DQPHC Online Application for Employment DebestQuality Private Home Care is an equal opportunity employer. We are regularly hiring RNs, LPNs, PCTs, CNAs, HCAs and other Personal Care Professionals. Apply today! We are constantly hiring for Physical Therapists and Physical Therapy Assistants. You can download the Application Form here and fill it out with your information OR complete the form below. *REQUIRED INFORMATION TODAY'S DATE TIME * REFERRAL SOURCE REFERRAL SOURCE* Yellow Pages Job Fair YELLOW PAGES JOB FAIR (WHERE) Newspaper Family-Friend-Employee NAME NEWSPAPER NAME* ADDRESS* TELEPHONE NUMBER 1 * TELEPHONE NUMBER 2 TELEPHONE NUMBER 3 TELEPHONE NUMBER 4 TYPE OF TRANSPORTATION* Car Bus Other OTHER TRANSPORTATION JOB FAIR (WHERE) AREAS WILLING TO WORK / TRAVEL 5-NORTH EAST GA. ClarkWaltonJacksonGreenNewton 3-ATLANTA REGION FultonDekalbClaytonRockdaleDouglasHenryPaulding 4-SOUTHERN CRESENT ButtsCarrollCowetaHeardLamarMeriwether 8. CENTRAL SAVANNAH REGION BurkeColumbiaGlascockHancockJeffersonJenkins 7-MIDDLE GEORGIA BibbBaldwinMonrowPutmanPulaski 8 HEART OF GEORGIA LaurensToomsTreutlenWayneWheeler 7-WEST CENTRAL ChattahoocheeCrispDoolyMuscogeeSummerCobbFayetteGwinnettCherokeePikeSpaldingTroupUpsonLincolnMc DuffieRichmondScrevenTaliaferroWarrenWashingtonWilkes HEART OF GEORGIA ApplingBleckleyCandlerDodgeEmanuelEvansJeff DavisJohnsonWilcoxMontgomeryTattnallTelfair OTHER COUNTIES AVAILABLE TO WORK DAYS AVAILABLE FOR WORK MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY SHIFT PREFERRED* LIVE-IN 7A-7P 7P-7A 7A-3P 8A-4P 3P-11P AVAILABLE FOR SHORT SHIFTS* Yes No DO NOT CALL BETWEEN THE HOURS OF OFFICE USE REVIEWED BY REFERENCES DATE VERIFIED REFERENCES REVIEW BY HIRE DATE Debest Private Quality Home Care is an equal opportunity employer. We adhere to policy of making employment decisions without regard to race, religion, color, national origin, sex, age, marital status, veteran status or disability. PERSONAL INFORMATION LAST NAME * FIRST NAME* MIDDLE NAME DATE OF BIRTH* SOCIAL SECURITY NUMBER LICENSE / CERTIFICATION NUMBER PRESENT ADDRESS ( STREET )* Email Address* CITY * COUNTY* STATE * Please select?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP CODE* HOME PHONE* WORK PHONE* PAGER/ CELL PLEASE ANSWER THE FOLLOWING QUESTIONS WITH YES OR NO HAVE YOU EVER BEEN SHOWN BY ANY CREDIBLE EVIDENCE TO HAVE ABUSED, NEGLECTED, SEXUALLY ASSAULTED, EXPLOITED, OR DEPRIVED, ANY PERSON OR HAVE SUBJECTED ANY PERSON TO SERIOUS INJURY AS A RESULT OF INTENTIONAL OR GROSSLY NEGLIGENT MISCONDUCT AS EVIDENT BY AN ORAL/WRITTEN STATEMENT? * YES NO HAVE YOU EVER BEEN CONVICTED OF A FELONY THAT WAS NOT EXPUNGED OR SEALED IN COURT? * YES NO JOB INTEREST JOB INTEREST * CNA PCA MINIMUM SALARY DESIRED * LPN RN SPECIALTY * TYPE * Home care Home visit HAVE YOU PREVIOUSLY APPLIED FOR EMPLOYMENT AT DEBEST PRIVATE QUALITY HOME CARE ?* Yes No ARE YOU NOW WORKING OR HAVE YOU EVER WORKED FOR OTHER AGENCIES?* Yes No EDUCATION HIGH SCHOOL HIGHEST GRADE COMPLETED 9 10 11 12 NAME OF SCHOOL ADDRESS GRADUATED? Yes No YEAR GRADUATED NAME OF NURSING SCHOOL / COLLEGE ADDRESS GRADUATED? Yes No YEAR GRADUATED NURSE AIDE TRAINING SCHOOL ATTENDED NAME OF SCHOOL ADDRESS GRADUATED? Yes No YEAR GRADUATED EMPLOYMENT HISTORY EMPLOYER POSITION ADDRESS DUTIES CITY STATE Please select?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP CODE TELEPHONE DATES EMPLOYED (FROM) DATES EMPLOYED (TO) BEGINNING SALARY ENDING SALARY SUPERVISOR REASON FOR LEAVING EMPLOYER POSITION ADDRESS DUTIES CITY STATE Please select?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP CODE TELEPHONE DATES EMPLOYED (FROM) DATES EMPLOYED (TO) BEGINNING SALARY ENDING SALARY SUPERVISOR REASON FOR LEAVING EMPLOYER POSITION ADDRESS DUTIES CITY STATE Please select?