1 The Arc of Vigo County 11 Cherry St. Terre Haute, IN 47807 (812) 232-4112 EOE Provider Application In compliance with Federal and State Equal Opportunity Employment Laws, qualified applicants will be considered for all positions without regard to race, color, religion, gender, sex orientation, gender identity, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state, and local laws, and to make all employment decisions so as to further this principle of equal employment opportunity. Directions: Please answer all questions, do not state See Resume. All applications will be kept on file for one year. : Name: Are you at least 18 years of age? Address: Street City State Zip Phone Number: Best time to call: Cell Phone Email Address: (optional) (Cell phone required if employed) In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. The Arc of Vigo County participates in E-Verify. Referred By: Ivy Tech Arc Job Newspaper Employee Job Zone Website Walk-in Friend Fair Other For what position are you applying? Have you ever applied for a position or been employed by the Arc of Vigo County? If yes, when: Which do you prefer? Full Time Part Time Temporary Seasonal How many hours per week do you prefer to work? Please list times you would be available to work: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Please list times you ARE NOT available to work: Monday Tuesday Wednesday Thursday Friday Saturday Sunday
2 Education: School name Address Major High School College Employment History (start with current or most recent employer) Name of Company: Hire : Termination : Job Responsibilities: Address: Title: Phone: Supervisor Name: Name of Company: Hire : Termination : Job Responsibilities: Address: Title: Phone: Supervisor Name: Name of Company: Hire : Termination : Job Responsibilities: Address: Title: Phone: Supervisor Name: May we contact your current and /or past employers? Yes No Please discuss any experience you have had working with individuals who have Developmental / Emotional or Physical disabilities:
3 Provider Questionnaire GENERAL INFORMATION Do you drive? Yes No Do you have a valid driver s license? Yes No Do you have active liability auto insurance? Yes No Are you certified in any of the following? CPR EMT First Aid Other Do you have experience or training in any of the following areas? (Check all that apply) Trach care Catheter Injections Sign Language Transfers Bed baths Vital Signs Special Diets Tube Feeding Patient Lifts Colostomy care Apnea Monitors Oxygen Range of Motion Other CLIENT PREFERENCE It will be helpful in matching individuals to know who you would most like to serve. Male Female A. Type of disability: All disabilities other If other, please check the disabilities of people you prefer to work with. Developmental disabilities Mental Retardation Vision Impairment At Risk (infants / children) Autism Emotional disabilities / mental illness Cerebral Palsy Hearing Impairment Multiple disabilities Seizure control B. Population you prefer to work with. Adults Children Both TYPE OF SERVICE PREFERRED Because of the varied needs of people our Respite Program serves, we offer families options as to where the respite will occur. Some families need respite care in their homes, some in the provider s home and others prefer community outings. Please state the type of respite you would prefer providing. In-Home Respite Are you available to provide respite in the family s home? Yes No Are you available to provide overnight respite? Yes No Out-of-Home Respite Yes No
4 Are you interested in providing Respite in your home? Yes No The following information is required if Respite will be in employees home. DESCRIPTION OF YOUR HOME Accessibility purposes, where do you live? Apartment House Mobile Home Do you have homeowner s/renter s insurance? Yes No Due to allergies, do you have pets? Yes No If yes, what kind? Can you provide a smoke free environment for our clients? Yes No Do you have a fire extinguisher in your home? Yes No Do you have a smoke alarm in your home? Yes No If there are children in your home will there be someone to care for them during the time the client is in your care, so as to keep one on one with client? Yes No Please give detailed directions to your home: CERTIFICATION OF APPLICANT I hereby certify that there are not misrepresentations in or falsifications of these statements or answer to questions. I am aware in making application for employment that an investigative report may be made regarding information as to my personal character and general reputation through personal interviews with friends, neighbors or other acquaintances. I hereby authorize such investigation, and am aware that falsification on this application or any other accompanying data may result in my discharge from my position with the Arc of Vigo County. It is the prerogative of the Arc to discharge an employee for any reason other than those specifically prohibited by laws, or adopted policies and procedures. I understand that employment with the Arc of Vigo County will require a criminal background check done through the Indiana State Repository and any state or county I have lived or worked in for the past three years, also a background check of the Nurses Registry and Drivers License check upon offer of employment. The Arc of Vigo County prohibits employing a person convicted of the offenses listed in state law 460 IAC 6-10-5. Signature of Applicant
