CODAC BEHAVIORAL HEALTH SERVICES, INC.
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1 CODAC BEHAVIORAL HEALTH SERVICES, INC. Human Resources 1650 East Ft. Lowell Rd. Suite 202 Tucson, Arizona Administration: Human Resources: Fax: Website: Intern/Volunteer Packet Please read all instructions carefully and complete all sections of the application completely and accurately. You must provide sufficient information to indicate that you meet the minimum qualifications for the job for which you wish to be considered. If you would like to request a reasonable accommodation to complete the packet or to participate in any phase of the selection process, please make your request to the Human Resource Office in advance. A separate application is required for each position for which you want to be considered. All staff working with or around children and/or other agency designated positions must be fingerprinted per Arizona Statutes. Date: Type of Intern/Volunteer: (NP, PA, BHP, MA s, Admin, Supervisor, License, other) General Information Last Name First Name Middle Other names used: Address City State Zip Home Phone Cell Phone Work Phone Other E mail Address Are you a current CODAC employee? (check one) Yes No Are You legally authorized to work in the USA? (check one) Yes No Note: You must be at least 21 years or older for Intern/Volunteer requiring member contact. Are You 21 years of age or older? Yes No If no, are you at least 18 years of age? Yes No Have you ever been employed with CODAC? (check one) Yes No (If yes give dates) Have you had a previous Intern/Volunteer with CODAC? (check one) Yes No (if yes give dates) Type of Intern/Volunteer required: Length of Intern/Volunteer required: Admin Clinical C&F Approx Start Date: Approx End Date: Emergency Contact Phone: Address: Relationship:
2 CRIMINAL BACKGROUND Have you ever plead no contest to, plead guilty to, or been convicted of a felony or misdemeanor crime other than a minor traffic violation? Yes C No Explain, Yes answers below; state nature, resolution and date of the case(s): Name of Institution EDUCATION (Institution requiring the Intern/Volunteer) Location Degree working toward? Major Total Intern/Volunteer Hours Required Contact Person: Contact Telephone Number: Hours Available: (check all that apply) Days Nights Weekends Total Hours Per Week: Mon: Tues: Wed: Thurs: Fri: Sat: Sun: Previous Intern/Volunteer Experience / Practicum Organization & Location Dates: (start end) Supervisor Hours Completed Please list any other relevant experience / place of employment, etc. LANGUAGE List any foreign languages you can speak, read and/or write and you level of proficiency. (Basic, Intermediate, Advanced) Language: Speak: Read: Write: Language: Speak: Read: Write: Familiarity with Adult Behavioral Health System (PEER) Are you a Family Member (care giver, parent) of a consumer (past or present) of the adult behavioral health system? Yes No Are you a consumer (past or present) of the adult behavioral health system? Yes No
3 References Please list at least 2 references (Instructors) and 1 personal associate we may contact as references. Please do not list relatives. Institution Institution: Institution: Telephone: Professional / Educational: Telephone: Professional/Educational: Telephone: Professional/Educational: Intern/Volunteer Description (Note: if Intern/Volunteer is less than 40 hours; no equipment set up is required) General job description, responsibilities and tasks, supervisor, minimum skills required for the position, expectations of the Intern/Volunteer during the project, knowledge/skills gained upon project completion.
4 Confidentiality Waiver In accordance with federal and state confidentiality laws I understand that any information I may encounter while visiting CODAC Clinic is protected. I understand I must not share this information with anyone at anytime. I understand that all information from the forgoing sources, which I may encounter visually, verbally, written, electronic, or by any other means is sensitive and must be protected. I also agree to not release any information I may be privy to, to anyone outside of CODAC. This agreement does not expire. Print Signature: Witness Witness Signature: I certify that all the information I have provided is true and complete to the best of my knowledge. I give CODAC Behavioral Health Services, Inc. and its authorized agent s permission to verify and/or disclose any information give in connection with this application for personnel/employment purposes. I understand that any misstatements or omissions in these application materials or interview process may be grounds for rejection of my application or termination of employment if hired. I hereby authorize any and all persons and agencies to furnish to CODAC Behavioral Health Services any information, including documents in my personnel file, which may be necessary to verify this application and any other materials submitted and hereby waive any rights of privacy to the information or documents which I may have under any federal, state, or local law, ordinance or rule. I understand that employment in certain positions may be conditional upon a review of criminal records. I also understand that an incomplete application packet may delay or prevent employment opportunities with CODAC. Applicant s Signature Date CODAC Behavioral Health Services, Inc. is an EEO/AA Employer.
