APPLICANT IDENTIFICATION AND RELEASE REGARDING INVESTIGATION OF FOUNDED CHILD AND DEPENDENT ADULT ABUSE, CRIMINAL HISTORY, MEDICARE FRAUD AND DRIVING RECORD IDENTIFICATION: (Please complete) Name: __________________________________________________________________________

First Last Middle ________________________________________________________________________________ Alias, Maiden, previous Married Name (Please list every previous name) ________________________________________________________________________________ Mailing Address City State Zip ________________________________________________________________________________ Date of Birth Social Security Number ________________________________________________________________________________ Race Sex (M/F) Driver’s License Number State Professional License (ie. nursing license) Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime in this state or any other state? No Yes If yes, please explain the nature of the incident and date of occurrence. _______________________ _________________________________________________________________________________ _________________________________________________________________________________ AUTHORIZATION AND RELEASE The undersigned acknowledges: 1. I have executed this document in conjunction with an application for employment with Kossuth Regional Health Center. (Hereinafter referred to as “KRHC”) 2. I hereby authorize KRHC access to any criminal history record produced by federal, state or local

law agencies pertaining to me. 3. I voluntarily give KRHC permission to obtain a certified driver’s record if my position requires

having a valid driver’s license record. I release KRHC and all providers of information from any liability as a result of furnishing and receiving this information.

4. I agree to release KRHC and any other person, company or other entity from any and all causes of action that otherwise might arise from supplying KRHC with information it may request pursuant to this release.

5. I understand that any false answers or statements, or misrepresentations by omission made by me on this form or any related document, will be sufficient cause for rejection of my application or for my immediate discharge should such falsifications or misrepresentation be discovered after my employment.

________________________________ Applicant Signature Date

Memorandum of Understanding

Regarding Immunizations, Vaccinations and Other Tests or Treatments

Kossuth Regional Health Center is committed to improving and enhancing patient and colleague safety as well as providing a healing environment. The Center for Disease Control and Prevention (CDC), OSHA and other regulating agencies designate that various immunizations, vaccinations and other tests or treatments are important for disease prevention. Examples of such vaccinations and immunizations include, but no limited to: TB Testing Measles, Mump, Rubella (MMR) Hepatitis B Series Flu Shot/Mist Tetanus Pertussis Meningitis Additional vaccines, test/treatments as they arise. I understand and consent that upon acceptance of any offer of employment, I will be required to meet these safety standards by completing all immunizations, vaccinations and tests/treatments as deemed necessary by Kossuth Regional Health Center, both pre-employment and periodically including the annual influenza vaccine. I also understand that failure to do so as required is considered my voluntary resignation. My signature below is my ongoing consent (pre-employment and during the term of my employment). ____________________________________ Applicant* ____________________________________ Date

*In the event applicant refuses to sign, further clarification will be required in order for KRHC to continue to consider applicant for the position.

2 KRHC_Employment_Application_v2.pdf1 Generic_Application_Aug_20111 Page 1.pdf2 Generic_Application_Aug_20112 Page 2.pdf3 Generic_Application_Aug_20112 Page 3.pdf4 Generic_Application_Aug_20112 Page 4.pdf5 Generic_Application_Aug_20111 Page 5.pdf

background_check.pdfMOU_Immunizations.pdf

Kossuth Name: Print: KRHC Submit: Name: Home Area Number: Home Phone Number: Cell Area Number: Cell Phone Number: E-Mail: Address: City: State: Zipcode: List any other names by which you have been known to include alias maiden or previous married: List any other names by which you have been known to include alias maiden or previous married 2: 18 or over: Offvalid Drivers license: OffLicense Number: In what state: Proof of auto insurance: Offexcluded patient care: Offexcluded from providing patient care explain: record abuse: OffDo you have a record of founded child or dependent adult abuse 1: Do you have a record of founded child or dependent adult abuse: convicted crime: Offconvicted of crime 1: convicted of crime 2: Position Desired: Date Available: Alternate position: Full-time: OffPart-Time: OffPRN cb: OffTemp: OffIf parttime how many hours per week: Summer: OffSunday: 0: Off

