CARETEL INNS ~ INITIAL SCREEN
Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, citizenship, height, weight, hadicap, or any other legally protected status
This is an initial screen of information to determine if your credentials match our open positions. Included is the required criminal background questionnaire. All information must be completed in full in order to be considered for employment.
Date of application (mm/dd/yy):
Position Applied For:
Specifically:
Facility Location:
Referral Source:
Name
Last
First
Middle
Address
Number and Street
City
State
Zip Code
Telephone
Social Security Number
Area Code and Phone Number
If employed and you are under 18, can you furnish a work permit? ....................................................
Have you filed an application here before? .........................................................................................
Are you currently working? ................. ........................................................................................
May we contact your present employer? ........................................................................................
Are you prevented from lawfully becoming employedin this country because of Visa or Immigration Status? (Proof of citizenship or immigration status may be required upon employment)
On what date would you be available for work?
Are you available to work:
(check all that apply)
Are you currently on lay-off and subject to recall? ..........................................................................
Can you travel if the job requires it? ...........................................................................................
Have you been convicted of a crime? .........................................................................................
(Conviction will not necessarily disqualify an applicant from employement)
If yes, please explain
Have you ever been administratively determined by a federal, state or local governmental agency to have committed abuse or neglect? ...................................................................................................
If yes, when, where and nature of the case
Are you on a court-supervised probation or parole? ....................................................................
If yes, please explain:
Have charges ever been substantiated against you in a Department of Labor and Economic Growth/Department of Community Health or Family Independence Agency adult foster care licensing investigation? .............
If yes, please explain:
Have charges ever been substantiated against you for abuse, neglect, exploitation, mishandling client funds or any other recipient rights violations in an investigation by:
Department of Labor and Economic Growth/Department of Community Health? ...............................
Family Independence Agency? ..............................................................................................
A local Community Mental Health Recipient Rights Office? ......................................................
Any other recipient rights office? ...........................................................................................
If yes is answered to any of the above, please explain:
Have you ever been employed by this organization before? .....................................................
If yes, give dates employed and indicate if employed under a different name
Please indicate the names of any relatives already employed by this employer
Will you submit to a drug-screening test? ............................................................................
Are you capable of performing in a reasonable manner with or without reasonable accommodation, the activities involved in the job or occupation for which you have applied? ..........................................
EDUCATION
High School
Name:
Years Completed:
College/University:
Years Completed:
Degree Level:
Course of Study:
Professional, trade, business or civic activities and offices held. (You may exclude those that indicate race, color, religion, sex or national origin):
Graduate/Professional:
Name:
Years Completed:
Degree Level:
Course of Study:
SPECIAL SKILLS AND QUALIFICATIONS: Summarize special skills and qualifications acquired from employment or other experience:
EMPLOYMENT EXPERIENCE
Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names that indicate race, color, religion, sex or national origin.
Employer
Address
City/State/Zip Code:
Job Title:
Hourly Rate or Salary:
Dates Employed From (mm/dd/yy):
To:
Supervisor:
Work Performed:
Reason for Leaving:
Employer:
Address:
City/State/Zip Code:
Job Title:
Hourly Rate or Salary:
Dates Employed From (mm/dd/yy):
To:
Supervisor:
Work Performed:
Reason for Leaving:
Employer:
Address:
City/State/Zip Code:
Job Title:
Hourly Rate or Salary:
Dates Employed From (mm/dd/yy):
To:
Supervisor:
Work Performed:
Reason for Leaving:
If there are any periods between these employers when you were not employed, please state the dates you were not employed and the reasons for the non-employment.
ACKNOWLEDGEMENT
By typing my name below, I certify that the answers given in this initial screening are true and complete to the best of my knowledge and understand that false or misleading information or omission of information given may result in rejection of this questionnaire.
Name:
Date: (mm/dd/yy)
(Please continue for the Criminal Background Check and Consent Form)
CRIMINAL BACKGROUND CHECK
APPLICANT INFORMATION SHEET
As part of the application process for applying to work in our facility, we are required by the State of Michigan and the Federal government to conduct various background checks. These background checks include the following registries:
* U.S. HHS Medicare/Medicaid OIG Exclusion List
* Nurse Aide Registry (NAR)
* Public Sex Offender Registry (PSOR)
* Offender Tracking Information System (OTIS)
Prior to completing the application process, we must perform the above listed background checks. If you wish to proceed with your application for employment with our facility, the following information is needed:
First Name
Last
Any former first name used:
Any former last name used:
Maiden last name (if applicable):
Date of Birth (mm/dd/yy)
Place of Birth
Country of Citizenship:
Height: Ft. In.
Weight:
lbs.
Hair Color:
Eye Color:
Gender:
Race:
Social Security Number: (xxx-xx-xxxx)
Address:
City:
State:
Zip Code:
County:
Drivers License or State Identification:
Professional License Number (if applicable)
Certified Nurse Aide Number (if applicable)
CONSENT
Check One: Employment
A criminal record will not necessarily disqualify an applicant from consideration for employment.
As a prospective employee, I understand it is a policy to secure criminal history information as part of the pre-employment screening process.
As a condition of being considered for employment or hiring:
a. I hereby consent to and authorize the health or AFC facility/agency to conduct a background check that includes a search of state and federal abuse and neglect registries and databases, in addition to a search of state and federal criminal history records that include a fingerprint-based check. I understand that this consent extends to the release and sharing of such information with the Michigan Departments of Community Health, Human Services, Corrections, and State Police.
b. I hereby authorize the release of any relevant information to the health or AFC facility/agency to be used to conduct the background check as required under Michigan Public Acts 27, 28 and 29 of 2006.
c. I understand that the health or AFC facility/agency will make the final employment determination. I also understand that the health or AFC facility/agency may terminate the background check or determine not to hire at any stage of the process.
d. I understand that the health or AFC facility/agency, in denying employment to an applicant, and reasonably relying on information obtained through a background check, is provided immunity from any action brought by an applicant due to the employment decision.
e. I hereby release this company and their officers, directors, or employees from any and all liability and damages for requesting, releasing, and using information concerning me, my work and performance record.
Name:
Date: (mm/dd/yy)
