new hire packet - nebula.wsimg.com

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NEW HIRE PACKET

Manager:

Please remember to submit the Employment Application and signed Job Description should also be

given to HR for the employee's personnel file.

New Hire Forms

for new employees to complete and return to Human Resources prior to beginning work

• Employment Application & Employee Contact Form

• W4 & I-9

Bring identification with you when submitting forms - see below for acceptable identification

• Direct Deposit Form

• Training A c k n o w l e d g e m e n t

Acceptable Identification for Form 1-9

• Passport

• Permanent Resident Card

• Driver's License AND Social Security card

(both are needed, driver's license alone is NOT enough)

• Driver's License AND Birth Certificate


• Driver's License AND Native American tribal document


• School ID with photograph AND Birth Certificate

(for students only)

Other combinations are listed on page 2 of the /-9 form.

APPLICATION FOR VIP HEALTHCARE EMPLOYMENT

Copyright © 2017 VIP HEALTHCARE Form #102O

APPLICATION FOR VIP HEALTHCARE PRACTICE EMPLOYMENT

Date: _________________________ For what position are you applying? __________________________________________

Last Name First Middle Home Phone: (_______)___________________

Business Phone: (_______)___________________

Address (Number, City, State, Zip) Are you at least 18 years old? [ ] Yes [ ] No (If no, please provide work permit)

Social Security Number Do you have the legal right to work in the U.S.? [ ] Yes [ ] No (Proof will be required upon employment)

EXPERIENCE AND SKILLS

WHAT IS YOUR SKILL LEVEL?

WHAT IS YOUR SKILL LEVEL?

OFFICE SKILLS Yes No Fair Good Exc. CLINCAL SKILLS Yes No Fair Good Exc.

Typing (word per minute) CPR Training

Multi line phone Medical Certification Customer Service Take VitalsComputer Skills Phlebotomy/VenipunctureCountess Phone Skills Rooming PatientsPatient Account Collections Sterile Techniques/EquipmentCommunication Skills Transcribing Cash Handling Manage Multi TaskMedical Terminology Wound Care TreatmentInsurance Verification EMR User Appointment Scheduling Preparing ChartCheck In/Out Patients Schedule Tests/Treatments

Process Referral/Rx RefillsObserve HIPAA Laws

Observe OSHA & Safety Rules

EDUCATION

Name of School and Address Graduated # of Years Course or Major

High School Y / N

College Y / N

Post Graduate Y / N

Special Courses or Training Y / N

Additional

Special Courses or Training Y / N

CERTIFICATES OR LICENSES MA PA LPN RN CPR Other

Certificate/License #

Date Earned

State Issued

Current Through (give date)

User

Stamp


GENERAL INFORMATION

Can you fulfill the job duties and responsibilities of the position for which you are applying as they have been described to you, with or without a “reasonable” accommodation? [ ] Yes [ ] No

Are you available for the work hours required of the position for which you are applying? [ ] Yes [ ] No

If applicable, do you have the required license(s) to perform the job? [ ] Yes [ ] No

Have completed all vaccination requirements? [ ] Yes [ ] No

Can your vacations be arranged at practice convenience? If no, please explain: [ ] Yes [ ] No

Do you illegally use drugs? [ ] Yes [ ] No

Have you ever been convicted of a crime other than a traffic violation? If yes, please attach explanation. (Note: A conviction does not necessarily bar employment) [ ] Yes [ ] No

Date available to start?

Salary requirements: $_____________/hour $_____________/daily $____________/month

Benefit requirements:

Please indicate your availability to work: [ ] Days [ ] Evenings _____ Days/wk _____Hrs/wk Hours from ______ to ______

Circle the days of the week you will NOT be available to work: Mon Tue Wed Thu Fri Sat Sun

EMPLOYMENT / WORK EXPERIENCE List the last 7 years, including periods of self-employment or unemployment. Answer all questions here and throughout this employment application—do not substitute with a resume. List present or most recent position first. Attach additional pages if needed.

Name of employer: Address (Number, City, State, Zip): Phone:

Employed: From and To (Month and Year) Position(s) Held: Supervisor’s Name and Title:

Average # of hours worked per week: Rate of Pay: Starting and Ending Your last name at time of employment:

Describe your duties:

Give specific reason(s) for leaving:

May we contact this employer: [ ] Yes [ ] No






May we contact this employer? [ ] Yes [ ] No

Copyright © 2017 VIP HEALTHCARE







May we contact this employer? [ ] Yes [ ] No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

PLEASE READ THE FOLLOWING AND SIGN BELOW

GENERAL AGREEMENT If hired, I will provide legal proof of identity and authority to work in the United States. I agree to conform to the rules and standards of the practice, as amended from time to time at the employer's discretion. I understand that any misrepresentation, falsification, or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, in my dismissal from employment. I hereby certify that the information contained in this application form is true and correct to the best of my knowledge.

EMPLOYMENT RELATIONSHIP If hired, I understand that employment with the practice is not for a specified term and can be terminated “At Will”, with or without cause, and with or without notice, at any time, either at the option of the employee or the employer. No employee or representative of the practice, other than its owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the employer may not alter the “At-Will” nature of the employment relationship unless it is done specifically in writing and is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the “At-Will” nature of my employment relationship. There are no oral or collateral agreements regarding this issue.

