, or suspended? Yes No If your answer is yes, please provide details: Are you now involved in malpractice litigation? Yes No If your answer is yes, please provide details: Do you now have professional liability insurance coverage? Yes No Name of Carrier: Expiration Date: Please briefly state your philosophy of (a) healthcare and (b) rationale for seeking employment with JM Staffing: REFERENCES References: Three professional and two personal. Professional references must be persons who have supervised your professional work or been associated with you professionally and who know you well. Personal references cannot be family members. Name Title Phone/Address During what years did he/she know you? What was his/her relationship to you professionally? Equal Opportunity Employer Page 3 of 10

5 PREVIOUS EMPLOYMENT Company Name Job Title Supervisor Name Phone # Address City State Zip Start Date End Date Starting Salary Ending Salary Responsibilities: Reason for leaving: May we contact for a reference? Yes No Company Name Job Title Supervisor Name Phone # Address City State Zip Start Date End Date Starting Salary Ending Salary Responsibilities: Reason for leaving: May we contact for a reference? Yes No Equal Opportunity Employer Page 4 of 10

6 EMPLOYMENT VERIFICATION It s about partnership. It s about people. It s about success. Applicant Name Social Security # Position Held Dates of Employment Current/Previous Employer Supervisor Contact # Address City State Zip Code I hereby give permission to the above named employer to release information to JM Staffing regarding my performance while employed at that facility. Applicant Signature Date (APPLICANT, complete top section only) EMPLOYER - The person above has registered with JM Staffing and has listed you as a previous employer. We would appreciate your assistance in verifying employment and evaluating job performance. All information is confidential. Title: Start Date: End Date: Personal Evaluation Excellent Above Average Quality of work Quantity of work Attitude Adaptability to work situations Dependability Cooperation Ability to get along with others Attendance and punctuality Personal Appearance Comments Satisfactory Below Average Poor Is this employee eligible for rehire? Yes No Employer s Signature Company Name Date Print Name Title Contact # EMPLOYER, please return the completed form to hr@jmstaffing.com or fax (909) , thank you. For JM Staffing Use Only: Verbal Verification Date Contact # Spoke with Title Company Name

7 JM STAFFING It s about partnership. It s about people. It s about success. EMPLOYMENT VERIFICATION Applicant Name Social Security # Position Held Dates of Employment Current/Previous Employer Supervisor Contact # Address City State Zip Code I hereby give permission to the above named employer to release information to JM Staffing regarding my performance while employed at that facility. Applicant Signature Date (APPLICANT, complete top section only) EMPLOYER - The person above has registered with JM Staffing and has listed you as a previous employer. We would appreciate your assistance in verifying employment and evaluating job performance. All information is confidential. Title: Personal Evaluation Start Date: Excellent Above Average Satisfactory End Date: Below Average Poor Quality of work Quantity of work Attitude Adaptability to work situations Dependability Cooperation Ability to get along with others Attendance and punctuality Personal Appearance Comments Is this employee eligible for rehire? Yes No Employer s Signature Company Name Date Print Name Title Contact # EMPLOYER, please return the completed form to hr@jmstaffing.com or fax (909) , thank you. For JM Staffing Use Only: Verbal Verification Date Contact # Spoke with Title Company Name

8 ADDITIONAL INFORMATION Are you currently employed? Yes No Have you ever worked for another temporary agency: Yes No If Yes, which one(s): Have you ever been employed with this company before? Yes No If Yes, when? Do you have any friends/relatives employed by this company? Yes No If Yes, provide their names/relationship to you: Are you currently on lay off status and subject to recall? Yes No If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.? Yes No Are you able to perform all of the essential functions of the job for which you are applying Yes No with or without reasonable accommodation? If hired, are there any accommodations the company would need to provide so that you Yes No can perform all those essential functions and duties of the position being applied for? If Yes, please explain: If hired, do you have a reliable means of transportation to and from work? Yes No How far are you willing to travel: Have you ever been convicted of a felony, misdemeanor, or DUI? Yes No If Yes, please explain: List any seminars, classes, or other education which may help qualify you for this position: List any professional, trade, business, or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability, or any other protected status. Identify formal job training that relates to this position. Identify what skills or certification you possess related to this position. If you are hired, what value would you add to our company? Equal Opportunity Employer Page 5 of 10

9 Describe what you believe are the most unique features of your work history. List any languages other than English that you can speak, read, or write that could be of benefit to the position applied for. Equal Opportunity Employer Page 6 of 10

