Envision Home Health
  Employment Application
* Indicates Mandatory Fields

*First Name
Middle Name
*Last Name
*D.O.B. *Gender
  
*Address 1
Address 2
*Zip *City *State *S.S.N.
          
*Cell Phone
Home Phone
*Email Address
Languages
*Position Applying For:
*How Were You Referred: Referred Person:
*Are you legally Eligible to be Employed in United States?
*Will you now or anytime in the future need to be sponsored for Employment Visa Status?
( Office Positions can skip this section )
Willing to provide service to a client with a pet? Cat  Dog
Willing to provide service to a client who smokes?
Own reliable transportation?
Do you have a valid driver’s license?
DL. No.:  
DL. Expiry Date:
Preferred Day and Time
Day From To
( Office Positions can skip this section )
Select All Day
Monday  Apply Time to All
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Certifications
Certificate Name Expiry Date
Add More Certifications
Skills
Education
Name Zip City State Major / Subject # Yrs Attended Graduate
High School
College/University
Vocational/Technical
Previous Employment
Previous Employment 1
Employer: Yes No
Address: Zip:
City: State:
Job Title: From: To:
Supervisor: Phone:
Previous Employment 2
Employer: Yes No
Address: Zip:
City: State:
Job Title: From: To:
Supervisor: Phone:
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Clinical Reference
Clinical Reference #1
Name:
Company Name: Company Phone:
By initialing this box, I hereby release from all liability the company or person completing this form and authorize them to release all information regarding my employment with them. I understand that his information may be released to clients of the requesting company and other requesting third parties on a need to know basis. I also release the requesting company from all liability for any damages from the disclosure of this information.
Name/Title: Date:
Clinical Reference #2
Name:
Company Name: Company Phone:
By initialing this box, I hereby release from all liability the company or person completing this form and authorize them to release all information regarding my employment with them. I understand that his information may be released to clients of the requesting company and other requesting third parties on a need to know basis. I also release the requesting company from all liability for any damages from the disclosure of this information.
Name/Title: Date:
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References
Reference 1
Name:
Address: Zip:
City: State:
Home Phone: Work Phone:
Relation: Years known:
Reference 2
Name:
Address: Zip:
City: State:
Home Phone: Work Phone:
Relation: Years known:
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Comments
Statement of Employability
1. * Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other?
Yes  No
2. If yes, please explain.   
3. * Please select the choice that accurately refects your Hepatitis B Vaccine status:
I have had the Hepatitis B Vaccine before at an earlier date.
I do not wish to have the Hepatitis B Vaccine.
I wish to recieve the Hepatitis B Vaccine.
4. * Mycobacterium Tuberculosis is transmitted by air, carried in droplets that are created when a person with respiratory TB coughs, sneezes or shouts. TB Infection occurs when someone inhales the droplet particles containing the Mycobacterium. A person may have no symptoms, but still have latent TB infection (LTBI) and may develop TB disease at some point in their lives. TB skin tests may become positive in 2 to 12 weeks after the exposure. The following criteria is utilized to identify if an employee has potential TB. This criteria is also utilized to determine if an employee needs another chest xray. This information is also presented in training. Do you have any of the following Potential active symptoms of TB which include but limited to: Persistent cough greater than 2 weeks duration, Bloody sputum, Hoarseness, Fatigue, Chest pain, Night sweats, Weight loss, Anorexia, or Fever?
Yes   No
5. * Do you consider yourself part of any of the following groups that have a higher prevalence of TB infection? 1. Medically underserved populations 2. Homeless individuals 3. Current or past prison inmates 4. Alcoholics 5. Injecting drug users 6. Elderly 7. Foreignborn persons from Asia, Africa, the Caribbean and Latin America 8. Contacts to individuals with TB 9. Groups with a greater risk to progress from latent TB infection to active disease 10. Individuals with HIV infection, silicosis, SIP gastrectomy or jejunoileal bypass surgery, greater than 10 lb. Below normal body weight, chronic renal failure, diabetes mellitus, immunosuppressed due to medication, and those with some malignancies. 11. Individuals who have been infected within the past 2 years and individuals with fibrotic lung disease on chest xray.
Yes  No