Employment Application | Wellness Home Health LLC

👤 Personal Information

Applicant Name (Last, First, Middle) *

Email Address *

Current Address *

City, State, Zip *

Home Phone

Cell Phone *

💼 Position Information

🎓 Educational History

Type	Name and Location of School	Last Year Attended	Graduated	Degree
High School
College 1
College 2
Other

Professional Licenses (type, number, issuing state)

Professional Memberships, Honors, or Activities

Languages Spoken Other Than English

Other Skills (computer experience, typing speed, etc.)

🏢 Work History

List most recent employer first. Attach additional sheet if needed.

Previous Employer #1

Company Name

Supervisor's Name

Complete Address (City, State, Zip)

Phone Number

Type of Business

Full Time Part Time Per Visit

Date Started

Date Left

Reason for Leaving

Ok to Contact Supervisor?

Yes No

Job Title, Responsibilities, and Accomplishments

Previous Employer #2

Company Name

Supervisor's Name

Complete Address (City, State, Zip)

Phone Number

Type of Business

Full Time Part Time Per Visit

Date Started

Date Left

Reason for Leaving

Ok to Contact Supervisor?

Yes No

Job Title, Responsibilities, and Accomplishments

Previous Employer #3

Company Name

Supervisor's Name

Complete Address (City, State, Zip)

Phone Number

Type of Business

Full Time Part Time Per Visit

Date Started

Date Left

Reason for Leaving

Ok to Contact Supervisor?

Yes No

Job Title, Responsibilities, and Accomplishments

👥 References & Emergency Contacts

Personal References (Name, Phone, Relationship)

Emergency Contact

Emergency Contact Name *

Relationship

Phone

Address

Out-of-State Contact (if possible)

Out-of-State Contact Name

Relationship

Phone

Address

📋 Agency Policies & Acknowledgments

Please read each policy carefully and check the box to acknowledge.

Confidentiality (HIPAA): The Agency maintains confidentiality of operations and client information according to HIPAA and the Texas Medical Records Privacy Act. Confidential information must never be used as the basis for social conversation or gossip.

I have read and understand the Confidentiality policy

Drug Testing Policy: The Agency maintains a Drug-Free Workplace policy. Violation can result in disciplinary action up to and including termination.

I acknowledge receipt of the Agency's drug testing policy

Harassment Policy: The Agency is committed to a work environment free from all forms of discrimination and unlawful harassment including sexual harassment.

I have read and understand the Harassment policy

Non-Discrimination: The Agency does not discriminate against employees or clients based on race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

I have read and understand the Non-Discrimination policy

Abuse, Neglect, and Exploitation: Agency employees will report suspected abuse, neglect, and/or exploitation to TDFPS, Texas HHS, and Agency management. Employees suspected of abuse or neglect will be suspended immediately pending investigation.

I have read and understand the Abuse, Neglect & Exploitation policy

Statement of Employability: I acknowledge the Agency may conduct a State of Texas criminal history check, search of the Nurse Aide Registry, Employee Misconduct Registry, and OIG LEIE check prior to and during employment per Texas H&SC 250.006.

I acknowledge and agree to the Statement of Employability

Hepatitis B Vaccination:

I wish to receive the Hepatitis B vaccine series at no cost to me.
I decline the Hepatitis B vaccine series. I understand the risk of declining.
I have already received the Hepatitis B vaccine series.

Accept vaccine Decline vaccine Already received

Confidentiality of Client Information: I agree to maintain confidentiality of all client information, password-protect all devices used for documentation, and comply with the Agency's Medical Record Information Confidentiality Policy.

I agree to the Confidentiality of Client Information policy

Certification: I certify that the information in this application is true and complete. I understand that false or misleading information may result in termination. I authorize background checks including criminal history, OIG LEIE, NAR, and EMR. I authorize prior employers and educational institutions to release information as requested.

I certify the above and authorize the background check and release of information

✍️ Applicant Signature

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Applicant Signature

Sign above

Date *

Application for Employment

👤 Personal Information

💼 Position Information

🎓 Educational History

🏢 Work History

👥 References & Emergency Contacts

📋 Agency Policies & Acknowledgments

✍️ Applicant Signature