Pediatric Healthcare Connection - Application Packet

Employee Application - Step 1 of 9

1%

mail_outline
local_phone
place
local_phone
date_range
date_range

Are you a citizen of the United States?


If no, are you authorized to work in the United States?


Have you ever worked for this company before?

If yes, when?

date_range
date_range


Education


place
date_range
date_range

Did you Graduate?


place
date_range
date_range

Did you Graduate?


place
date_range
date_range

Did you Graduate?


Previous Employment


local_phone
place
date_range
date_range

May we contact your previous supervisor for a reference?


Previous Employment 2


local_phone
place
date_range
date_range

May we contact your previous supervisor for a reference?


Military Service


date_range
date_range

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.


Employment Verification - Step 2 of 9

10%

Previous Employment (1)


phone
place
date_range
date_range

Previous Employment (2)


local_phone
place
date_range
date_range

I hereby authorize the release of information regarding employment.


Peer References - Step 3 of 9

20%

References


local_phone

local_phone

local_phone

local_phone

Statement of Employability - Step 4 of 9

30%

By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253.


Criminal History Check

I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and that I may not have face-to-face patient contact until results are returned. I will be notified of results.

CONVICTIONS BARRING EMPLOYMENT

(A) A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:

  • An offense under Chapter 19, Penal Code (criminal homicide);
  • An offense under Chapter 20, Penal Code (kidnaping and unlawful restraint);
  • An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
  • An offense under Section 21.08, Penal Code (indecent exposure);
  • An offense under Section 21.11, Penal Code (indecency with a child);
  • An offense under Section 21.12, Penal Code (improper relationship between educator and student);
  • An offense under Section 21.15, Penal Code (improper photography or visual recording);
  • An offense under Section 22.011, Penal Code (sexual assault);
  • An offense under Section 22.02, Penal Code (aggravated assault);
  • An offense under Section 22.021, Penal Code (aggravated sexual assault);
  • An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or a disabled individual);
  • An offense under Section 22.041, Penal Code (abandoning or endangering a child);
  • An offense under Section 22.05, Penal Code (deadly conduct);
  • An offense under Section 22.07, Penal Code (terroristic threat);
  • An offense under Section 22.08, Penal Code (aiding suicide);
  • An offense under Section 25.031, Penal Code (agreement to abduct from custody);
  • An offense under Section 25.08, Penal Code (sale or purchase of a child);
  • An offense under Section 28.02, Penal Code (arson);
  • An offense under Section 29.02, Penal Code (robbery);
  • An offense under Section 29.03, Penal Code (aggravated robbery);
  • An offense under Section 33.021, Penal Code (online solicitation of a minor);
  • An offense under Section 34.02, Penal Code (money laundering);
  • An offense under Section 35A.02, Penal Code (Medicaid fraud);
  • An offense under Section 42.09, Penal Code (cruelty to animals);
  • An offense under Section 36.06, Penal Code (obstruction or retaliation);
  • An offense under Section 42.09, Penal Code (cruelty to livestock animals);
  • An offense under Section 42.092, Penal Code (cruelty to nonlivestock animals); or
  • A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.
  • An offense the Agency determines to be contraindicated to employment with the consumers the Agency serves

(B) A person may also be barred from employment the duties of which involve direct contract with a client in a facility if convicted of any of the following crimes within the past 5 years:

  • An offense under Section 22.01, Penal Code (assault punishable as a Class A misdemeanor or as a felony);
  • An offense under Section 30.02 , Penal Code (burglary);
  • An offense under Chapter 31, Penal Code (theft that is punishable as a felony);
  • An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or
  • An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or a felony).
  • An offense under Section 37.12, Penal Code (false identification as a peace officer); or
  • An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).

(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:

  • Of an offense under Section 30.02, Penal Code (burglary); or
  • Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code.

(D) In addition to the prohibitions on employment prescribed by Subsections (A), (B) and (C), a nurse aide listed as unemployable per amendment to TAC 40, §94.10(l) and §94.11( c) (d) and is listed on the NAR or EMR stating a finding of abuse, neglect or misappropriation will not be recertified therefore, is unemployable.

(E) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.


DPS CCH Verification - Step 5 of 9

40%

DPS Computer Criminal History (CCH) Verification


I, have been notified that a Computerized Criminal History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply.

Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization conducting the criminal history check for background screening is not allowed to discuss any criminal history record information obtained using the name and DOB method. Therefore, the agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I have been made aware that in order to complete this process I must make an appointment with L1 Enrollment Services, submit a full and complete set of my fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company, L1 Enrollment Services.

Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.



TB Fact Sheet - Step 6 of 9

50%

The following criteria is utilized to identify if an employee has potential TB. This criteria is also utilized to determine if an employee needs another chest x-ray. This information is also presented in training.


