Jobs

Employment Opportunities

Pre—Employment Questionnaire

Position(s) for which application is being completed:

Name

Social Security Number

Phone

Email Address

Address

City

State

Zip

Length of time residing in Pittsburgh or Southwestern Pennsylvania area?

Are you older than 18? Yes No

If under age 18, date of birth

If under age 18, can you furnish a work permit? Yes No

EDUCATION

Highest grade completed:

High School

College

Other

Special Training

Are you a smoker? Yes No

Related skills to the position(s) for which you are applying?

Are you presently employed? Yes No

When would you be available to begin work if offered a position of employment?

Have you ever been employed by St. Barnabas Health System? Yes No

If yes, Corporation / Department

Have you worked in a long-term care facility or other health care facility before? Yes No

If yes, please supply details

Why are you interested in working for St. Barnabas Health System?

How did you learn about employment possibilities with St. Barnabas?

Are you interested in

Part-time

Full-time

Temporary work

If temporary, please explain

Are there any hours when you would not be available for work at St. Barnabas? Yes No

If yes, please specify and give reasons

Are you willing to work weekends? Yes No

Overtime? Yes No

How many days were you absent from work? 2009 2008

Have you been discharged from any employment other than layoff due to lack of work? Yes No

If yes, give details

Have you been convicted of any crime? Yes No

If yes, please explain

Have you ever been barred or sanctioned by Medicaid or Medicare? Yes No

If yes, give details

Do you use any illegal drugs of any kind? Yes No

If yes, explain

Please set forth any training or special skills you possess:

MILITARY SERVICE

Did you serve in the U.S. Armed Forces? yes No Branch

Entered Discharged

Final Rank Selective Service Classification

Type of discharge :

Present military status

Active

Inactive

Reserve

PERSONAL REFERENCES (Other than relatives or former employers.)

Name, Occupation, Address, Telephone and Years Known are required. List three

EMPLOYMENT EXPERIENCE
Please start with your present or last job. You may include any volunteer activities. You should exclude organizations, which indicate race, color, religion, gender, national origin, sexual orientation, disability or other protected status.

Employer		Position / Job Title
Address		Dates Employed
Phone Number		Hourly Rate / Salary
Supervisor		Reason for Leaving
Work Performed

Employer		Position / Job Title
Address		Dates Employed
Phone Number		Hourly Rate / Salary
Supervisor		Reason for Leaving
Work Performed

Employer		Position / Job Title
Address		Dates Employed
Phone Number		Hourly Rate / Salary
Supervisor		Reason for Leaving
Work Performed

May we contact the employers listed above? Yes No

If not, indicated references and which one(s) you do not wish us to contact

I hereby agree to submit to any lawful drug, alcohol or integrity testing that may be required as a condition of employment or continued employment and understand that refusal to submit to such testing may result in the termination of my employment.

I understand that all statements made here are subject to verification by St. Barnabas Health System and I release from all liability or responsibility all persons, companies, or other health care institutions supplying such information. I agree that St. Barnabas Health System may use the contents of this application form and related reports in any lawful manner. I further understand that misrepresentation of facts is sufficient cause for rejection of this application or discharge if I am employed by St. Barnabas Health System. I understand that the company does not offer specific terms of employment and accordingly my employment is terminable at will, by either party.

Signature Date