Interview Questions

Date: _________________
Applicant: ____________________________________________
1.

What type of work interest you most (motivation)?

2.

Do you like to be supervised (work style)?

3.

Do you like to make decisions on your own (work style)?

4.

What did you like best about your past jobs (work style)?

5.

What did you like least about your past jobs (work style)?

6.

How would you supervise other employees (leadership)?

7.

What new ideas have you had in your work (creativity)?

8.

What do you do in your spare time (energy)?

9.

Do you like to have a lot of different jobs to do at once (stress tolerance)?

10. How do you define doing a good job (work standard)?

11. Tell me about the experiences you have had with deaths of family members or close friends (experience with death)?
12. What are your goals for the next five years (career ambitions)?
13. What kind of writing have you done or what kind of presentations have you given (communication)?
14. Why do you want to work for home health/hospice (motivation)?
15. What is good customer service?
16. How computer literate are you? Microsoft Excel abilities
17. What is good attendance?
18. How would you handle an angry client or family member?
19. Do you have the ability to work in a close team environment with a lot of distractions?
Appearance: _____________________________________________________________________________________
Attitude: ________________________________________________________________________________________
Communication: __________________________________________________________________________________
Comments:

!1
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

Additional optional questions for candidates:

1. What are you looking for?
2. FT or PRN?
3. What days/times can you work
4. What area can you travel?
5. Do you have hospice, home health experience, or LTC?
6. Are you currently licensed or certified?
7. What is your salary range?
8. Have the candidate rank herself on a scale of 1-10 on any area you are interested in.

Admin Assistant:
Do you have any policy/procedure experience?
Do you have experience with developing agendas, taking notes of meetings and preparing minutes for meetings?
Do you have any dictation/transcription experience?
Do you have any experience with creating/revising forms?

What is your experience with completing and sending group mailings?

Do you have medical record experience? If so, what?

!2
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS

PLEASE COMPLETE ALL PAGES

DATE
______________________________________

Name _______________________________________________________________________________________________
Last

First

Middle

Maiden

Present address _______________________________________________________________________________________

Number

Street

How long ____________________

Telephone (

City

State

Zip

Social Security No. _______ _____ _________

If under 18, please list age _____________________

Days/hours available to work
No Pref _______ Thur _________
Mon __________ Fri __________
Tue __________ Sat __________
Wed __________ Sun _________

Position applied for (1) ________________________

and salary desired (2) ________________________
(Be specific)

How many hours can you work weekly? _________________________ Can you work nights? ________________________
Employment desired

{ }FULL-TIME ONLY

{ }PART-TIME ONLY

{ }FULL- OR PART-TIME

When available for work? _______________

____________________________________________________________________________________________________

TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION
(Complete mailing
address)

NUMBER OF YEARS
COMPLETED

High School

College

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

MAJOR & DEGREE

Bus. or Trade School

Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME? { } No

{ } Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation. ___________________________________________________
____________________________________________________________________________________________________

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT

DO YOU HAVE A DRIVERS LICENSE?

{ } Yes

{ } No

What is your means of transportation to work? _______________________________________________________________

Drivers license
number _____________________________ State of issue _______

{ } Operator

{ } Commercial (CDL)

{ }Chauffeur

Expiration date _______________________

Have you had any accidents during the past three years?

How many? ___________________

Have you had any moving violations during the past three years?

How Many? ___________________

OFFICE ONLY

Typing

{ } Yes
{ } No

Personal
Computer

{ } Yes
{ } No

_____ WPM
PC
Mac

{ } Yes
10-key { } No

{}
{}

Word
Processing

{ } Yes
{ } No

_____ WPM

Other
__________________________________________________
Skills
__________________________________________________

Please list two references other than relatives or previous employers.

Name ________________________________________

Name
__________________________________________________

Position _______________________________________

Position
__________________________________________________

Company _____________________________________

Company
__________________________________________________

Address ______________________________________

Address
__________________________________________________

______________________________________
Telephone (

Telephone (

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the
space below to summarize any additional information necessary to describe your full qualifications for the specific position for
which you are applying.