AUTHORIZATION OF REFERENCE AND BACKGROUND CHECKING All offers of employment are conditioned upon receipt of satisfactory responses to reference requests and background inquires and exams. Unless I have otherwise indicated above, I authorize the references listed, as well as all other individuals who may be contacted, to provide any and all information concerning my previous employment, background, and any other pertinent information that they may have. Additionally, contingent upon a conditional offer of employment and as part of screening for the position for which I am applying, if required, I agree to take a physical exam, drug test, and/or authorize a background check which may include a review of criminal convictions, driving record and credit history. Further, I release all parties and persons from all liability for any damages that may result for furnishing the practice with such information as well as from the use or disclosure of such information by the employer or any of its agents, employees or representatives.

[ ] I hereby waive my right to receive a copy of any public record(s) obtained from the prospective employer checking references.

Applicant’s signature: _________________________________________ Date: _____________________

Application forms will be retained the entire period of employment. Note: This Application for Employment was prepared for general use throughout the United States and in consultation with legal counsel. It is designed to comply with Federal and State Fair Employment Practice laws. However, since State and local laws vary, VIP HEALTHCARE assumes no responsibility for the inclusion in this application form of any questions that may violate Federal, State, or local laws.

Copyright © 2017 VIP HEALTHCARE

EMPLOYEE CONTACT FORM

Employee Information:

Name: ______________________________________________ Position:

Mailing Address:______________________________________________________________________

Physical Address (if different):____________________________________________________________________

Contact Number:_____________________________ Alternate Number:_________________________

Email Address:______________________________________________

Emergency Contact

Name: _____________________________________ Relationship:____________________

Contact Number: _____________________________

Name:_______________________________________ Relationship:____________________

Contact Number:______________________________

I have voluntarily provided the above contact information and authorize VIP Healthcare and its representatives to contact any of the above on my behalf in the event of an emergency.

I choose not to furnish any emergency contact information to VIP Healthcare at this time.

I authorize VIP Healthcare to have an ambulance transport me to nearest Emergency Room at if it is deemed to be necessary.

In the event of an emergency, I authorize VIP Healthcare to inform emergency personnel of the

medical/health condition(s) (including allergies, etc .) described below. This medical information will be maintained confidentially and will only be disclosed to medical personnel as necessary.

Medical / Health Conditions

_________________________________________________________________________________

_________________________________________________________________________________

Employee Signature ________________________________________ Date: ______________

Employee Direct Deposit Enrollment Form

To enroll in Full Service Direct Deposit, simply fill out this form and give to your manager. Attach a voided check for each checking account - not a deposit slip. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn’t always the same as the number on a savings deposit slip. This will help ensure that you are paid correctly.

Below is a sample check MICR line, detailing where the information necessary to complete this form can be found.

|: 012345678|: 123456789” 0101

Memo__________________________

Check # (this number matches the number

in the upper right corner of the check – not needed for sign-up)

Checking Account # Routing/Transit #

(A 9-digit number always between these two marks)

IMPORTANT! Please read and sign before completing and submitting. I hereby authorize VIP Healthcare to deposit any amounts owed me, as instructed by my employer, by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by VIP Healthcare to my account. In the even that VIP Healthcare deposits funds erroneously into my account, I authorize VIP Healthcare to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until VIP Healthcare and Bank have received written notice from me of its termination in such time and in such manner as to afford VIP Healthcare and Bank reasonable opportunity to act on it.

Employee Name: Social Security #: __ __ __ - __ __ - __ __ __ __

Employee Signature: Date:

Account Information The last item must be for the remaining amount owed to you. To distribute to more accounts, please complete another form.

Make sure to indicate what kind of account, along with amount to be deposited, if less than your total net paycheck.

1. Bank Name/City/State: ____________________________________________________________________

Routing Transit #: __ __ __ __ __ __ __ __ __ Account Number: _________________________________

1Checking 1Savings 1Other I wish to deposit: $ _______.____ or 1Entire Net Amount



1Checking 1 Savings 1Other I wish to deposit: $ _______.____ or 1Entire Net Amount



1 Checking 1 Savings 1 Other I wish to deposit: $ _______.____ or 1Entire Net Amount

Employers must keep a copy of the enrollment form on file as long as the employee is using Direct Deposit, and for two years thereafter.

Mandatory Training for All Employees

VIP Healthcare requires that all employees complete HIPAA, OSHA and Compliance

Training course. These are online courses and can be taken on any company computer,

and must be completed within 30 days of hire. A link to the training website will be

provided by Human Resources.

Additional Information

All employees must read and acknowledge receipt of the Employee Handbook and Code

of Conduct. Human Resources will provide all documents. Signed acknowledgment must

be completed within 30 days of hire.

Employee Name: _______________________________________________________

Employee Signature: ________________________________________ Date:___________________

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 11/14/2016 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

8. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. Native American tribal document

7. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

6. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 11/14/2016 N

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.