Country Court Healthcare Center 2013 Bronze Award for Outstanding Quality Care

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Online Employment Application

COUNTRY COURT NURSING CENTER

Application for Employment

PLEASE PRINT OUT AND FILL OUT ALL SECTIONS COMPLETELY

Contact Information

Name
Social Security #
Address
City, State, Zip
Telephone (Day)
Telephone (Night)
Telephone (Cell)
Email

Position Applying For

Date of Application		Date Available to Start Work
Position Applying for		Hourly Rate Desired
Availability (Check all that apply)	Full Time Part Time PRN / As Needed	Days Evenings Nights	If desiring Part Time, list available days and times:
Hours/Days unwilling or unable to work

Professional Licensure or Certification

Certificate/License #	State	Expiration Date	Licensing Agency

Personal References

Name & Occupation	Address (City, State, Zip)	Phone Number

Country Court Nursing Center is an Equal Opportunity Employer, and is committed to providing employment opportunities based upon personal capabilities and qualifications regardless of race, color, religion, sex, age, national origin, disability, or any other protected characteristic as established by law.

Education Record

	Name of School	Location	Highest Grade Completed	Degree/Course
High School
Business-Technical
Nursing
College
Other

Work History

List your prior employers. Use additional sheets if you have not listed all prior employment below.

Most Recent Employer
Employer Address
Position Held		Reason for Leaving
Start Date		End Date
Starting Salary		Ending Salary
Supervisor		Supervisor Phone #

Former Employer
Employer Address
Position Held		Reason for Leaving
Start Date		End Date
Starting Salary		Ending Salary
Supervisor		Supervisor Phone #

Former Employer
Employer Address
Position Held		Reason for Leaving
Start Date		End Date
Starting Salary		Ending Salary
Supervisor		Supervisor Phone #

Former Employer
Employer Address
Position Held		Reason for Leaving
Start Date		End Date
Starting Salary		Ending Salary
Supervisor		Supervisor Phone #

General Questions

If you need additional room to answer any of the following questions or wish to provide explanations of any of your answers, then please write on an additional piece of paper that includes the question number that you are answering.

1)	Do you have legal authorization to be employed in the U.S.?	Yes	No
2)	Are you older than 18 years old? Or if you are under 18 years old, can you furnish a work permit?	Yes	No
3)	Are you capable of performing the duties set forth on the attached job description with or without accommodation?	Yes	No
4)	Do you have any relatives working for our company?	Yes	No
5)	Have you ever applied to Country Court Nursing Center (or, any related company) before?	Yes	No
6)	Have you ever been an employee of Country Court Nursing Center (or, any related company) before?	Yes	No
7)	Have you ever been fired, dismissed or asked to resign from any job?	Yes	No
8)	Have you ever been convicted of or pled guilty or no contest to any criminal offenses? (Depending on the nature of the offense, conviction may not be an absolute bar to employment.) (This question specifically includes convictions, which have been sealed and/or expunged; such convictions will be disclosed on your criminal records check.)	Yes	No
9)	Have you ever been charged with, convicted of, or pled guilty or no contest to, abusing, neglecting or mistreating a nursing facility resident in a court of law? (This question specifically includes convictions which have been sealed and/or expunged; such convictions will be disclosed on your criminal records check.)	Yes	No
10)	Have you ever been accused of patient/resident abuse or neglect by a resident, family member, former employer, etc.?	Yes	No
11)	Are you currently (or have you ever been) excluded from a federally funded health care program, such as Medicare or Medicaid?	Yes	No
12)	Have you ever been investigated, sanctioned, or entered into a settlement agreement for the violation of any State or Federal law related to laws regarding the billing of services and the referral of patients, laws relating to resident abuse and neglect or health care fraud?	Yes	No

Working Conditions & Requirements

You are applying to work in a nursing facility. There are certain risks and conditions of employment inherent in working in a health care facility that you should consider before submitting this Application. The job for which you are applying:

May require you to work throughout the facility, which may include the nursing service areas, such as resident rooms, bathing rooms, kitchen and dining area.
Will involve interactions with residents, fellow employees, visitors, contractors/vendors, and government officials.
May expose you to air contaminants, hazardous chemicals, blood, body fluids, infectious diseases, including, but not limited to, tuberculosis, hepatitis, HIV/AIDS, and Legionnaire's disease.
May subject you to hostile and emotionally upset residents, family members, personnel and visitors.

