Virginia Health Hospice Application for Employment

Drug Free Workplace.
Please complete the form below to apply for a position with us.
Position Desired
Shift Preferred

DayEveningNight
Full Time/Part Time?

Full TimePart Time
Other Positions of Interest
When are you available?
Facility you are most interested in for employment Please select desired location. (Selection does not guarantee employment will be at preferred location.)*
APPLICANT'S PERSONAL DATA
Full Name

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Desired Start Date

MonthDayYear
Date
HAVE YOU EVER BEEN EMPLOYED WITH VHS?

YesNo
IF YES:
Facility:
Deptartment:
Supervisor:
When:
ARE YOU UNDER 18 YEARS OLD?

YesNo
PERSON TO IDEINTIFY IN CASE OF EMERGENCY

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Cell Phone Number
ALTERNATE EMERGENCY CONTACT

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Cell Phone Number

EDUCATION
HIGH SCHOOL
Name and Address of School
Years Completed
Did you graduate?

YesNo
Diploma?
COLLEGE
Name and Address of School
Years Completed
Did you graduate?

YesNo
Degree or Diploma?
GRADUATE
Name and Address of School
Years Completed
Did you graduate?

YesNo
Degree or Diploma?
OTHER (specify)
Type of School/Training
Name and Address of School
Years Completed
Did you graduate?

YesNo
Degree or Diploma?

WORK EXPERIENCE

START WITH PRESENT OR MOST RECENT POSITION. LIST EMPLOYER’S NAME, FULL ADDRESS AND
TELEPHONE NUMBER. ALL EXPERIENCE MUST BE ACCOUNTED FOR TO INCLUDE PERMANENT,
TEMPORARY, MILITARY OR VOLUNTEER WORK.
Position 1:
From
Month/Year
To
Month/Year
Company Name
Company Address
Position Held
Reason for Leaving
Position 2:
From
Month/Year
To
Month/Year
Company Name
Company Address
Position Held
Reason for Leaving
Position 3:
From
Month/Year
To
Month/Year
Company Name
Company Address
Position Held
Reason for Leaving
Position 4:
From
Month/Year
To
Month/Year
Company Name
Company Address
Position Held
Reason for Leaving
MORE WORK EXPERIENCE? UPLOAD YOUR LIST.

UPLOAD A DOCUMENT WITH ADDITIONAL WORK EXPERIENCE HERE. START WITH PRESENT OR MOST RECENT POSITION. LIST EMPLOYER’S NAME, FULL ADDRESS AND TELEPHONE NUMBER. ALL EXPERIENCE MUST BE ACCOUNTED FOR TO INCLUDE PERMANENT, TEMPORARY, MILITARY OR VOLUNTEER WORK.
Upload additional work experience information here

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Have you ever been discharged or asked to resign by an employer?

YesNo
If YES, explain:

LICENSURE
PROFESSIONAL LICENSE 1:
Profession
License or Certification Number
Expiration Date
State Issued
PROFESSIONAL LICENSE 2:
Profession
License or Certification Number
Expiration Date
State Issued
If you are not a U.S. Citizen, identify your legal authorization to work/study in the U.S.:
HEALTH CARE PROVIDERS ONLY:
Have you ever been disciplined in any manner by a state regulatory agency for any reason?*

YESNO
If YES, please explain:

REFERENCES

Give the names of three persons, not relatives, who know you and can give information about your suitability for employment. Some examples may include an employer, teacher, counselor, and/or clergyman.
Reference 1 Name

First NameLast Name
Reference 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 1 Phone Number
Reference 2 Name

First NameLast Name
Reference 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2 Phone Number
Reference 3 Name

First NameLast Name
Reference 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 3 Phone Number

PLEASE READ CAREFULLY:

EACH PARAGRAPH MUST BE READ AND INITIALED BEFORE THE APPLICATION IS SIGNED:
I consent to the release to Virginia Health Services, Inc. from current and former employers, schools, law enforcement agencies, and other individuals and organizations, information relevant to my consideration for employment. Such parties may rely upon this authorization as a waiver of any claim whatsoever I may have as a result of the party responding candidly to an inquiry from Virginia Health Services. In providing this release, I acknowledge that unfavorable references from any of the above listed references may be used to evaluate my employment with VHS.
Initials
I understand that employment within Virginia Health Services, Inc. is considered employment-at-will, and may be terminated at any time, for any reason without cause. Additionally, hours of work and work assignments can be altered to meet the needs of the company.
Initials
I understand that a false statement or omission of facts and circumstances on this application and/or on other documents related to my qualifications and background may be grounds for not hiring me or for termination. I certify that to the best of my knowledge and belief, all statements are correct, complete, current, and made in good faith and that I will attach information necessary to meet this disclosure requirement.
Initials
If I am offered employment, I understand that I will be subject to and agree to abide by Virginia Health Services policies, procedures, rules, and practices. I also understand that I may be required to agree and submit to alcohol and/or substance abuse tests prior to my acceptance by Virginia Health Services and to periodic testing thereafter at the discretion of Virginia Health Services, in accordance with applicable Virginia Health Services policies and/or practices.
Initials
I understand that I may be offered employment even though certain background checks and investigations, and checking of references may not have been completed. If such inquiries, upon completion, establish information which in Virginia Health Services opinion makes me unqualified, I understand the job offer will be revoked.
Initials
I agree that Virginia Health Services may, without further consent, make lawful use of any photographic picture or video image it may make or cause to be taken of me.
Initials
Signature

Clear
Today's Date

MonthDayYear
May we contact your present employer?

