Career

First Name *

Middle Name

Last Name *

Address *

City *

State/Province *

ZIP / Postal Code *

Telephone No. *

Telephone No. 2

Position Applying for *

Are you interested in: *Part-TimeFull-Time

Date available to start work *

How did you learn of this opening? *

Have you or anyone you know ever worked for this agency before? *YesNo

Explain (If Yes) *

Have you ever been convicted of any criminal offense? *YesNo

Explain (If Yes) *

Are you currently awaiting sentencing ordisposition for any crime or traffic violation or are you currently on probation? *YesNo

Explain (If Yes) *

Do you have any current or open investigations involving you, criminally or with MUI?

WORK HISTORY(List most recent first)

Name of Employer *

Telephone No. *

Street Address *

Name & Title of Supervisor *

Job Title *

Dates of Employment *

To *

Salary: Beginning *

USD

Ending : *

USD

Describe Responsibilities *

Reason for leaving *

REFERENCESList three references, who can assess your professional abilities and whom this agency has permission to contact.

Name *

Occupation *

Relationship *

Telephone Number

EDUCATIONPlease list education you have received

School Name *

Street Address *

Graduated *YesNo

Major *

EDUCATIONPlease list education you have received

College Name *

Street Address *

Graduated *YesNo

Major *

Graduate

Graduate (yes/no) *YesNo

Business/ Trade

Business/ Trade (yes/no) *YesNo

Other

Other (yes/no) *YesNo

HIPAA/ CONFIDENTALITY AND INDIVIDUAL RIGHTS

Name *

Date *

Confidentiality

As a contractor/employee, I will have access to confidential and proprietary information. Information of any kind, nature or description concerning individuals being served and their families, service plans, data and program/ agency operations. This information is confidential and protected by state and federal HIPAA laws. This information will be disclosed only under specific conditions and with prior written authorizations and consents.

Accordingly I agree to:

Hold the information received in strict confidence
Not disclose or divulge this information unless first authorized to do so in writing
Not reproduce the information nor use this information for any purpose other than the performance of my duties and
Upon request or termination of my relationship return all notes, documents and materials originating from my activities.

Rights afforded to ALL Individuals

In LDHCA recognizes and respects the constitutional, civil, and human rights of all the individuals for whom we provide services. This includes but is not limited to:

The right to be treated with dignity and respect
The right to sufficient clothing, food shelter and recreation
The right to be free from physical and sexual abuse, verbal harassment/abuse and neglect
The right to privacy and freedom from intrusion
The right to communicate with family, peers and members of the community through visitation, telephone contact and mail, unless otherwise indicated in the treatment/service plan
The right to practice or not to practice a religion of his or her choice
The right to an education
The right to professional, age appropriate services and treatment
The right to be involved in the service planning process and to express opinions on issues concerning services provided
The right to a competent guardian or advocate
The right to file complaints and grievances.

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