Thank you for your interest in employment with Augusta Health and Rehabilitation and SilverLeaf of Augusta. Please either fill out the form below and click "Submit Application" or print this form and mail it to the address listed below.

 

Augusta Health & Rehabilitation
901 Bridge Creek Lane
Augusta, WI 54722

SilverLeaf Of Augusta
909 Bridge Creek Lane
Augusta, WI 54722

Employment Application

Phone: 715-286-2266Fax: 715-286-2653

This Facility is an Equal Opportunity Employer

No question on this form is asked for the purpose of limiting or excluding any applicant's consideration because of race, color, sex, creed, ancestry, political affiliation, national origin, age, marital status, religion, or status with regard to public assistance, disability, handicap, sexual orientation, or conviction of a felony. Thank you for your interest in employment with us.






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If So When?

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DaysEveningsNights

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Education Hisory

Fr. 1So. 2Jr. 3Sr. 4

Fr. 1So. 2Jr. 3Sr. 4






Employment Record (List Most Recent First, including Military)

Date Of Hire:

To:







Date Of Hire:

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Date Of Hire:

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Date Of Hire:

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YesNo

No, you may contact anytimeDO NOT contact now, you may contact at a later date, e.g. after acceptance of offer, or a specific date, if appropriate

AUTHORIZATION TO WORK

It is unlawful for Augusta Health and Rehabilitation to hire individuals that are not authorized to work in the United States. Accordingly, Augusta Health and Rehabilitation. hires only citizens or aliens that are authorized to work in the United States. If you receive an offer, before you will be placed on the payroll, all new employees will be required to document that they are a U.S. Citizen or an alien that is authorized to work in the United States.

Yes

  • A citizen or a national of the United States
  • An alien lawfully admitted for permanent residence.
  • An alien authorized by the Immigration and Naturalization Service to work indefinitely in the United States.

If you are hired at Augusta Health and Rehabilitation one of the following documents must be reviewed before you can begin employment: a U.S. Passport, a Certificate of U.S. Citizenship, a Certified of Naturalization, or an unexpired Foreign Passport with an attached Employment Authorization.

If you do not have one of the above documents, then you will need to present two documents; one of the following: a State driver's license with a photograph, an I.D. card with a photograph, or information including name, sex, date of birth, height, weight and color of eyes. And one of the following: an original Social Security Number Card, a Birth Certificate issued by a State, Country or Municipal authority bearing a seal or an unexpired INS Employment Authorization.

References (Not Former Employers Or Reletives)




I cerify that the facts in this application are true and complete.

I hereby authorize investigation of all statements contained in this application and agree that if any misrepresentation has been made by me herein or the results of an investigation are not satisfactory for any reason, any offer of employment made to me by Augusta Health and Rehabilitation may be terminated immediately without any obligation or liabillty to me other than for payment, at the rate agreed upon, for service actually rendered if I have been employed.

In connection with my application for employment, I authorize Augusta Health and Rehabiliation. and any agent on its behalf, to conduct an inquiry as to my record of any or all of my former employers, references, criminal background, and any or all educational institutions. Moreover, I hereby release Augusta Health and Rehabilitation and any agent acting on its behalf, from any and all liability of whatsoever nature by reason of requesting such information form any person. I also release from any and all liability all individuals and organizations who provide information to Augusta Health and Rehabilitation in good faith and without malice concerning my employment competence, ethics, character, and other qualifications, including other privileged or confidential information.

I understand that if I am employed by Augusta Health and Rehabilitation my employment can be terminated by either the company or me at will, with or without cause, and with or without notice, at any time.

I hereby acknowledge that I have read and understand the foregoing.

DEPARTMENT OF HEALTH SERVICESDivision of Enterprise Services
F-82064A (02/2014)

STATE OF WISCONSINChapters 48.685 and 50.065, Wis. Stats. DHS 12.05(4), Wis. Admin. Code

BACKGROUND INFORMATION DISCLOSURE (BID)
INSTRUCTIONS

The Background Information Disclosure form (F-82064) gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make employment, contract, residency, and regulatory decisions. Complete and return the entire form and attach explanations as specified by employer or governmental regulatory agency. NOTE: If you are an owner, operator, board member, or non-client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions.

CAREGIVER BACKGROUND CHECK LAWIn accordance with the provisions of Chapters 48.685 and 50.065, Wis. Stats., for persons who have been convicted of certain acts, crimes, or offenses:

  1. The Department of Health Services (DHS) may not license, certify, or register the person or entity (Note: Employers and Care Providers are referred to as "entities");
  2. A county agency may not certify a child care or license a foster or treatment foster home;
  3. A child placing agency may not license a foster or treatment foster home or contract with an adoptive parent applicant for a child adoption,
  4. A school board may not contract with a licensed child care provider; and
  5. An entity may not employ, contract with or, permit persons to reside at the entity.

The list of offenses affecting caregiver eligibility that require rehabilitation review is available from the regulatory agencies or through the Internet at http://DHS.wisconsin.qov/caregiver/StatutesINDEX.HTM.

THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS / CARE PROVIDERS (Referred to as "Entities"):

  • Programs Regulated under Chapter 48, Wis. Stats.

    Treatment Foster Care, Family Child Care Centers, Group Child Care Centers, Residential Care Centers for Children and Youth, Child Placing Agencies, Day Camps for Children, Family Foster Homes for Children, Group Homes for Children, Shelter Care Facilities for Children, and Certified Family Child Care.

