Employment Application

Personal Information

E-mail Address

Cell Phone

Gender MaleFemale

Previous Employment

Name of Employer 1

Nature of Business

Employer Contact Info

Name of Employer 2

Nature of Business

Employer Contact Info

Name of Employer 3

Nature of Business

Employer Contact Info

May we contact your current or previous employer(s)? YesNoNot applicable

Have you ever plead “guilty” or “no contest” to, or been convicted of, a health care related crime, crime of moral turpitude or felony? If yes, please explain date(s) and details. YesNo

Educational Background

Level of Education:

Personal References (please supply three)

Personal Strengths

Languages Spoken

Career Plans

Rate Your Typing Skills ExcellentGoodFairRudimentary

Words per Minute if Known

Rate Your Computer Skills ExcellentGoodFairRudimentary

Rate Your Familiarity with Medical Vocabulary GoodFairMinimal

EMT, MA or Other Relevant Certifications

Medical Courses Taken AnatomyMedical VocabularyPhysiologyOther

Availability

I am available to start training/working

My work plans with ABC Scribes (select from options listed):I plan to work part-time for two or more years while a full time studentI plan to work part-time now but will have full-time availability during an upcoming gap yearI plan on working full-time long termOther (explain below)

How Many Hours (per week) do You Plan on Working While in School (if applicable) - a commitment to work up to two shifts per week may apply

If hired, do you agree to work your fair share of nights, weekends and holidays (eg: Thanksgiving and seasonal school breaks)? Yes or no. If no, please explain:

Medical Information

Working in a health care institution requires a more stringent set of health screening than does work elsewhere. As an employee of ABC Scribes, you will be required to follow the protocols of the institution at which you are working and all screening must be completed prior to commencing work.

Documentation will be required at time of hire (photocopies of your records) for the following:

PPD (TB Skin Test) within the last 12 months; two-step if over 12 months ago. Report of follow up chest x-ray for any positive test.

History of chickenpox or vaccination. Date:

Hepatitis B Vaccination Date of Completion (may opt to decline this in writing prior to hiring):

MR or MMR Vaccination Date:

Health Insurance:

Health Insurer

Policy Holder

Policy Number

Attestations

Please initial the following if you agree:

I understand that if I have a known infectious disease, I shall not place myself in areas in which I would jeopardize others while working for ABC Scribes, Ltd. If I become aware that I might have a serious infectious disease, I will notify my collaborating physician and ABC Scribes as soon as practicable.

I agree to perform only those functions assigned to me by ABC Scribes, Ltd.

I understand that there are certain laws in place that protect the rights of patients to privacy. I agree to observe those privacy rights as regulated by the Federal Health Insurance Portability and Accountability Act of 1996, and any updates since. This means that any individual’s medical data or information that I may hear, see, or observe is not to be disclosed to any individual outside the intent and purpose of my job function with ABC Scribes, Ltd. The information may be disclosed and discussed amongst the people directly involved in conducting legitimate functions related to the patient’s visit. I understand and agree to maintain this confidentiality. This means that I may not read a patient’s chart unrelated to my duties with ABC Scribes, Ltd., cannot tell others outside the hospital that a person is in the hospital, and cannot tell anyone information about any patient. I understand that there are severe fines and penalties for violating these provisions.

I do not use alcohol to an extent where it could, or ever has, caused impairment of job performance and will not work for ABC Scribes, Ltd. with alcohol in my system.

I do not use any illegal drugs.

I have United States citizenship or proof of authorization to work in the United States.

I am at least 18 years of age or will be when I commence working for ABC Scribes.

I will provide enough availability that I can be scheduled for up to 20 hours per week if I am part-time in school including my fair share of nights, weekends and holidays.

I am able to perform the duties of a scribe with reasonable accommodation.

I will maintain immunizations as may be required by the Health Care Institution(s) where I will be working.

Certification

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application are grounds for dismissal. Type name and enter date:

How did you hear about us? AdvertisementMy Educational InstitutionABC EmployeeOther

Please elaborate if "other" selected.