10 AFFIRMATIVE ACTION QUESTIONNAIRE (Confidential and Voluntary) JM Staffing is committed to an Affirmative Action Program which includes giving full consideration for employment to qualified individuals without regard to race, color, religion, gender, or national origin. The following information is being requested of all applicants for employment. You re providing this information is strictly voluntary. The self-identification request is made in compliance with the regulations issued by the U.S. Department of Labor. Responses will be used for the purpose set forth in these regulations. Its purpose is to assist JM Staffing in monitoring its Affirmative Action Program and to aid in complying with required Government record keeping and periodic reporting. This information is not part of the employment application. It will be processed separately and will not be considered in the employment/selection process. If you choose to provide information, please complete the following: Applicant Name Position Applying for Date Social Security Number: Sex: Female Male Race/Ethnicity (check one): American Indian or Alaskan Native A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam Black or African American A person having origins in any of the Black racial groups in America Native Hawaiian or other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands White A person having origins in any of the original peoples of Europe, North Africa, or the Middle East Hispanic or Latino (all races) A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race Two or more races: Are you: Disabled Veteran Non-Veteran Vietnam Veteran I wish to decline Applicant Source of Recruitment (check one): Newspaper Advertising Walk-In Employee Referral. If Employee Referral, name of Employee: Internet. If Internet, website name: MILITARY SERVICE Have you ever been in the armed forces? Yes No Are you now a member of the National Guard? Yes No Specialty: Date Entered: Discharge Date: Equal Opportunity Employer Page 7 of 10

11 DISCLAIMER AND SIGNATURE I agree that I will settle any and all previously unasserted claims, disputes or controversies arising out of or relating to my application or candidacy for employment and/or cessation of employment with JM Staffing, exclusively by final and binding arbitration before a neutral Arbitrator. By way of example only such claims include claims under federal state and local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the law of contract and the of tort. I agree to these terms Please Read Carefully I do further authorize JM Staffing to investigate, request, and receive any information it deems appropriate, in its sole discretion, relating, to my past employment, education or activities. I indemnify JM Staffing against any liability which may result from such investigation and receipt of information. Any false answer or statement or implication by me to JM Staffing or any of its clients shall be sufficient cause for denial or discharge from any temporary employment which I may secure. If I am temporarily employed by JM Staffing, I agree to strictly obey the work rules and regulations of and regulations as they may occur form time to time. I understand that nothing contained in the application or in the granting of an interview or in any policy practice is intended to create an employment contract between JM Staffing and myself. No promise regarding employment have been made to me and I understand that no such promise or guarantee is binding upon JM Staffing. If a temporary employment relationship is established, I understand that such relationship can be terminated at any time by JM Staffing for any reason. I agree to these terms Applicant Signature Date Equal Opportunity Employer Page 8 of 10

12 HEPATITIS B VACCINATION OSHA requires that all healthcare workers at risk of acquiring Hepatitis B have the opportunity to receive the Hepatitis B vaccination by their employer. JM Staffing will provide this opportunity to you as is appropriate based upon your responses to the following: a. If you have completed the vaccination series, please indicate where appropriate below. b. If you are in the process of receiving the series, please indicate where appropriate below. Please indicate if you require a dose of the vaccine while working on an assignment with JM Staffing. c. If you decline to have the Hepatitis B vaccination, indicate where appropriate below. My signature below certifies that I have been provided with general educational materials regarding exposure to blood borne pathogens as required by OSHA regulations. Further, I understand that I will be provided appropriate training at my assigned workplace and will adhere to the policies and procedures of the facility to which I am assigned by JM Staffing. I understand that due to my occupational exposure to blood and/or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no cost to me, while on active assignment with JM Staffing. Choose the appropriate response form the options below; sign and date where indicated: I understand the OSHA guidelines and I completed the vaccine series on / / (Please include copies of vaccination) Signature: Date: I need # or booster, in the series (Please make arrangements with JM Staffing). Signature: Date: I DECLINE: the Hepatitis B vaccine series. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to myself, while on assignment with JM Staffing. I accept the responsibility to inform JM Stafing of this decision at that time. Signature: Date: Equal Opportunity Employer Page 9 of 10

13 PHYSICIAN STATEMENT Please Note: Most of our client facilities require a statement of good health. Therefore, certification of health must be updated on a yearly basis. However, you should not delay in sending in your completed application even if this statement cannot be competed immediately. This statement can be sent at a later date, but it must be received before you begin employment. We accept alternate physician statement forms if they include the information as required below. Name: PLEASE ATTACH COPIES OF ALL TEST RESULTS TB / PPD Skin Test: Date: Results: OR Chest X-Ray: Date: Results: MMR Date: or the following titres: Mumps Titre Date: Immune Not Immune Rubella Titre Date: Immune Not Immune Rebeola Titre Date: Immune Not Immune Varicella Zoster Titre Date: Immune Not Immune Hepatitis B Vaccine #1 #2 #3 Date Date Date Hepatitis Booster Date: The above named individual has been examined by me and is found to be in good physical health, free from communicable diseases, and able to perform all job duties as a traveling healthcare professional without any limitations. Physician Signature Print Name Date License Number Address Equal Opportunity Employer Page 10 of 10