Job Application | Hillsdale Hospital

Career Application

Step 1 of 7

Code of Commitment
Dear Applicant,
Prior to completing an application for consideration of employment, you must review and agree to adhere to the Hillsdale Hospital Code of Commitment encompassing: professionalism, customer services, quality and teamwork.
Professionalism
I recognize that I will be the reputation of Hillsdale Hospital and therefore will exhibit professionalism in my appearance, communication, phone etiquette, behavior
Customer Service
I recognize my treatment of patients and visitors will determine the success or failure of Hillsdale Hospital and I will therefore exhibit courtesy, gratitude, offering respect and privacy for our patients and their families and will provide service recovery when a member of our team does not provide excellent customer service.
Quality
As a member of Hillsdale Hospital, I will provide the highest level of quality through demonstrating integrity and personal accountability for the care I give, demonstrate compassion to every person I meet on our campus, and promote the health and safety of patients and their families.
Teamwork
I recognize that every employee and contracted service of Hillsdale Hospital makes a valuable contribution to the patient experience and as such I will demonstrate positive and upbeat communication with the team I am assigned to work. I will remain accountable for my actions to co-workers and will treat patient and employee information confidentially. I will ensure that all patients receive a warm and friendly handoff to another co-worker so that care is uninterrupted.

I understand that I am Hillsdale Hospital and because of the care I give, the attention that I pay and the attitude I exhibit, Hillsdale Hospital will remain the best place for providing excellent health care services.

I understand it is my responsibility to know and adhere to these established standards of behavior should I become a member of the Hillsdale Hospital Team.
Consent*
I agree.

Employment Record Continued
Please explain all periods of unemployment.
Have you ever been fired?*
- Yes
- No
Please explain.*
Have you ever been convicted of or pled "no contest" or "guilty" to a felony, misdemeanor or any other offense other than a minor traffic violation?*
Offers of employment are contingent upon criminal background checks and fingerprinting results. A conviction will not necessarily disqualify you from consideration. However, failure to fully disclose will result in immediate denial or termination of employment.
- Yes
- No
If so, for what, when, and where?*
Are there any felony charges pending against you?*
- Yes
- No
If so, for what, when, and where?*
Have you ever been or are you currently excluded from any Federal health care program?*
The Office of Inspector General (OIG) is authorized to exclude individuals and entities who have engaged in fraud or abuse related to Federal health care programs from participation in Medicare, Medicaid and all other Federal health care programs.
- Yes
- No
If so, please state from which program you have been excluded, the date of exclusion, and the reason for the exclusion:*
Resume Upload
If you have one, please upload your resume here. (Word document or PDF only, please.)
File
References
Please list at least three professional references who are not related to you, and are not a direct supervisor/manager.
Professional References*
First Name Last Name Phone Number (include area code)
Applicant's Additional Comments

Applicant Authorization and Certification
I voluntarily authorize Hillsdale Hospital to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information.

I understand any offer of employment will be contingent upon the results of a pre-placement placement medical examination which will include screening for illicit substances, and tobacco. I also acknowledge that if I am in need of any reasonable accommodations during the hiring process or ultimately in order to perform the essential functions of the job for which I am applying, I will notify Hillsdale Hospital as soon as possible.

I understand that if I am hired by Hillsdale Hospital, my employment relationship is at-will, meaning that either Hillsdale Hospital or I may terminate the employment relationship at any time, with or without notice and with or without cause. I acknowledge that Hillsdale Hospital may alter my position, job responsibilities, shift and work schedule at its sole discretion. I also understand this provision supersedes any oral or written representations to the contrary, unless I have been provided a written agreement, signed by the President of Hillsdale Hospital that specifically states my employment is not at-will.

I certify that the information given by me in this employment application is true, accurate and complete. I understand that if I have given any false information on this application or if I have omitted any material facts, I may be disqualified from employment with Hillsdale Hospital, or, if hired, I may be discharged immediately upon discovery of such misrepresentations or omissions.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Consent*
I agree to the terms of employment.

Informed Consent and Release Form for Illicit Controlled Substance Screening
I understand that, according to Hillsdale Hospital policy which I have read and understand, following a conditional offer of employment, I am required to submit to a pre-placement urinalysis, blood testing, or other screening. I understand that the analysis will be conducted by a qualified testing laboratory. I also understand if I refuse to consent, this will be viewed as my withdrawal from consideration for employment.

The purpose of this analysis is to determine the absence or presence of illicitly controlled substances as well as tobacco. I understand a documented chain of specimen custody will be followed to ensure the identity and integrity of my specimen throughout the collection and testing process.

If I am offered a position of employment by Hillsdale Hospital, I hereby consent to collection of a specimen of my urine an/or blood for purposes of performing a drug and/or tobacco screening. Furthermore, I hereby release and hold harmless Hillsdale Hospital and its employees and agents from the request to furnish my specimens, the testing of my specimens, and the disclosure of the testing results.
Consent*
I agree to the above terms and conditions.

Coronavirus Covid-19 Information

Application

Career Application

Step 1 of 7

Code of Commitment

Professionalism

Customer Service

Quality

Teamwork

Personal Information

Employment Information

Education

High School

College

Other Education

Professional Licenses and/or Certifications

License/Cert. #1

License/Cert. #2

License/Cert. #3

Employment Record (List last or present position first.)

Employer 1

Employer 2

Employer 3

Employment Record Continued

Resume Upload

References

Applicant Authorization and Certification

Informed Consent and Release Form for Illicit Controlled Substance Screening

Registered Nurse | Full-Time (Days) | Med Surg
Registered Nurse | Full-Time (Nights) | Med Surg
Registered Nurse / LPN | Full-Time | Skilled Nursing Facility
Registered Nurse | Full-Time | CCU
Registered Nurse | Casual | Obstetrics Department
Registered Nurse | Full-Time | Emergency Department
Registered Nurse | Full-Time | Emergency Department
Nursing Assistant | Full-Time | Med Surg
Nursing Assistant | Full-Time | Skilled Nursing Facility
Nursing Assistant | Full-Time | Skilled Nursing Facility
Medical Assistant | Full-Time | Hillsdale Health & Wellness
Medical Assistant | Casual | Clinics
Social Worker | Full-Time | Behavioral Health Unit
Case Manager or Social Worker | Casual | Case Management
Ultrasound Technologist | Part-Time | Medical Imaging Department
Surgical Technologist | Full-Time | Surgery Department
Medical Office Receptionist | Full-Time | Pain Clinic
Phlebotomist | Full-Time | Laboratory
Phlebotomist | Casual |Laboratory
Environmental Services Aide | Full-Time | Housekeeping
Dietary Aide | Casual | Dietary Department

First Name	Last Name	Phone Number (include area code)