Employment application - The Center for Nursing and ...



2159000952500Employment ApplicationApplicant InformationFull Name:Date:LastFirstM.I.Address:Street AddressApartment/Unit #CityStateZIP CodePhone:EmailDate Available:Social Security No.:Desired Salary:$Position Applied for:Are you a citizen of the United States?YES FORMCHECKBOX NO FORMCHECKBOX If no, are you authorized to work in the U.S.?YES FORMCHECKBOX NO FORMCHECKBOX Have you ever worked for this company?YES FORMCHECKBOX NO FORMCHECKBOX If yes, when?Have you ever been convicted of a felony?YES FORMCHECKBOX NO FORMCHECKBOX If yes, explain:EducationHigh School:Address:From:To:Did you graduate?YES FORMCHECKBOX NO FORMCHECKBOX Diploma::College:Address:From:To:Did you graduate?YES FORMCHECKBOX NO FORMCHECKBOX Degree:Other:Address:From:To:Did you graduate?YES FORMCHECKBOX NO FORMCHECKBOX Degree:ReferencesPlease list three professional references.Full Name:Relationship:Company:Phone:Address:Full Name:Relationship:Company:Phone:Address:Full Name:Relationship:Company:Phone:Address:Previous EmploymentCompany:Phone:Address:Supervisor:Job Title:Starting Salary:$Ending Salary:$Responsibilities:From:To:Reason for Leaving:May we contact your previous supervisor for a reference?YES FORMCHECKBOX NO FORMCHECKBOX Company:Phone:Address:Supervisor:Job Title:Starting Salary:$Ending Salary:$Responsibilities:From:To:Reason for Leaving:May we contact your previous supervisor for a reference?YES FORMCHECKBOX NO FORMCHECKBOX Company:Phone:Address:Supervisor:Job Title:Starting Salary:$Ending Salary:$Responsibilities:From:To:Reason for Leaving:May we contact your previous supervisor for a reference?YES FORMCHECKBOX NO FORMCHECKBOX Military ServiceBranch:From:To:Rank at Discharge:Type of Discharge:If other than honorable, explain:Disclaimer and SignatureI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Signature:Date:In addition to this application, applicant must complete the following form which appears below:Drug Test Policy / Consent for Drug Testing Form57150-2857500Drug Testing PolicyIt is the policy of the Center to prohibit the unlawful use of illegal drugs or abuse of prescription drugs by employees in the workplace, on the Center’s premises or while engaged directly or indirectly in Center business.Pre-Employment Testing-Every applicant that is offered a position at the Center will be required to undergo and pass a drug test before commencing employment. Failure to submit to drug testing shall be grounds for refusal of employment. If the test shows a positive result for the presence of drugs, then the offer of employment shall be rescinded. If the test result is diluted, the applicant will be notified of the result and may be given a second opportunity to be tested. Each applicant will acknowledge the Center’s right to screen by signing the employment application and a Drug Test Consent Form. (Attachment A – see below)Post-Accident Testing-If an employee has been involved in a work-related incident resulting in the need for treatment/evaluation of injuries, the Center reserves the right to require the employee submit to a drug test as a condition of continued employment. Refusal of any employee to participate in drug testing shall be grounds for termination. All employees will be asked to sign a Drug Test Consent Form (Attachment A)Reasonable Suspicion - If, at any time, there is reasonable suspicion that an employee is under the influence of drugs or alcohol, the employee will be required to submit to a drug test. Reasonable suspicion will be based upon observable actions, alone or in conjunction with other factors including but not limited to:Dangerous conduct, potentially resulting in injury to the employee, co-workers, residents and or others.Drug related signs such as paraphernalia.Physical symptoms such as bloodshot eyes, dilated pupils, etc.Disciplinary Procedures-Any employee who tests positive as a result of a drug test or refuses to submit to drug testing will be suspended immediately. If the positive test result is confirmed, the employee will be subject to disciplinary action up to and including termination.Drug Testing Procedure- All drug testing will be completed at the Hoosick Falls Family Health Center, 16 Danforth Street, Hoosick Falls, NY 12090.Specimens (urine) will be screened for the following: amphetamines, barbiturates, benzodiazepines, cannebinoids, cocaine, methadone, opiates, phencyclidine, propoxyphene and methaqualone.All drug test results will be reported to the Employee Orientation Health Nurse. If a positive test result is received for an applicant, the Employee Orientation Health Nurse will contact the candidate in writing to rescind the offer of employment based on the failure to successfully complete pre-employment requirements. If the positive test result is for an existing employee, the Administrator and/or Director of Nursing will contact the employee to discuss the results. The employee will be suspended and referred to a substance abuse professional for assessment. The employee will be required to provide written documentation of successful participation or completion of the substance abuse professional’s recommendation/plan to be eligible to return to work. The employee may be subject to drug testing upon return to work and for up to one year following the employee’s return to work. Any employee who tests positive a second time during the course of employment will be terminated immediately. 198691510033000 Attachment AConsent for Drug Testing FormAny offer of employment will be contingent upon the successful completion of a Urine Drug Screen (UDS). A positive drug test or failure to comply with the time requirements will rescind any offer and preclude you from any further consideration. ? This test will be completely funded by the Center and will take place at the Hoosick Falls Family Health Center (Glens Falls Hospital) 16 Danforth Street, Hoosick Falls at a time established prior to applicant’s start date. You will need two pieces of ID for the screening, one of which needs to be a picture ID. Additionally per the Drug Testing Policy, the Consent for Drug Testing Form will be used in conjunction with any required Post Accident testing and any testing under the Reasonable Suspicion section. Please sign below acknowledging your consent to complete the Drug Test prior to employment. This form must be returned to the Center for Nursing and Rehabilitation at Hoosick Falls along with the Application for Employment. You should not give notice to your current employer, sell real estate, or incur any other expense associated with acceptance of employment until you receive notification of the drug screen results. I (please print name) __________________________________________, hereby consent to a pre-employment Urine Drug Screen (UDS) to be performed at the Hoosick Falls Family Health Center at a date and time to be established prior to start of employment. I understand that a positive test result will delay and may terminate any offer of employment previously agreed upon and preclude my application from further consideration.Signature of Applicant or GuardianDatePrint Name of Applicant or GuardianDate ................
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