May cause you to work beyond normal working hours, on weekends and holidays, and in other positions temporarily, when necessary.
Will require you to adhere to a dress code.
Is subject to call-back or call-in during emergency conditions and when staffing needs require.
May subject you to injury from falls, equipment, residents acting out, etc. through the workday, as well as reactions to resident medications.
Will require you to work rotating weekends and holidays.

It is important that you fully understand that regardless of the position for which you are applying, working in a nursing facility requires patience, skills, and certain physical requirements. With or without the aid of an accommodation, the job for which you are applying may require you to:

Move intermittently throughout the day.
See and hear (or use prosthetics or devices that will enable these senses to function adequately) to ensure that the requirements of the position are met.
Maintain good physical and mental health.
Maintain the stamina to work effectively under adverse conditions.
Be available to assist in the evacuation of residents during emergency situations.

Read, speak and write English fluently.
Cope with the mental and emotional stress of the position, which may include resident physical and mental sickness and death.
Relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile, people within the facility.
Push, pull, move and/or lift a minimum of 25 pounds to a minimum height of 5 feet, and be able to push, pull, move and/or carry such weight a minimum distance of 50 feet.

By signing and submitting this Application, you are asserting that you have read and understood the working conditions and requirements noted above, and that you can meet or exceed all of the requirements and are willing to work under the conditions noted. Different positions may have more strenuous physical requirements as outlined in the applicable job description.

CERTIFICATIONS & UNDERSTANDINGS

I understand that it is important that I fill out all parts of this Application completely and accurately. I understand that an incomplete application will delay Country Court Nursing Center's ability to consider me for the position for which I am applying, and may eliminate me from consideration.
I certify that the information given in this application is true, complete and accurate to the best of my knowledge, and I recognize that my future employment is subject to termination without notice should any of the information be found to be false, incomplete or inaccurate.
I understand that this application is not an offer of employment. My qualifications for employment will be determined, in part, from this Application, a personal interview and a background check.
I understand that this application will be considered only for the open position for which I am applying. If I wish to apply for another position or reapply to Country Court Nursing Center at a later point, I will need to complete a new application. I understand that that this application will only be considered active for 60 days.
I understand that I have an ongoing duty to update the information contained in this application immediately should it change at any point.
I understand that even though I may be hired to work a particular shift or hours, this may be changed at the sole discretion of Country Court Nursing Center. I understand that I may be required to work overtime periodically based on the staffing needs of Country Court Nursing Center.
I understand that I will be subject to a pre-employment alcohol and drug test before an offer of employment can be made, and that if an offer of employment is made, that I will then be subject to a medical examination completed by a physician designated by Country Court Nursing Center prior to the performance of any job duties. Further random drug and alcohol tests may be scheduled at the discretion of the employer.
I understand that my background and references will be checked and I hereby authorize Country Court Nursing Center to investigate all statements made in this application as necessary, and to contact any person or entity identified in this application in order to obtain information about me, my education, and my prior job performance. By signing below, I hereby release Country Court Nursing Center, including any and all of its officers, directors, managers, and employees, from any and all liability and/or damages relating to or arising from such background investigation.
I understand that because of the sensitive nature of the services that Country Court Nursing Center provides, Country Court Nursing Center will conduct a criminal background check on me. If I have been convicted of certain offenses listed in the Ohio Revised Code, Country Court Nursing Center will not employ me, except in very limited circumstances. I also understand that there is an exception to the general rules in Ohio regarding sealed records for background checks conducted for people who work in long-term care facilities. Thus, the background checks conducted by Country Court Nursing Center will reveal all offenses, even if they have been sealed. I understand that even if my record has been sealed, the details of my conviction will be released to Country Court Nursing Center, and Country Court Nursing Center will not employ me.
I understand that if I am hired, my employment with Country Court Nursing Center will be "at will", for no definite period of time, and may be terminated at any time and for any reason without prior notice.

______________________________________________

Date

Name