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES?

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?

{ } Yes

{ } No
{ } Yes

{ } No

Specialty ___________________________________ Date Entered _________________ Discharge Date _______________

Work
Experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer
Address

Name of last
supervisor

City, State, Zip Code

Phone number

Employment dates

Pay or salary

From

Start

To

Final

Your last job title

Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer
Address

Name of last
supervisor

City, State, Zip Code

Phone number

Employment dates

Pay or salary

From

Start

To

Final

Your Last Job Title

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

PLEASE PRINT ALL

INFORMATION REQUESTED
EXCEPT SIGNATURE
APPLICATION FOR EMPLOYMENT
Work
experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer
Address

Name of last
supervisor

City, State, Zip Code

Phone number

Employment dates

Pay or salary

From

Start

To

Final

Your last job title

Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer
Address

Name of last
supervisor

City, State, Zip Code

Phone number

Employment dates

Pay or salary

From

Start

To

Final

Your last job title

Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

May we contact your present employer?

{ } Yes

{ } No

Did you complete this application yourself

{ } Yes

{ } No

If not, who did? _______________________________________________________________________________________

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by FAMILIA HEALTHCARE SERVICES (hereinafter
called the Company), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship,
either in the position applied for or any other position, and regardless of the contents of employee
handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to
time, or other Company practices, shall serve to create an actual or implied contract of employment, or to
confer any right to remain an employee of FAMILIA HEALTHCARE SERVICES , or otherwise to change in
any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot
be altered except by a written instrument signed by the Administrator of the Company. Both the undersigned
and FAMILIA HEALTHCARE SERVICES may end the employment relationship at any time, without
specified notice or reason. If employed, I understand that the Company may unilaterally change or revise
their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the
misrepresentation or omission of facts called for is cause for dismissal at any time without any previous
notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise
indicated), references, and others, and hereby release the Company from any liability as a result of such
contract.
I further understand that my employment with the Company shall be probationary for a period of sixty (60)
days, and further that at any time during the probationary period or thereafter, my employment relation with
the Company is terminable at will for any reason by either party.
I certify with my signature below that all information provided in this form is true and accurate.
Signature of applicant__________________________________________ Date: ___________________

FAMILIA HEALTHCARE SERVICES is an equal employment opportunity employer. We adhere to a policy

of making employment decisions without regard to race, color, religion, sex, sexual orientation, national
origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company
depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

JOB ACCEPTANCE STATEMENT

I have received, have read and agree to the terms specified in this job description for the position I
presently hold. I further understand that this job description may be reviewed at any time and that I
will be provided with a revised copy.

Employee Signature

Date

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

STATEMENT OF EMPLOYABILITY
By execution of this document, I ______________________________,
hereby acknowledge that I have been informed by FAMILIA HEALTHCARE SERVICES that a criminal
history check will be performed on my name. I have informed this agency of all names (i.e., maiden
name, aliases) that I have used in the past. I understand that I have been employed on an emergency
basis and that my employment is temporary or interim pending the results of the criminal history
check.
I hereby profess that I have not been convicted of any of the following crimes which are a
permanent automatic bar to employment by this agency:

An offense under Section 19, Penal Code (criminal homicide);

