Name                                                                                                                                                                           

                                                (Last)                                                      (First)                                                                      (Middle Initial)

Present Address                                                                                                                                                          

                                                                (No.)                                                                       (Street)

                                                (City)                                                       (State)                                                                     (Zip Code)

Telephone: (h)                                       (c)                                  Social Security Number:                                             

Position Applied For:                                                                                                   

Position Status:            o Full Time       o Part Time      o Per Diem

Position(s) desired in order of preference:

1.                                                                                            

2.                                                                                            

3.                                                                                            

Are you willing to work all assignments as scheduled, including Weekend/Holiday and On Call?                            oYes oNo

If hired, when are you available to start?       /       /            

Can you with or without reasonable accommodation perform the essential functions of the

Job you are applying for?                                                                                                                                  oYes oNo

Are you legally authorized to work in the United States?                                                                                      oYes oNo

Have you worked for us before?                                                                                                                                    oYes oNo

If yes, when, under what name, and what position held?                                                                                                

Do you have a current New Jersey professional license and/or certification?                                                        oYes oNo

If yes, have any of your licenses, registrations, or certifications ever been suspended, restricted,

revoked or under review for disciplinary action by any or all state boards?                                                                       oYes oNo

If yes, please explain:                                                                                                               

Do you have a driver’s license valid in the State of New Jersey?                                                                          oYes oNo

Have you ever been convicted of a crime or pleaded guilty to a felony or misdemeanor?                                     oYes oNo

Do you have any criminal convictions or any pending criminal charges in any state?                                             oYes oNo

If yes, please explain                                                                                                                

(Conviction of a crime is not an automatic disqualification for employment. All factors will be considered)

Have you ever been suspended, debarred or excluded from participating in any federal health care program?       oYes oNo

If yes, please explain in detail:                                                                                                                                      

Are you over the age of 18?                                                                                                                               oYes oNo

If not, do you have a work permit?                                                                                                         oYes oNo

EDUCATION

SKILLS

Do you have any special skill, belong to a professional organization, or have any relevant volunteer experience? (Please list)

Do you know Medical Terminology?       oYes oNo

EMPLOYMENT HISTORY

List last position first, including any military service. If Student, list summer or part-time jobs.

DESCRIBE YOUR DUTIES

DESCRIBE YOUR DUTIES

DESCRIBE YOUR DUTIES

May we contact the employers you listed?                                                                                                          oYes oNo

If no, indicate below which one(s) you do not wish us to contact:

If previous work record was under a different name, please state name(s) under which you worked:

                        NAME                                                   PLACE WORKED

How were you referred to In Home Health Services?                                                                                                       

PERSONAL REFERENCES, OTHER THAN RELATIVES OR FORMER EMPLOYERS

            NAME                                       ADDRESS/TELEPHONE#                      POSITION                     YEARS KNOWN

1.                                                                                                                                                                                  

2.                                                                                                                                                                                  

Federal and State law prohibits discrimination in employment because of race, color, creed, sex, national origin, age, marital status, veteran status or disability.

PLEASE READ CAREFULLY

APPLICANT’S CERTIFICATION AND AGREEMENT

I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements or omission on this application shall be considered sufficient cause for dismissal. Further, I release all individuals who submit information at the agency’s request to facilitate the assessment of my qualifications, from any liability for their statements made in good faith and without malice. I acknowledge that the burden of producing the necessary information for a proper evaluation rests with me, the applicant. I understand my employment is contingent upon successful completion of a physical examination/drug screen and satisfactory reference results, including a criminal background check and/or a credit history check as well as checking other appropriate sources. If employed by In Home Health Services, I understand that my employment may be terminated with or without cause and with or without notice at any time at the discretion of the Agency.

As a potential employee of In Home Health Services, I am willing to commit to living the values of the Agency as stated on the attachment to this application. I understand that this application for employment shall be considered active for 1 year.

DATE                                                                                     SIGNATURE                                                                                                                        

In Home Health Services is an Equal Opportunity Employer

IN HOME HEALTH SERVICES

CUSTOMER SATISFACTION STANDARDS

AGENCY MISSION

The Mission of In Home Health Services is to provide comprehensive, professional, cost effective health care to persons in need through highly qualified staff in a progressive, caring environment, without discrimination as to race, color, creed, sex, national origin, age, handicap, religious or political beliefs, and source of payment.

SERVICE MISSION

To improve the quality of life for all those we touch through excellence in patient care and community service

VISION

Creating the best possible environment for our patients to heal, our physicians to practice and our employees to work.

SERVICE STANDARDS FOR EXCELLENCE

·         First Impression

·         Professional and Effective Communication

·         Ownership

·         Care / Respect

·         Teamwork

VALUES OF OUR AGENCY

Each member of the healthcare team is committed to providing quality healthcare to our patients while incorporating into their professional practice the following core values of the agency:

INTEGRITY

Reliability and trust will be the foundation of our professional interactions.

SERVICE

We will strive to exceed our customers’ expectations with each and every encounter.

COMPASSION

Our caring will be evident in all of our interactions.

RESPECT

Every individual will be treated with dignity and value.

TEAMWORK

Working together to achieve excellence