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP CODE TELEPHONE DATES EMPLOYED (FROM) DATES EMPLOYED (TO) BEGINNING SALARY ENDING SALARY SUPERVISOR REASON FOR LEAVING PERSONAL AND PROFESSIONAL REFERENCES NAME RELATION Co-worker Friend PHONE NUMBER YEARS KNOWN NAME RELATION Co-worker Friend PHONE NUMBER YEARS KNOWN ADDITIONAL INFORMATION DO YOU HAVE HOSPITAL / HOME CARE/ NURSING HOME EXPERIENCE? * Yes No DO YOU HAVE ANY PHYSICAL DISABILITIES THAT PRECLUDE YOU FROM PERFORMING ANY WORK FOR WHICH YOU ARE BEING CONSIDERED? * Yes No IN CASE OF EMERGENCY NOTIFY NAME * ADDRESS * PHONE * HOW WERE YOU REFERRED TO DEBEST QUALITY PRIVATE HOME CARE? Job Fair DPHC Employee Newspaper Internet Dept. of Labor Other OTHER SPECIFY I hereby certify that all statements made on this application is accurate and true, complete, and correct to the best of my knowledge and believe and realize that inclusion of false information or omission of material could result in DISMISAL of employment or REMOVAL of my application from further consideration. I also hereby certify that I am not suffering from a communicable disease or mental disorder which would hinder my job performance, nor have I been charged with or convicted of a crime involving abuse, neglect, exploitation, or deprivation of child or adult. I hereby authorize all my employers and police/sheriff dept. unless otherwise stated to release any and all information in regards to my employment as requested. DO THE ABOVE EMPLOYMENT DATES CORRESPOND TO YOUR RECORDS? DOES THE ABOVE POSITION CORRESPOND TO YOUR RECORDS? * SUBJECT TO REHIRE? ANY COMMENTS ON THIS APPLICANT. GENERAL COMMENTS SIGNATURE POSITION DATE RELATIONSHIP TO APPLICANT IF VERIFIED BY PHONE CONTACT NAME POSITION DATE Please send me information on DebestQuality Private Home Care. If responding by mail send to: Attn: Human Resources 2210 Noelle Place, Powder Springs, GA 30127 If responding by fax send to Attn: Human Resources 678-967-4877 (Nurses and allied health personnel available locally and on traveling contracts to help meet your staffing requirements). DEBEST QUALITY PRIVATE HOME CARE EMPLOYEE POLICIES AND PROCEDURES Every employee or independent contractor is expected to conduct themselves in a professional manner while in the client's home or workplace. You are depended upon to arrive at assigned client's home on time and in proper uniform. Once working, you are expected to provide quality patient care and or services according to your job classification and description. You must follow the policies and procedures of the Medicaid / Medicare program as well as DEBEST QUALITY PRIVATE HOME CARE. THE FOLLOWING IS GROUNDS FOR DISMISSAL AND MAY RESULT IN DISQUALIFICATION FOR UNEMPLOYMENT BENEFITS All information about the client must be kept confidential (HIPPA policies and procedures must apply to all clients information).An unusual amount of cancellations (2 (two) cancellations in 30 days called in after 4pm to on call manager.A no-show for a previously confirmed shift (neglecting to call office to cancel shift) will result in 2 months suspension for booking shifts.Habitual tardiness as reported by the client.Failure to provide all required documentation (CPR, FIRST AIDE, TB certification completed IN-SERVICES) for personnel files.Falsification of records or timesheets.Client complaints caused by poor performance on an assignment.Insubordination to administrative staff.Non-compliance to OSHA/ Infection Control Standards or with Drug Free Workplace Policies.Theft of client's property, borrowing money or other items from the client.Sleeping while on an assignment, live —in cases need more clarification.Illegal possession or attempting to take part in illegal sale and trafficking of illegal drugs or contraband.Willful disregard for clients and DebestQuality Private Home Care's policy.Unauthorized removal of property belonging to client e.g. food, drinks etc.Smoking in authorized areas.Excessive use of cell phone or blue tube while in home while providing client care with excessive incoming and outgoing personal calls. (Cell phones are to be used for emergencies or communicating with the DebestQuality Private Home Care office).Spreading malicious rumors or gossip about co-workers, the clients, or DebestQuality Private Home Care .Leaving work early without contacting the staffing coordinator.Employees can not accept any gifts or valuables without permission from DebestQuality