An offense under Section 20, Penal Code (kidnapping and false imprisonment);
An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
An offense under Section 21.08, Penal Code (indecent exposure);
An offense under Section 21.11, Penal Code (indecency with a child);
An offense under Section 21.12, Penal Code (improper relationship between educator and student);
An offense under Section 21.15, Penal Code (improper photography or visual recording);
An offense under Section 22.011, Penal Code (sexual assault);
An offense under Section 22.02, Penal Code (aggravated assault);
An offense under Section 22.021, Penal Code (aggravated sexual assault);
An offense under Section 22.04, Penal Code (injury to a child, elderly individual or disabled individual);
An offense under Section 22.041, Penal Code (abandoning or endangering a child);
An offense under Section 22.05, Penal Code (deadly conduct);
An offense under Section 22.07, Penal Code (terroristic threat);
An offense under Section 22.08, Penal Code (aiding suicide);
An offense under Section 25.031, Penal Code (agreement to abduct from custody);
An offense under Section 25.08, Penal Code (sale or purchase of a child);
An offense under Section 28.02, Penal Code (arson);
An offense under Section 29.02, Penal Code (robbery);
An offense under Section 29.03, Penal Code (aggravated robbery);
An offense under Section 33.021, Penal Code (online solicitation of a minor);
An offense under Section 34.02, Penal Code (money laundering);
An offense under Section 35A.02, Penal Code (Medicaid fraud); and
An offense under Section 42.09, Penal Code (cruelty to animals); or
A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an
offense containing the elements that are substantially similar to the elements of an offense listed above.

I also hereby profess that I have not been convicted of any of the following crimes within the
past 5 years (applicable only to those hired on or after September 1, 2007 unless otherwise
noted):
An offense under Section 22.01, Penal Code (assault punishable as a Class A Misdemeanor or felony)
[applicable to those hired on or after September 1, 2003];
An offense under Section 30.02, Penal Code (burglary) [applicable to those hired on or after September
1, 2003];
An offense under Chapter 31, Penal Code (theft punishable as a felony)[applicable to those hired on or
after September 1, 2001]
An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a
financial institution punishable as a Class A Misdemeanor or felony) [applicable to those hired on or after
September 1, 2003];

!1
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

 An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable
as a Class A misdemeanor or felony) [applicable to those hired on or after September 1, 2003];.
An offense under Section 37.12, Penal Code (false identification as peace officer); or
An offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).

I understand that if I have been placed on deferred adjudication community supervision for an
offense listed above, successfully completed the period of deferred adjudication community
supervision, and received a dismissal and discharge according to Section 5(c), Article 42.12,
Code of Criminal Procedure, I am not considered convicted of that offense.
I acknowledge that if I am found to have been convicted of any other offense(s), that these
offenses may also bar my employment.
I understand that all information obtained by this agency regarding any criminal history will
remain confidential.
I certify that the information on this form contains no willful misrepresentation and that the
information given is true and complete to the best of my knowledge.

_____________________________________________
Signature of Applicant
_____________________________________________
Printed Name
_____________________________________________
Date

!2
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

TELEPHONE REFERENCE CHECK LIST

Reference check on _______________________________, from:_____________

(Full name of company, person talked to and title)
Was this person a supervisor?_______________________________________
Worked from ___________to______________(Do dates agree?_______)
Job & Title?________________________________________________
Skills _________________________Explain______________________
Quality of work:

Very good_________
Satisfactory________
Unsatisfactory______
Please explain________________________________________________

Get along with:

Superiors__________
Co-workers________
Subordinates_______
Please explain________________________________________________
____________________________________________________________

Work habits (attendance, punctuality, etc.)

Very good_________
Satisfactory________
Unsatisfactory______
Please explain________________________________________________
___________________________________________________________
Can you confirm salary starting and ending as $_________________
to $_____________? If not correct, what was it?________________
Would you rehire?________If not, why_____________________________________________
Other comments:_______________________________________________________________
Thank the person and assure them we would show the same courtesy. You may need to tell them we have the
applicant's authorization to check.) This is to be attached inside application.

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

AUTHORIZATION FOR CRIMINAL HISTORY CHECK

I release FAMILIA HEALTHCARE SERVICES its officers, employees and agents from any and all
liability from the results and preparation of any reports concerning my background or myself. I
understand that a criminal history report will be requested from the Texas Department of Public
Safety Code 250.006.

