Lakeview Applications

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Lakeview Specialty Hospital

Application for Employment

Mission Statement

“Lakeview facilitates the full realization of human potential for individuals affected by neurological and behavioral challenges through the provision of clinically sound, goal oriented treatment in a safe and caring environment.”

Lakeview Healthcare Systems is an equal opportunity employer. It is our policy not to discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, gender, sexual orientation, marital status, national origin, disability or handicap, veteran status, or any other classification.

As of November 6, 1986, the Immigration Act requires that all employers hire only U.S. citizens and aliens lawfully authorized to work in the United States. Any offer of employment will be contingent upon you providing Lakeview with the documentation required by the INS to establish that you meet these requirements.

IMPORTANT, PLEASE READ AND SIGN

I hereby certify that the facts set forth in this application and the items included on my resume are true and complete to the best of my knowledge and authorize Lakeview Healthcare Systems (LHS) to verify their accuracy. I consent to taking any physical examination, medical or drug test which may be required by LHS, now or in the future, in order to determine my ability to perform the essential functions of the job, and I authorize the release of the result of such examinations or testing to LHS. I further voluntarily give LHS the right to make a thorough investigation of my past employment activities, criminal record, driving record, check reference information and personal history that is job related. I agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, and corporations supplying such information. I hereby release LHS from any and all liability of any kind and nature that at any time, could result from obtaining and having employment decisions based on such information. I agree to use protective clothing or devices as required by LHS and to comply with the safety rules. If subsequently employed by LHS, I understand that falsified statements of any kind or omitted facts called for on this application shall be considered sufficient basis for termination. I also understand that if I am employed by LHS and subsequently am convicted of a crime (other than a minor motor vehicle offense) or found to be in violation of any Federal or State law, administrative rule or programmatic requirement that I must immediately notify LHS’ Manager of Human Resources, or designee. I understand and acknowledge, that unless otherwise defined by applicable law, all employees in Wisconsin are regarded as “at will.” An “at will” employment relationship is one where the employee may resign at any time, for any reason with or without cause. In addition, the employer may also discharge the employee at any time with or without cause. It is further understood that there is no contract, expressed or implied, for continued employment. I understand that LHS requires the successful completion of a Criminal Record Check, Driver’s Record Check, TB screen, drug screen and a pre-employment physical as a condition of employment. If employed, I agree to engage in no outside activity that would involve a material conflict of interest with, or that would reflect adversely on LHS. If employed, I agree to hold in strictest confidence any information concerning LHS and its clients.

Applicant Name*

Applicant Signature

Date

MM slash DD slash YYYY

Today’s Date

MM slash DD slash YYYY

Have you ever filed an application with us before?

Yes

PERSONAL INFORMATION

Name*

Last Name First Name Middle Initial

Address*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone Number:

Cell Phone Number

Social Security Number

Position Desired

Please specify shifts you can work

Days

Days 7am-7:30pm (Hospital Staff)

NOC 7pm to 7:30am (Hospital Staff)

Days 6am to 6pm (CBRF Staff)

NOC 6pm to 6am (CBRF Staff)

Date available to start work

MM slash DD slash YYYY

I can work

Full-Time 32-40 hours

Part-Time, 24-31 hours

Per diem

EDUCATION INFORMATION – PLEASE PROVIDE IF NOT ON RESUME

High School/GED

School Name, City and State

Major

Did you graduate? If yes, list degree received and date

College

School Name, City and State

Major

Did you graduate? If yes, list degree received and date

Advanced Degree

School Name, City and State

Major

Did you graduate? If yes, list degree received and date

Other

School Name, City and State

Major

Did you graduate? If yes, list degree received and date

(Most recent position first; please provide all work experience, attach separate sheet if necessary)

EMPLOYMENT HISTORY – PLEASE PROVIDE IF NOT ON RESUME

Employer

Supervisor Name

May we contact?

Yes

Employer Address

Phone Number

Job title/description of work

Start Date of employment

MM slash DD slash YYYY

End Date of employment

MM slash DD slash YYYY

Rate of Pay

Reason for leaving

Employer

Supervisor Name

May we contact?

Yes

Employer Address

Phone Number

Job title/description of work

Start Date of employment

MM slash DD slash YYYY

End Date of employment

MM slash DD slash YYYY

Rate of Pay

Reason for leaving

Employer

Supervisor Name

May we contact?

Yes

Employer Address

Phone Number

Job title/description of work

Start Date of employment

MM slash DD slash YYYY

End Date of employment

MM slash DD slash YYYY

Rate of Pay

Reason for leaving

CREDENTIALS

Are you licensed in your profession?

