Do you need clinical
care after a hospitalization?
WE CAN HELP
Is it a taxing effort to get to your doctor or therapist?
WE CAN HELP
Would you rather stay in your home and still receive professional care?
WE CAN HELP
VNA of Rhode Island/VNA Support Services
Employment Application
475 Kilvert St.Suite 400, Warwick, RI 02886
(401) 574-4900
VNA of RI and VNASS are SMOKE FREE Environments

Date:
Position Applied for:
Name:
 
(Last)
(First)
(MI)
Address:
City:
State:
Zip code:
Home Phone #: ()
Work Phone #: ()
 
 
May we contact you at work?
Are you a citizen of the U.S. or Alien authorized to work in the United States:
Are you at least 18 years old?
Availability:
Education: List current or most recent first, or attach resume.
School Name and Address Course of Study Did You Graduate? Degree/Diploma
 
Professional Licenses/Certifications State Number
Are you currently:
List other training and skills you possess:
Employment History: List current or most recent first, or attach resume
1) Present or most recent employer -
Company Name: 		Position Title:
 Dates of Employment:
From: To:
Address:
 Supervisor:
 May we contact?
Duties:
 Reason For Leaving:
2) Previous Employer - Company Name:
 Position Title:
 Dates of Employment:
From: To:
Address:
 Supervisor:
 May we contact?
Duties:
 Reason For Leaving:
3) Previous Employer - Company Name:
 Position Title:
 Dates of Employment:
From: To:
Address:
 Supervisor:
 May we contact?
Duties:
 Reason For Leaving:
  • Can you perform the essential functions of the position for which you are applying?
  • Do you have a RI driver's license?
  • Do you have a car available for travel?
  • Can you provide proof of auto insurance?
  • Rhode Island law requires employees of home health agencies be subject to a criminal background check. Would you be opposed to such a check?
    • Have you ever been convicted of a felony?
    • Have you had such a check within the last 18 months?
      (Background Check Disqualifying information does not necessarily exclude one from employment.)
  • Has any action ever been taken on your professional license in any state?
  • Has any action ever been taken involving your clinical privileges (including voluntary suspension and non-renewal) in any state?
  • Has professional liability insurance ever been denied or cancelled?
  • Have any professional liability claims ever been made against you?
  • Are you currently, or have you ever been, or has the government proposed that you be, excluded from participation in federal health care programs (e.g., Medicare, Medicaid)? If yes, please describe the circumstances and indicate the period of the exclusion:
  • By what source did you come to apply?
References: List 3 references who can evaluate your work. Also, list how they are known to you.
Name How do vou know them? Address / Telephone#
Were you ever previously employed by VNA of Rhode Island, or VNA Support Services
Have you any friends or relatives working here?
(If yes, give name and relationship)

I hereby affirm that the information given on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge if discovered at a later date. If I am released under these conditions, I will be paid only through the day of release and my employer has the right to cancel any benefits that I may have accrued.

I understand that acceptance of an offer of employment doesn't create a contractual obligation to continue to employ me in the future.

It is the policy of VNA of Rhode Island/VNA Support Services to check references offered by applicants. It is our objective to obtain information on ability, previous job performances, character and reputation for the sole purpose of considering you for employment.

I hereby give VNA of Rhode Island/VNA Support Services permission to request and obtain any such information that will assist in becoming employed.

Signature:
Date:

Affirmative Action
Voluntary Information

To be completed by applicant. Not for interview purposes. To be filed separately from application. This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or is necessitated by another federal law or regulation.

As required, we comply with govermment regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.

Please be advised that this survey is not apart of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

We consider applicants for all positions without regard to race, color, religion, national origin, age, veteran status or any other legally protected status.
Position(s) applied for Date:
Referral Source
Name of person who referred you (if applicable):
Applicant Information
Name:
 
(Last)
(First)
(MI)
Address:
City:
State:
Zip code:
Please check one of the following Equal Employment Opportunity Identification Groups:
 
Special Notice

To Vietnam Era Veterans, Disabled Veterans an Individuals with physical or mental disabilities:

Government contractors subject to Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans, veterans of the Vietnam Era and qualified handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential. Refusal to provide this information will not adversely affect your consideration for employment.

If you so wish to be identified, please check if any of the following are applicable:
Resume