I authorize FAMILIA HEALTHCARE SERVICES to submit a request for a Criminal History Check to
the Texas Department of Public Safety
Date:
Print Name:
Signature:
Maiden Name:
Date of Birth:
Race:

SS#:
Sex:

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

Acknowledgement Form

I, ____________________________the undersigned, acknowledge by signing below that:

I have read and understood all policies summarized in this manual
I will comply with all HIPAA rules and respect patients confidentiality as outlined
in the policies and procedures
I have read and understand the Agencys Abuse, neglect and Exploitation policy and
will always follow the guidelines of this policy
I have been offered access to all pertinent policies of FAMILIA HEALTHCARE
SERVICES
I do intend, if hired by FAMILIA HEALTHCARE SERVICES to abide by all its
policies and procedures
I am aware of the fact that any violation of policies may result in termination or
suspension, if hired
If hired by FAMILIA HEALTHCARE SERVICES my employment is at-will and
may be terminated in compliance with the policies of this agency
This manual is not a contract
I will also be bound to policies summarized in this manual.

______________________________________

_________________

Prospective employee name

Date signed

Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

Pre-Employment TB Questionnaire
To Be Completed by Employee:
Name: ______________________________________ SSN:_____________________
! Yes

! No

2. Have you ever had the BCG vaccine?

! Yes

! No

3. Do you have prolonged or recurrent fever?

! Yes

! No

4. Have you recently lost weight?

! Yes

! No

5. Do you have a chronic cough?

! Yes

! No

6. Do you cough up blood?

! Yes

! No

7. Do you have sweating at night?

! Yes

! No

8.

! Yes

! No

1. Have you ever had a positive TB skin test, or history of TB

infection?
If the answer is yes, please answer the following:

9. Do you have any of the following risk factors, which may

substantially increase the risk of tuberculosis?
_______ Silicosis (Lung Disease)
_______ Gastrectomy
_______ Intestinal Bypass
_______ Weight 10% or more below ideal body weight
_______ Chronic Renal Failure
_______ Diabetes Mellitus
_______ Prolonged high-dose corticosteroid therapy or
other immunosuppressive therapy
_______ Hematologic disorder (i.e. leukemia or
lymphoma)
_______ Exposure to HIV or AIDS
_______ Other malignancies

Employee Signature:____________________________________________

Date:____________________
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com

Page 1 of 1

TB AGREEMENT

Last Revised:
Adopted:

RV
IC

ES

FAMILIA HEALTHCARE SERVICES Infection Control: IC-41

LT
H

AR

SE

I understand that due to my possible occupational exposure to patients with Tuberculosis

(TB), I may be at risk of acquiring this bacterial infection. I have been given the opportunity to
attend an in-service which provided me with training and information of the hazards of TB
transmission, its signs and symptoms and the protocol to follow in the case of an exposure. I
have also been fit tested for the High Efficiency Particulate Respirator (HEPA), along with
viewing a video on how to properly fit my respirator. If an exposure should occur I am aware
that my employer is to provide me free of charge, with the Mantoux skin test and provide
follow up training and evaluation as per protocol.

______________________
Instructor's Signature

EA

____________________
Employee Name

__________
Date

FA
M

IL
IA

_____________________
Employee Signature

INFECTION
!78

Copyright MI PUEBLO HEALTHCARE SOLUTIONS www.mipueblohealthcare.com

Page 1 of 1

HEPATITIS VACCINE DECLINATION

Last Revised:
Adopted:

RV
IC

SELF-EMPLOYED CONTRACTOR

ES

FAMILIA HEALTHCARE SERVICES Infection Control: IC-13

AR

SE

I understand that due to my occupational exposure, or potential exposure, to blood and/or other
potentially infectious material, I may be at risk of acquiring Hepatitis B virus (HBV) infection. As
a self-employed contractor, I understand that it is my responsibility to be informed regarding the
risks (health and otherwise), disease process, exposure routes, prevention symptoms and
treatment of this disease. I understand that by declining this and treatment of this disease. I
understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a
serious disease. I hereby release the Agency from any and all liabilities arising from my
declination to be immunized.

LT
H

________________________________________________________________
SIGNATURE

FA
M

IL
IA

EA

_____________
DATE

INFECTION
!32

Copyright MI PUEBLO HEALTHCARE SOLUTIONS www.mipueblohealthcare.com