Yes

License Type

State Licensed in Expiration Date

MM slash DD slash YYYY

If licensure is pending, please describe and indicate when expected.

GENERAL INFORMATION

How did you hear about us? Please check one of the following and include name of the source

Newspaper Ad

Employment Agency

Referral

Job Fair

Website

Other

Please Specify

Have you previously been employed by LHS? If so, when?

Are you a citizen?

Yes

If no, can you prove that you are eligible to work in the U.S.?

Yes

Are you related to any current LHS employee?

Yes

If yes, please list names and relation.

Are you currently on layoff or leave status from any other employer?

Yes

Many of our positions have physical requirements. Please list concerns. PLEASE NOTE: You are not required to disclose any physical disabilities during the pre-hire process.

Have you had any criminal convictions or violations of the law? Please include any Military Court Marshals. (Include any convictions now on appeal)

Yes

If yes, describe conditions

Have you ever been convicted of a felony, abuse, neglect, assault, misappropriation, or exploitation?

Yes

If yes, describe conditions

REFERENCES (Please list at least TWO professional references and ONE personal) - PLEASE PROVIDE IF NOT ON RESUME

First

Second

VOLUNTEER WORK - PLEASE PROVIDE IF NOT ON RESUME

Please list volunteer work, civic activities, memberships, or affiliations. Please note: applicable volunteer work may count as work experience.

Name of Reference – Professional

How know and for how long

Telephone Number of Reference

Name of Reference – Professional

How know and for how long

Telephone Number of Reference

Name of Reference – Personal

How know and for how long

Name of Reference – Professional

Background Information Disclosure (BID) For Entity Employees and Contractors

Purpose: State and federal law require background checks for certain types of employment, contract, or other roles involving contact with vulnerable persons receiving care or treatment. The information you provide on this form will be used to verify your eligibility for such a role. Providing inaccurate or incomplete information on this form may result in a forfeiture or other sanction, as provided in Wis. Stats. § 50.065(6)(c).

Type*

Applicant/employee

Volunteer

Contractor

Household member

Student

Other

Specify

Describe the position for which you are applying or renewing

Applicant information

Name*

First Middle Last

Social Security number*

Date of birth (MM/DD/YYYY)

MM slash DD slash YYYY

Sex

Male

Female

Phone number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Have you had or used any other names, including prior to marriage?

Yes

If yes, list each name fully

Employer or organization verifying eligibility

Name of employer or organization that asked you to complete this form

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Disclosures

If additional space is needed for answering the questions below, please use the additional page at the end of this form.

1. Pending criminal charge

Do you have any criminal charges pending against you, including in federal, state, local, military, and Tribal courts?

Yes

If yes, describe the charge and indicate the name of the court, the state, city, month and year you were charged.

2. Convictions for crimes

Were you ever convicted of any crime anywhere, including in federal, state, local, military, and Tribal courts, or in another country?

Yes

If yes, describe the crime and indicate the name of the court, the state, city, month and year you were convicted.

3. Abuse or neglect of a child Please note that Wis. Stat. § 48.981, abused or neglected children and abused unborn children, may apply to information concerning findings of child abuse and neglect.

Has a government or regulatory agency (other than the police) ever found that you abused or neglected a child?

Yes

If yes, describe the conduct and indicate the agency that made the finding, the state, city, month and year of the finding.

4. Abuse or neglect of an adult

Has a government or regulatory agency (other than the police) ever found that you abused or neglected an adult?

Yes

If yes, describe the conduct and indicate the agency that made the finding, the state, city, month and year of the finding.

5. Stealing or other misappropriation

Has a government or regulatory agency (other than the police) ever found that you stole or misappropriated (improperly took or used) a person’s property (e.g., money, medications, etc.), identity, or financial information (e.g., credit card, checks, etc.)?

Yes

If yes, describe the conduct and indicate the agency that made the finding, the state, city, month and year it occurred.

6. Restriction on credentials

Do you have a government issued credential that is not current or has been revoked, suspended, or that limits you in any way from providing care to clients?

Yes

If yes, identify the type of credential and indicate the credentialing agency, the restriction, and the state, city, month and year it was issued.

7. Denial, revocation, or limitation on license, certification, or registration

Has a government or regulatory agency ever denied, revoked, or limited your license, certification, or registration to provide care, treatment, or educational services?

Yes

If yes, indicate the license, certification, or registration type and indicate the issuing agency. Include a description of the denial, revocation, or limitation, and the state, city, month and year it was issued.

8. Denial, revocation, or limitation on ability to reside on certain premises

Has a government or regulatory agency ever denied, revoked or limited your ability to live on the premises of a facility that provides care or treatment?