Detection of employees who may have active TB are based on the following criteria:


Potential active symptoms:
  1. Persistent cough greater than 2 weeks duration
  2. Bloody sputum
  3. Night sweats
  4. Weight loss
  5. Anorexia
  6. Fever

Groups with a higher prevalence of TB infection:
  1. Medically underserved populations
  2. Homeless individuals
  3. Current or past prison inmates
  4. Alcoholics
  5. Injecting drug users
  6. Elderly
  7. Foreign-born persons from Asia, Africa, the Caribbean and Latin America
  8. Contacts to individuals with TB
  9. Groups with a greater risk to progress from latent TB infection to active disease
  10. Individuals with HIV infection, silicosis, S/P gastrectomy or jejuno-ileal bypass surgery, greater than 10lb. Below normal body weight, chronic renal failure, diabetes mellitus, immunosuppressed due to medication, and those with some malignancies.
  11. Individuals who have been infected within the past 2 years and individuals with fibrotic lung disease on chest x-ray

I have reviewed the signs and symptoms of TB. I am not experiencing symptoms of TB. I understand if I experience any of the above symptoms I am to report to management immediately.


HIPAA Agreement - Step 7 of 9

60%

Employee Acceptance of HIPAA Privacy Rules and Regulations

(Health Insurance Portability and Accountability Act of 1996)


I understand that while performing my jobs duties for Pediatric Healthcare Connection (PHC) at my workplace, I may have access to protected health information (PHI) about patients or residents of hospital or nursing homes and rehabilitation centers (hospital).

PHI means any information specifically relating to the past, present or future physical or mental health condition of an individual, the provision of healthcare to an individual or payment for healthcare to an individual, and is limited to information created or received by me from the hospital.

To insure confidentiality and privacy of PHI, I agree to:

  • Access, use or review PHI only as needed for the purpose of performing the job for which I was officially employed.
  • Never use PHI out of curiosity, or for personal interest or advantage, or in the presence of an unauthorized third party.
  • Never take with me any photocopies of documents from any patient or resident medical or personnel file when I end my daily shift or employments.
  • Report to the designated primary officer or my workplace, and to Pediatric Healthcare Connection, any use or disclosure of PHI by anyone else that is not permitted of which I may become aware within 24 hours of my discovery of such unauthorized use or disclosure.


Skills Checklist - Step 8 of 9

70%

This checklist is to ensure all patient care staff are proficient in skilled care. Employee will self assess the skills below in accordance to their experience and comfort level to be performed in an independent environment. The supervising RN will validate competency of skills listed below, either verbally or by demonstration, prior to employee working independently with a patient.


Vital Signs


1. Assessment


HEENT


1. Assessment


Neurological


1. Assessment


2. Seizure precautions and interventions


Cardiovascular


1. Assessment


Respiratory


1. Assessment


2. Oxygen - Nasal cannula/mask replacement


3. Oxygen - Regulator


4. Oxygen - Flow rate/adjustment


5. Oxygen level


6. Oxygen - Pulse Oximetry


7. Ventilator - Routine care


8. Ventilator - Application/disconnection


9. Ventilator - Settings


10. Ventilator - Bleeding O2


11. Ventilator - PEEP application


12. Ventilator - Alarms trouble shooting


13. Inhaler administration


14. Nebulizer administration


15. Nebulizer care/cleaning


16. Tracheostomy - Routine care


17. Tracheostomy - Suctioning


18. Tracheostomy - Inner cannula removal/care


19. Tracheostomy - Tube change


20. Oral - Suctioning


21. Sputum - Specimen collection


Genitourinary


1. Assessment


2. Catheter - Routine care


3. Catheter - Bag changes


4. Catheter - Bag emptying


5. Catheter - Insertion


6. Catheter - Irrigation


7. Urine - Specimen Collection


Gastrointestinal


1. Assessment


2. Routine Care


3. Tube change


4. Placement check


5. Feeding


6. Residual check


7. Colostomy - Pouch emptying


8. Colostomy - Pouch/wafer changes


9. Colostomy - Skin care


10. Stool - Specimen Collection


Integumentary


1. Assessment


Musculoskeletal


1. Assessment


Pain Management


1. Assessment


2. Use appropriate pain scale


3. Provide appropriate pain intervention


4. Reassessment of pain intervention


Wound Care


1. Assessment


2. Application of skin barriers


3. Non-Sterile dressing changes


4. Sterile dressing changes


5. Wound


IV Therapy


1. Assessment


2. Central line dressing changes


3. PICC Line dressing changes


4. PICC/Central line blood sampling


EMERGENCY PREPAREDNESS


1. Location Emergency Equipment


2. Address/location


3. Code status


OTHER


1. Positioning (ADLS)


2. Glucose Monitoring


Sign and Date - Step 9 of 9

80%

Please sign, enter today's date and click "Save" below, then click "Submit".


date_range

Application forms submitted - You're almost done!

100%

All PHC Employment Application forms have been submitted. You must also take the Clinical Competency Exam, Medication Exam and Ventilator Competency Exam to complete your application. Please click the buttons below, or use the links sent to you via email. A PHC team member will contact you once we have received your completed exams. We look forward to working with you!