5 EQUAL EMPLOYMENT OPPORTUNITY SELF-IDENTIFICATION FORM INTERN/VOLUNTEER NAME: DATE: CODAC Behavioral Health Services, Inc., as an equal opportunity, affirmative action employer recruits members of diverse racial and ethnic groups, persons with disabilities, veterans and women. CODAC requests your assistance in meeting Federal regulation by providing the following information. By applicable law, we are required to keep records and perform certain analysis of our applicant pool by race, ethnicity and sex. Such analysis only possible if we know the EEO profile of our applications, we ask you to voluntarily complete this survey. The information that applicants provide does not at all affect their prospects for employment and its treated very confidentially, the information is nevertheless very important to us. The categories listed below are those used by the U.S/ Bureau of Census and the Department of Labor and are the only options currently available for Federal reporting purposes. We recognize that these categories do not accommodate persons with diverse ethnic backgrounds; we ask that you choose only one. (If you choose more than one, we will be unable to perform any analysis). Gender: Sex: Male Female Race and ethnic identification (Check One Only): Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless or race. American Indian or Alaskan Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. African American/Black (Not Hispanic or Latino): A person having origins in any of the Black racial groups of Africa. White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, North Africa or the Middle East. Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian sub continent including for example: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other pacific islands. Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the five races. Disabled YES NO SPECIAL DISABLED VETERAN YES NO Veteran of the U.S military, ground, naval or air service who is entitled to compensation (or who but the receipt of military retired pay would be entitled to compensation under the laws administered by the Department of Veteran s Affairs. VETERAN OF THE VIETNAM ERA YES NO Veteran discharged or released with other than a dishonorable discharge, if any such active duty was performed: 9a) in the Republic of Vietnam between 02/28/1961, and 05/07/1975; or (b) between 08/05/1974, and 05/07/1975. NEWLY SEPARATED VETERANS YES NO Veteran who served on active duty, during the one year period beginning on the date of such veteran s discharge or release from active duty. OTHER PROTECTED VETERAN YES NO Veteran who served on active duty in the U.S military, ground, naval or air service during a war or in a campaign badge has been authorized.
6 CODAC BEHAVIORAL HEALTH SERVICE, INC. IS AN EEO/AA EMPLOYER AND DOES NOT DISCRIMINATE ON THE BASIS OF SEX, AGE, RACE, RELIGION, COLOR AND NATIONAL ORIGIN, DISABILITY, GENETIC INFORMATION, TRANSGENDER IDENTITY, VETERAN STATUS, OR SEXUAL ORIENTATION AND IS COMMITTED TO MAINTAINING AN ENVIRONMENT FREE FROM SEXUAL HARASSMENT AND RETALIATION. Intern/Volunteer Release Authorization I. In connection with my application for employment or continued employment at CODAC Behavioral Health Services, Inc. I understand that a consumer report and/or an investigative consumer report will be ordered that may include information as to my character, general reputation, personal characteristics, mode of living, work habits, performance, and experience, along with reasons for termination of past employment. I understand that to the extent permitted by applicable law and as directed by company policy and consistent with the job described, CODAC may be requesting information from public and private sources about me, including but not limited to: social security number validation criminal conviction records, employment and earnings history, education, credit, licensing, and certification checks, references, military service, sex offender registry, civil cases, OIG/GSA, OFAC/Patriot Act Records, any sanctions list, FBI fingerprinting and if applicable, worker s compensation injuries, driving record, drug testing results. If company policy requires and to the extent permitted by law, I am willing to submit to alcohol and/or drug testing to detect the use of alcohol or drugs prior to and during employment. II. III. IV. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies. In the event that an agency or record source requires an alternative release form or additional identifying characteristics in order to release the requested information, I agree to provide the additional information and sign any additional release authorizations, if so requested by CODAC. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or Insurance Company contacted by CODAC Behavioral Health Services, Inc. or its agent, to furnish the information described in Section I. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. I understand that this information is confidential and will not be used for any other purposes. I hereby release the employer, its agents, officials, representatives or assigned agencies, including officers, employees or related personnel, both individually and collectively and all person, agencies, and entities providing information or reports about me from any and all liability for damages of whatever kind of which may at any time result to me, my heirs, family or associates arising out of the request for or release of any of the above mentioned information or reports. Please print your full name Last First Middle Please print other names you have used (maiden name, surname, alias name). Current Address City State Zip Code Social Security Number (FOR IDENTIFICATION PURPOSES ONLY) Date of Birth A number of states, including but not limited to, AL, AR, FL, GA, IA, IL, IN, KS, MI, MN, MO, NE, NV, NH, PA, SC, TX, VA, WA, WV, and WI, require additional identifying characteristics in order to complete a criminal records search. For that purpose only, please provide the following: Sex: Male Female Race: White Black/African American Asian Hispanic or Latino American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Two or More Races Driver s License Number State Issuing License Name as it appears on license. I CERTIFY THAT THE INFORMATION THAT I PROVIDED ON THIS FORM IS TRUE AND CORRECT. I UNDERSTAND THAT FALSE INFORMATION, MISREPRESENTATIONS AND OMISSIONS MAY DISQUALIFY ME FROM CONSIDERATION FOR EMPLOYMENT, OR, IF I AM HIRED OR ALREADY WORK FOR THE COMPANY, THAT I MAY BE DISCIPLINED, UP TO AND INCLUDING TERMINATION. Signature Today s Date
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