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* Required Information

PERSONAL INFORMATION

GENERAL INFORMATION

EDUCATION & TRAINING

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REFERENCES

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EMPLOYMENT HISTORY



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* I certify that the information contained in this application is correct to the best of my knowledge and understand that any misstatement or omission of information may result in denial of employment or discharge. I authorized the reference listed above to give you any and all information concerning my previous employment and any pertinent information they may have personal or otherwise, and release all parties from all liability for any damage that may result from furnished same to you.

Background Screening

It is mandatory that all applicants be registered with the Missouri Department of Health and Senior Services Family Care Safety Registry. My signature below provides authorization for A Heavenly Hand Home Healthcare, Inc. to conduct a background screening on me. If I am not registered, I will pay thirteen dollars and twenty-five cents ($13.25) registration fee. If there are findings in my screening, and I want to become an employee, I agree to complete a “Good Cause Waiver” Application prior to being hired by A Heavenly Hand Home Healthcare, Inc. Once complete, A Heavenly Hand Home Healthcare, Inc. will receive a report from the Family Care Safety Registry indicating a Good Cause Waiver has been received and a case opened on my behalf. The Department of Health and Senior Services may grant (approve) a “Good Cause Waiver” at their discretion.

Pre-Employment Criminal Record Check

  • All applicants are required to obtain a criminal background check which is conditions of employment.

Family Care Safety Register (FCSR)

  • The FCSR will be checked four times a year.
  • Are you registered with the Family Care Safety Registry?
  • Have you applied for a Good Cause Waiver?

e-Verify

  • A Heavenly Hand Home Healthcare is required by the Department of Homeland Security to verify employment eligibility for all newly hired employees regardless of citizenship.

Employee Disqualification List (EDL)

  • The EDL maintained by the Department of Health and Senior Services is a listing of individuals who have been determined to have:
  • Are you listed on the Employee Disqualification List?
    • Abused or neglected a resident, patient, client, or consumer;
    • Misappropriated funds or property belonging to a resident, patient, client, or consumer; or
    • Falsified documentation verifying delivery of services to an CDS client or consumer
    • The EDL will be check four times a year

Office of Inspector General (OIG)

  • The Department of Health and Senior Services requires A Heavenly Hand Home Healthcare, Inc. to run this report on each employee monthly.

No applicant can be employed by A Heavenly Hand Home Healthcare, Inc. until they pass a screening of the Employee Disqualification List (EDL) and until A Heavenly Hand Home Healthcare, Inc. has obtained a clean background check on the application from the Family Care Safety Registry (FCSR). Anyone listed on the EDL will not, under any circumstances, be employed by A Heavenly Hand Home Healthcare, Inc. If hired, the attendant will have a copy of the background check and EDL placed in their application file. If any listings appear on either of these background checks, the attendant will no longer be able to be employed by A Heavenly Hand Home Healthcare, Inc.

Background Screening Application

* I have read this policy and understand my employment is conditional pending the outcome of the Missouri Department of Health and Senior Services final decision and determination. I also grant permission A Heavenly Hand Home Healthcare, Inc. to verify my employment eligibility through e-Verify, OIG, FCSR and EDL and criminal record check.

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