Yes

If yes, describe the denial, revocation, or limitation and identify the issuing agency, the state, city, month and year issued.

9. Rehabilitation review

Have you ever requested a rehabilitation review from the Wisconsin Department of Health Services, a county department, private child placing agency, school board, or DHS designated Tribe?

Yes

If yes, indicate the agency that conducted the review, the outcome, month, and year of the review.

Note: You must provide a copy of your rehabilitation review letter to your employer or organization. Your employer or organization must verify your status with the agency that issued the decision.

10. Armed forces

Have you been discharged from a branch of the US Armed Forces, including any reserve component?

Yes

If yes, indicate the month and year of discharge.

Note: You must provide your DD214 to your employer/agency, if you were discharged within the last three (3) years.

11. Out-of-state residence

Have you resided outside of Wisconsin in the last three (3) years?

Yes

If yes, list each state, city, and the dates you resided there.

12. Government employee

Are you applying or renewing eligibility to work as a government employee for the State of Wisconsin (e.g. a state agency, treatment facility, institute, etc.)?

Yes

If no, skip to the attestation below. If yes, have you resided outside of Wisconsin in the last seven (7) years?

Yes

If yes, list each state, city, and the dates you resided there.

Review your responses and the following attestation carefully before signing.

Attestation

I have completed and reviewed this form. The information I provided is accurate and complete. I understand that providing inaccurate or incomplete information on this form may result in a forfeiture or other sanction, as provided in Wis. Stats. § 50.065(6)(c).

Signature — Person completing this form

Date signed

MM slash DD slash YYYY

REFERENCE CHECK

Applicant Name*

Date*

MM slash DD slash YYYY

Position Considered For*

Department*

Authorization to Obtain Personal and/or Employment Verification

Click or tap here to enter text.

social security number

Click or tap here to enter text.

authorize Lakeview Specialty Hospital & Rehab to make any inquiries necessary to obtain employment and/or personal references relating to previous employment or character from the companies and/or persons I have listed on my application for employment. I hereby release employers/persons so named and Lakeview Specialty Hospital & Rehab from all liability for any damages whatsoever incurred in furnishing such information.

Applicant Signature

Date

MM slash DD slash YYYY

FOR OFFICE USE ONLY

Reference:

Personal

Business

Professional

Contact Name

Date

MM slash DD slash YYYY

Company

Phone

FOR OFFICE USE ONLY

From

Position Held

From

(Personal)How do you know the applicant?

(Personal)How long have you known the applicant?

Work Habits:

Attendance

Excellent

Good

Unsatisfactory

Dependability

Excellent

Good

Unsatisfactory

Ability to supervise

Excellent

Good

Unsatisfactory

Ability to follow direction

Excellent

Good

Unsatisfactory

Motivation/Initiative

Excellent

Good

Unsatisfactory

Quantity of work

Excellent

Good

Unsatisfactory

Professionalism

Excellent

Good

Unsatisfactory

Is applicant eligible for rehire?

Yes

If not, why?

Comments

Referenced Checked by?

Dept

Signature

Date

MM slash DD slash YYYY

Education Information and Release form

Name*

Title*

Personal Email Address*

Best Personal Contact Number

Name

(As listed on the diploma/certificate)

Title

(As listed on the diploma/certificate)

Diploma/ Certificate Received

School issued by

School Location – City

State

Click or tap here to enter text.

social security number

Click or tap here to enter text.

authorize Lakeview Specialty Hospital & Rehab to make any inquiries to obtain educational records from the school I have listed above. I hereby release the educational program named above and Lakeview Specialty Hospital & Rehab from all liability for any damages whatsoever incurred in furnishing such information.

Signature

Date

MM slash DD slash YYYY

If offered a position what would be the first available day to work

Where exceptional challenges meet extraordinary care

Lakeview Applications

Lakeview Specialty Hospital

Application for Employment

Mission Statement

IMPORTANT, PLEASE READ AND SIGN

PERSONAL INFORMATION

EDUCATION INFORMATION – PLEASE PROVIDE IF NOT ON RESUME

High School/GED

College

Advanced Degree

Other

EMPLOYMENT HISTORY – PLEASE PROVIDE IF NOT ON RESUME

CREDENTIALS

GENERAL INFORMATION

REFERENCES (Please list at least TWO professional references and ONE personal) - PLEASE PROVIDE IF NOT ON RESUME

VOLUNTEER WORK - PLEASE PROVIDE IF NOT ON RESUME

Background Information Disclosure (BID) For Entity Employees and Contractors

Applicant information

Employer or organization verifying eligibility

Disclosures

Attestation

REFERENCE CHECK