5 Reference Request (Current / Former Employer) * Required information. All other fields are for office use only. *Applicant Name: *: *Position Applied for: * Reference Name: *Phone: *Address: Best time to call: APPLICANT WAIVER AND RELEASES: I have applied for a position with the Arc of Vigo County and given your name as an employer reference. I authorize the respondent to furnish the Arc of Vigo County with whatever information they may have regarding my employment, including my reason for leaving. I am signing this Waiver and Release voluntarily and request that the respondent complete this reference inquiry with full and complete information, since this reference is an important part of my application for employment with the Arc of Vigo County. I therefore waive and release the respondent from any and all claims or causes of action in law or equity, including but not limited to, defamation of character or invasion of privacy, which might arise from responding to this reference check. * * Applicants Signature Signature of Arc Staff / Title Please confirm the following information about the applicant: s of Employment: From to Starting position: Last position held: Reason for leaving: Type of separation: Voluntary Involuntary Is applicant eligible for rehire? Yes No If no, please explain: Characteristics of applicant Ability to perform assigned duties Ability to communicate (oral/written) Ability to take direction (supervision) Ability to work with others (teamwork) Ability to settle conflicts with coworkers Ability to work under pressure Ability to adapt to changes in the job Ability to work independently Ability to solve problems Work attendance and dependability Positive attitude towards job/coworkers Below Above Comments Signature
6 Reference Request (Personal, Non-related persons whom you have known at least one year) * Required information. All other fields are for office use only. *Applicant Name: *: *Position Applied for: * Reference Name: *Phone: *Address: Best time to call: APPLICANT WAIVER AND RELEASES: I have applied for a position with the Arc of Vigo County and given your name as a Personal reference. I authorize the respondent to furnish the Arc of Vigo County with whatever information they may have regarding my characteristics. I am signing this Waiver and Release voluntarily and request that the respondent complete this reference inquiry with full and complete information, since this reference is an important part of my application for employment with the Arc of Vigo County. I therefore waive and release the respondent from any and all claims or causes of action in law or equity, including but not limited to, defamation of character or invasion of privacy, which might arise from responding to this reference check. * * Applicants Signature Signature of Arc Staff / Title Characteristics of Applicant Is he or she a hard worker? Is he or she enthusiastic? Is he or she honest? Is he or she courteous? Is he or she dependable? Is he or she organized? Does he or she have positive attitude? Does he or she make a good impression on people? Is he or she able to solve problems Is he or she friendly or easy to get along with? Is he or she emotionally stable and mature? Can settle his or her conflicts with others? Does he or she keep up his / her personal appearance? Does he or she handle frustration Below Above Comments Additional Comments: Signature
7 Reference Request (Personal, Non-related persons whom you have known at least one year) * Required information. All other fields are for office use only. *Applicant Name: *: *Position Applied for: * Reference Name: *Phone: *Address: Best time to call: APPLICANT WAIVER AND RELEASES: I have applied for a position with the Arc of Vigo County and given your name as a Personal reference. I authorize the respondent to furnish the Arc of Vigo County with whatever information they may have regarding my characteristics. I am signing this Waiver and Release voluntarily and request that the respondent complete this reference inquiry with full and complete information, since this reference is an important part of my application for employment with the Arc of Vigo County. I therefore waive and release the respondent from any and all claims or causes of action in law or equity, including but not limited to, defamation of character or invasion of privacy, which might arise from responding to this reference check. * Applicants Signature Signature of Arc Staff / Title * Characteristics of Applicant Is he or she a hard worker? Is he or she enthusiastic? Is he or she honest? Is he or she courteous? Is he or she dependable? Is he or she organized? Does he or she have positive attitude? Does he or she make a good impression on people? Is he or she able to solve problems Is he or she friendly or easy to get along with? Is he or she emotionally stable and mature? Can settle his or her conflicts with others? Does he or she keep up his / her personal appearance? Does he or she handle frustration Additional Comments: Below Above Comments Signature