Monday: OffTuesday: OffWednesday: OffThursday: OffFriday: OffSaturday: Offshift Day: Offshift Evening: Offshift Night: Offshift Holidays: OffWhat is your expected starting salary: employed before: Offemployed before explain: List the name and relationship of any relative currently employed by this organization: Employment Agency: OffJob-posting: OffJob Fair: OffFriend: Offemployee referral: Offwalk in: Offhear about position Other: OffEmployee referral name: Advertisement Please list publication: submit legal verification: OffName and Address Of SchoolPost High School ie College School of Nursing Vocational Technical School Graduate level: Course of StudyPost High School ie College School of Nursing Vocational Technical School Graduate level: Optional Years Attended From ToPost High School ie College School of Nursing Vocational Technical School Graduate level: last year completed 1: Offgraduate 1: OffDegree DiplomaYes No: Name and Address Of SchoolPost High School ie College School of Nursing Vocational Technical School Graduate level_2: Course of StudyPost High School ie College School of Nursing Vocational Technical School Graduate level_2: Optional Years Attended From ToPost High School ie College School of Nursing Vocational Technical School Graduate level_2: last year completed 2: Offgraduate 2: OffDegree DiplomaYes No_2: Name and Address Of SchoolPost High School ie College School of Nursing Vocational Technical School Graduate level_3: Course of StudyPost High School ie College School of Nursing Vocational Technical School Graduate level_3: Optional Years Attended From ToPost High School ie College School of Nursing Vocational Technical School Graduate level_3: last year completed 3: Offgraduate 3: OffDegree DiplomaYes No_3: Name and Address Of SchoolPost High School ie College School of Nursing Vocational Technical School Graduate level_4: Course of StudyPost High School ie College School of Nursing Vocational Technical School Graduate level_4: Optional Years Attended From ToPost High School ie College School of Nursing Vocational Technical School Graduate level_4: last year completed 4: Offgraduate 4: OffDegree DiplomaYes No_4: Name and Address Of SchoolHigh School: Course of StudyHigh School: Optional Years Attended From ToHigh School: last year completed 5: Offgraduate 5: OffDegree DiplomaYes No_5: Academic Honors: served as volunteer: Offand what jobs you performed 1: and what jobs you performed 2: and what jobs you performed 3: Presently employed: OffADDRESS: NAME OF EMPLOYER: areacode1: TELEPHONE NUMBER: Street: City1: State1: Your Position: Last Supervisor: starting salary: Final salary: FT-PT 1: OffDESCRIPTION OF WORK PERFORMED1 Present or most recent Employer Employment Dates From Mo Yr To Mo Yr: Mo: Yr: Mo_2: Yr_2: DESCRIPTION OF WORK PERFORMED1 Present or most recent Employer Employment Dates From Mo Yr To Mo Yr_2: REASON FOR LEAVING: contact employer 1: OffADDRESS_2: NAME OF EMPLOYER_2: Street_2: areacode2: TELEPHONE NUMBER 2: City2: State2: Your Position 2: Last Supervisor 2: starting salary 2: Final salary 2: FT-PT 2: OffDESCRIPTION OF WORK PERFORMED2: Mo_3: Yr_3: DESCRIPTION OF WORK PERFORMED2b: Mo_4: Yr_4: DESCRIPTION OF WORK PERFORMED2c: REASON FOR LEAVING_2: contact employer 2: OffADDRESS_3: NAME OF EMPLOYER_3: Street_3: areacode3: TELEPHONE NUMBER 3: City3: State3: Your Position 3: Last Supervisor 3: starting salary 3: Final salary 3: FT-PT 3: OffDESCRIPTION OF WORK PERFORMEDMo Yr Mo Yr: Mo_5: Yr_5: DESCRIPTION OF WORK PERFORMEDMo Yr Mo Yr_2: Mo_6: Yr_6: DESCRIPTION OF WORK PERFORMED3c: REASON FOR LEAVING_3: contact employer 3: OffADDRESS_4: NAME OF EMPLOYER_4: Street_4: areacode4: TELEPHONE NUMBER 4: City4: State4: Your Position 4: Last Supervisor 4: starting salary 4: Final salary 4: FT-PT 4: OffDESCRIPTION OF WORK PERFORMED4a: Mo_7: Yr_7: DESCRIPTION OF WORK PERFORMED4b: Mo_8: Yr_8: DESCRIPTION OF WORK PERFORMED4c: REASON FOR LEAVING_4: contact employer 4: OffProfession: State Issued: Number: Expiration Date: Profession_2: State Issued_2: Number_2: Expiration Date_2: OrganizationProfession: Number_3: Expiration Date_3: OrganizationProfession_2: Number_4: Expiration Date_4: ie ACLS BCLS CPR: ie ACLS BCLS CPR2: software medical terminology: software medical terminology2: software medical terminology3: level of typing: Please state any additional information you believe would be important in considering your application: Please state any additional information you believe would be important in considering your application2: Please state any additional information you believe would be important in considering your application3: Please state any additional information you believe would be important in considering your application4: Name1: Occupation1: Organization: Relationship1: ReferencePhone1: Address Email: Name_2: Occupation2: Organization2: Relationship2: ReferencePhone2: Relationship Telephone Number Address Email_2: Name_3: Occupation3: Organization3: Relationship3: ReferencePhone3: Relationship Telephone Number Address Email_3: Date: applicant signature: Job Title: management temp: Offmanagement prn: Offmanagement Other: OffDepartment: Work hours: Effective Start Date: Total Hourspay period: Preemployment physical date 1: RateofPay: Preemployment physical date 2: General Orientation date: mangement exempt: Offmanagement signature: mangement overtime: OffTodays Date: Name on Name Badge should read as follows: Job Title_2: management ft: Offmanagement ftadd: Offmanagement pt: Offmanagement pt add: Offmanagement temp add: Offmanagement cont add: OffDepartment_2: Work hours_2: Rate of Pay: Total Hourspay period_2: management signature2: Effective Date: Todays Date_2: Date_2: Time_6a: Date_2b: Time_6: Date_3: Time: Date_4: Time_2: Date_5: Time_3: Date_6: Time_4: Date_7: Time_5: Date_8: Date_9: