Employment Application
Position applied for: Habilitation Worker (Direct Service staff)/ Lead HAB Worker
Start with the most recent employment and list all of the jobs you have had. Additional Info may be placed on a separate sheet of paper and attached
For verifying educational, professional and employment records please indicate any name by which you have been known other than the name under which you are applying.
Telephone Reference Check Form
All clients of PLFGH have the right to confidentiality.
Client's personal identifiable information shall be stored in locked cabinet at resident of each client.
Client's information will not be released without written authorization/consent from client or guardian except by law, regulation, or policy.
Client's information may be disclosed to DDD district Human Rights Committees (HRC) upon request, Director in charge, DDD program coordinator, as necessary health/safety, and emergency personnel necessary to protect the health/safety of clients.
Retention shall be 5 years after client exit Pleasant Living Family Group Home, their information shall be shredded and destroyed.
Any violations of client's confidentiality and policy and procedure shall be reported to DDD and may be reason for termination, suspension, and/or re-training. An incident report will be written by house manager or its designee within 24hours and submitted to DDD before 24hours.
Staff will be trained annually on Confidentiality Policy and all of PLFGH Policies and Procedures by Director or its designee at Annual training and for all new hires before they work with PLFGH Residences.
PLFGH do not use Photography Consents and do not display or place or use photos of residents on internet sites, public places, or on cell phones.
PLFGH staff can use computers to email confidential information to Director or Manager only no information on clients can be taken home for review without written authorization from Client and/or Guardian, DDD or PLFGH Director. Any information taken home with permission can only be reviewed by PLFGH Staff.
PLFGH has signs posted on Staff board about confidentiality reminding staff to always remember that information discussed, read, and observed are confidential and can only be discussed with the individuals stated above.
Your signature states that you will not discuss anything regarding any residents at Pleasant Living Family Group Homes.
I understand that as a courtesy, Pleasant Living Family Group Home (PLFGH) will pay the upfront cost for my training and certificates, including Fingerprint Card, Article 9, CPR & First aid and Prevention and Support. However, I understand and agree that the cost for said trainings and certifications are solely my responsibility. I agree to reimburse Pleasant Living Family Group Home for each training and certificate that is paid for on my behalf, and that these funds will be taken from my payroll check(s) until PLFGH is reimbursed in full. I know I will not receive these certificates until they are paid in full. If I quit or am terminated before all documents are paid in full, I give PLFGH permission to take all of the remaining balance from my last check.
I, , employed with Pleasant Living Family Group Home, give my consent to Pleasant Living Family Group Home to use video audio cameras in the common areas of the Group Home.
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