YesNo
If no, please explain:

CRIMINAL HISTORY DISCLOSURE STATEMENT

Please read carefully and follow all instructions

The Code of Virginia prohibits licensed nursing homes, such as those owned and operated by Virginia Health Services, from employing individuals who have been convicted of the barrier crimes specified below. The Code also requires that all applicants for employment with a licensed nursing home in the Commonwealth of Virginia provide a sworn statement or affirmation disclosing any criminal conviction or any pending criminal charges in any jurisdiction, whether within or without the Commonwealth. Virginia Health Services will obtain a satisfactory criminal history record post-offer, pre-employment from the Central Criminal History Records Exchange of the Virginia State Police.

BARRIER CRIMES THAT PROHIBIT EMPLOYMENT WITH A LICENSED NURSING HOME

Murder
Crimes against Nature Involving Children
Abduction for Immoral Purposes
Incest
Assaults and Bodily Wounding
Robbery and Carjacking
Sexual Assault
Arson
Pandering
Delivery of Drugs to Prisoners
Escape from Jail
Felonies by Prisoners

Taking Indecent Liberties with Children
Abuse and Neglect of Children
Failure to Secure Medical Attention for an Injured Child
Abuse or Neglect of an Incapacitated Adult
Obscenity Offenses
Any Equivalent Offense in another State

Felony and/or misdemeanor convictions for crimes other than those specified as barrier crimes will not legally preclude employment by a licensed nursing home in the Commonwealth of Virginia. Virginia Health Services, in its sole discretion and judgment, may or may not choose to employ applicants with convictions for non-barrier crimes.

**You must check ONLY the one item in EACH box that applies to you. Sign and date below as acknowledgement.**

PLEASE READ CAREFULLY

Please note you must disclose any conviction within or ontside of the Commonwealth of Virginia.

CRIMINAL HISTORY

Check one of the following: *

I HAVE A CRIMINAL HISTORYI DO NOT HAVE A CRIMINAL HISTORY
SEX OFFENDER
Check one of the following: *

I AM A CONVICTED SEX OFFENDERI AM NOT A CONVICTED SEX OFFENDER
Please list convictions (if applicable):
FULL DISCLOSURE AND NOTIFICATION OF FUTURE CHARGES

I swear and affirm that I have given a full and truthful accounting of my criminal history as stated above. I also acknowledge the fact that if in the future, I am charged with any criminal offense, including those specified above as barrier crimes or sex offense within or without the Commonwealth of Virginia, I am required to notify my Administrator within 7 days of offense. Failure to report offense will result in disciplinary action up to and including tennination. I hereby give my consent for Virginia Health Services, Inc, or its divisions thereof, to conduct a criminal history background search on my behalf.
Signature

Clear
Date

MonthDayYear
Date
Any material falsification, misrepresentation, or omission off act relating to this statement shall be grounds for denial of or dismissal from employment with Virginia Health Services and shall deem you guilty upon conviction of a Class I misdemeanor.

Revised: 07/09/10, 07/0112013
Reviewed and Approved by QARC: 07/2112010, 07/12/2013

INVITATION TO SELF-IDENTIFY (VEVRAA)

(Pre-Offer)

1. This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. § 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans;
(3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A "disabled veteran" is one of the following: a veteran of the U.S.
military, ground, naval or air service who is entitled to compensation (or
who but for the receipt of military retired pay would be entitled to
compensation) under laws administered by the Secretary of Veterans
Affairs; or a person who was discharged or released from active duty
because of a service-connected disability.

A "recently separated veteran" means any veteran during the
three-year period beginning on the date of such veteran's discharge or
release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who,
while serving on active duty in the U.S. military, ground, naval or air
service, participated in a United States military operation for which an
Armed Forces service medal was awarded pursuant to Executive
Order 12985.

Protected veterans may have additional rights under USERRA-the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

2. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
CHOOSE ONE:

IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVEI AM NOT A PROTECTED VETERAN
3. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are consistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974. as amended.

4. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate. if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

5. Virginia Health Services, Inc. ("VHS") is subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974 (VEVRAA), as amended. and the Veterans' Employment Opportunity Act of 1998(VEOA). VEVRAA requires VHS to take affirmative action to employ and advance in employment special disabled veterans, veterans of the Vietnam era, and recently separated veterans covered by the Act. VEOA requires VHS to take affirmative action to employ and advance in employment "other eligible veterans" who served on active duty during a war or in any campaign or expedition for which award of a campaign badge has been authorized.
Signature

Clear
Date

MonthDayYear
Date

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.ⁱ To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know If I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Autism
Bipolar disorder
Post-traumatic stress disorder (PTSD)
Deafness
Cerebral palsy
Major depression
Obsessive compulsive disorder
Cancer

HIVIAIDS
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Diabetes
Schizophrenia
Missing limbs or partially missing limbs
Intellectual disability (previously called mental retardation)
Epilepsy
Muscular dystrophy

Please check one of the boxes below:

YES, I HAVE A DISABILITY (or previously had a disability)NO, I DON'T HAVE A DISABILITYI DON'T WISH TO ANSWER
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

i - Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at WM'I.dol.gov/ofccp.

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Virginia Health Hospice Application for Employment

REFERENCES

PLEASE READ CAREFULLY:

CRIMINAL HISTORY DISCLOSURE STATEMENT

BARRIER CRIMES THAT PROHIBIT EMPLOYMENT WITH A LICENSED NURSING HOME

CRIMINAL HISTORY

SEX OFFENDER

FULL DISCLOSURE AND NOTIFICATION OF FUTURE CHARGES

INVITATION TO SELF-IDENTIFY BY RACE AND GENDER

INVITATION TO SELF-IDENTIFY (VEVRAA)

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do I know If I have a disability?

Reasonable Accommodation Notice

ATTACH YOUR RESUME

SUBMIT YOUR APPLICATION