  • Programs Regulated under Chapters 50, 51, and 146, Wis. Stats.

    Emergency Mental Health Service Programs, Mental Health Day Treatment Services for Children, Community Mental Health, Developmental Disabilities, AODA Services, Community Support Programs, Community Based Stats. Residential Facilities, 3-4 Bed Adult Family Homes, Residential Care Apartment Complexes, Ambulance Service Providers, Hospitals, Rural Medical Centers, Hospices, Nursing Homes, Facilities for the Developmentally Disabled, and Home Health Agencies — including those that provide personal care services.

  • Others

    Child Care Providers contracted through Local School Boards

THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS:

  • Anyone employed by or contracting with a covered entity who has access to the clients served, except if the access is infrequent or sporadic and service is not directly related to care of the client. Exception: Emergency medical technicians and first responders are not covered under the Caregiver Law.
  • Anyone who is a Child Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14).
  • Anyone who lives on the premises of a covered entity and is 10 years old or over, but is not a client ("non-client resident").
  • Anyone who is licensed by DHS.
  • Anyone who has a foster home licensed by DHS.
  • Anyone certified by DHS.
  • Anyone who is a Child Care Provider certified by a county department.
  • Anyone registered by DHS.
  • Anyone who is a board member or corporate officer who has access to the clients served.

FAIR EMPLOYMENT ACTWisconsin's Fair Employment Law, Chapters 111.31 — 111.395, Wis. Stats., prohibits discrimination because of a criminal record or pending charge; however, it is not discrimination to decline to hire or license a person based on the person's arrest or conviction record if the arrest or conviction is substantially related to the circumstances of the particular job or licensed activity.

PERSONALLY IDENTIFIABLE INFORMATION This information is used to obtain relevant data as required by the provisions set forth by the Wisconsin Caregiver Background Check Law. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches. For example, the Department of Justice uses social security numbers, names, gender, race, and date of birth to prevent incorrect matches of persons with criminal convictions. The Department of Health Services' Cardgiver Misconduct Registry uses social security numbers as one identifier to prevent incorrect matches of persons with findings of abuse or neglect of a client or misappropriation of a client's property.

DEPARTMENT OF HEALTH SERVICESDivision of Enterprise Services
F-82064A (02/2014)

STATE OF WISCONSINChapters 48.685 and 50.065, Wis. Stats. DHS 12.05(4), Wis. Admin. Code

BACKGROUND INFORMATION DISCLOSURE (BID)

Completion of this form is required under the provisions of Chapters 48.685 and 50.065, Wis. Stats. Failure to comply may result in a denial or revocation of your license, certification, or registration; or denial or termination of your employment or contract. Refer to the instructions (F-82064A) on page 1 for additional information. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches.

PLEASE PRINT OR TYPE YOUR ANSWERS.



Employee / Contractor (including new applicant)Household member / lives on premises - but not a clientApplicant for a license or certification or registration (including continuation or renewal)Other — Specify:

Note: If you are an owner, operator, board member, or non-client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the Appendix. F-82069, and submit both forms to the address noted in the Appendix Instructions.





MaleFemale
American Indian or Alaskan NativeBlackUnknownAsian or Pacific IslanderWhite




SECTION A — ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION

YESNO

Do you have any criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts?

  • If Yes, list each crime, when it occurred or the date of the conviction, and the city and state where the court is located. You may be asked to supply additional information including a certified copy of the judgment of conviction, a copy of the criminal complaint, or any other relevant court or police documents.
YesNo

Were you ever found to be (adjudicated) delinquent by a court of law on or after your 10th birthday for a crime or offense? (NOTE: A response to this question is only required for group and family day care centers for children and day camps for children.)

  • If Yes, list each crime, when and where it happened, and the location of the court (city and state). You may be asked to supply additional information including a certified copy of the delinquency petition, the delinquency adjudication, or any other relevant court or police documents.
YesNo

Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? A response is required if the box below is checked:

  • (Only employers and regulatory agencies entitled to obtain this information per sec. 48.981(7) are authorized to, and should, check this box.)
  • If Yes, explain, including when and where it happened.
YesNo

Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client?

  • If Yes, explain, including when and where it happened.
YesNo

Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client?

  • If Yes, explain, including when and where it happened.
YesNo

Has any government or regulatory agency (other than the police) ever found that you abused an elderly person?

  • If Yes, explain, including when and where it happened.
YesNo

Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?

  • If Yes, explain, including credential name, limitations or restrictions, and time period.
YesNo

SECTION B — OTHER REQUIRED INFORMATION

YESNO

Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services?

  • If Yes, explain, including when and where it happened.
YesNo

Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility?

  • If Yes, explain, including when and where it happened and the reason.
YesNo

Have you been discharged from a branch of the US Armed Forces, including any reserve component?

  • If yes, indicate the year of discharge:
  • Attach a copy of your DD214 if you were discharged within the last 3 years.
YesNo

Have you resided outside of Wisconsin in the last 3 years?

  • If YeS, list each state and the dates you lived there.
YesNo

Have you had a caregiver background check done within the last 4 years?

  • If Yes, list the date of each check, and the name, address, and phone number of the person, facility, or government agency that conducted each check.
YesNo

Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services, a county department, a private child placing agency, school board, or DHS designated tribe?

  • If Yes, list the review date and the review result. You may be asked to provide a copy of the review decision.
YesNo

A "NO" answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.

I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1,000.00 and other sanctions as provided in DHS 12.05 (4), Wis. Adm. Code.