Private Home Care . REQUIREMENTS FOR CONTINUED EMPLOYMENT WITH UNISON HOME CARE Report to work 15 minutes before the assigned time of arrival to the client's home." "Must attend orientation session and read orientation handbook .Arrangements regarding orientation will be made for the specific client assigned to work with." "All services are to be provided in accordance with the Private Home Care and CCSP/SOURCE/ ICWP Policies and Procedures." "You must call-in 24 hours prior to start of the assigned time to do the home visit, to ensure time enough for the client to be covered by a fill-in home care aide. On weekends, call-outs will be considered an incident of absenteeism. Unless explained by a doctor's note or a verifiable excuse." "Two absences with-in 30 days that was not pre-scheduled (or called in between the hours of 8am and 4 pm office hours) or called in less than 24 hours will result in a 2 (two) month suspension, for new assignments and removal from assigned clients unless accompanied by a verifiable excuse or doctor's note." "All employees are expected to maintain telephones and to keep communication open with the staffing coordinator." "Employees are required to work at least 1 (one) out of 30 (thirty) days to retain an active status, unless prior arrangement have been made with DebestQuality Private Home Care ." "It is the employee's responsibility to report all work related injuries to DebestQuality Private Home Care . Immediately (within 24 hours). Failure to do so may waiver DebestQuality Private Home Care's responsibilities making the employee responsible for the cost of needed care. SIGNED BY NEW EMPLOYEES AND WITNESSED DURING EMPLOYMENT PROCESS I, have read and understand the above Policies and Procedures set by Debest Quality Private Home Care , and by signing I agree to uphold these Policies and Procedures. SIGNATURE* DATE * WITNESS* DEBEST QAULITY PRIVATE HOME CARE PLEASE READ CAREFULLY. APPLICATION FORM WAIVER In exchange for the consideration of my job application by Debest Quality Private Home Care . I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefits plans, policy statements, and the like as they might exist from time to time, or other DebestQuality Private Home Care practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of DebestQuality Private Home Care or otherwise to change in any respect the employment-at will relationship between it and the undersigned, and may end the employment relationship at any time, without specific notice or reason. If employed, I understand that DebestQuality Private Home Care may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give DebestQuality Private Home Care permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release DebestQuality Private Home Care from any liability as a result of such contract." "I understand that (1) DebestQuality Private Home Care has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of employment; and (3) continued employment is based on the successful passing of under such policy. I further understand that continued employment may be based on the successful passing of job related physical examinations." "I understand that, in connection with the routine processing of my employment application, DebestQuality Private Home Care will request a criminal background check and or an investigative consumer report including reported information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, DebestQuality Private Home Care will provide me with additional information concerning the nature and scope of any such report requested by DebestQuality Private Home Care , as requested by the Fair Credit Reporting Act." " I further understand that my employment with DebestQuality Private Home Care shall be probationary for a period of ninety (90) days and further that at any time during the probationary period or thereafter, my employment relation with DebestQuality Private Home Care is terminable at will for any reason by either party. SIGNATURE* DATE Thank you for completing this application package and for your interest in our business.
