Application For Employment
We are an Equal Opportunity Employer

If you are already an employee at KVCH applying for a different position,
DO NOT use this form. Use the "Inhouse Application" instead.


PERSONAL INFORMATION
Last Name
 First Name
 Middle Name
Social Security Number (123-45-6789)
 Email Address

Present Address
Street
 City
 State
Zip
 Home Phone (123-456-7890)

Permanent Address (if other than above)
Street
 City
 State
Zip
 Permanent Phone Number (123-456-7890)
Position Number

If you are not applying for a specific position, put OPEN in the field.		 Each Job Position Number is located in the Job Information on the Employment Opportunities page.

See the sample to the right.
Full-time   Part-time   Temporary   On-Call
If Temporary or On-Call, indicate when available
Indicate shift(s) you will work:
    1st Shift - Days   2nd Shift - Evenings   3rd Shift - Nights
Will you rotate shifts? Yes   No
Will you work weekends? Yes   No
Indicate days you are available to work:
    Sunday   Monday   Tuesday   Wednesday   Thursday   Friday   Saturday
If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes    No
Are you a military veteran? Yes    No      If yes, please list under Work Experience (below)
How did you learn about this position opening (check all that apply)?
   Newspaper Ad    Friend    Job Line    KVCH Website    Other
Have you any relatives employed here? Yes    No
If yes, please indicate name(s) and in what position(s)
Have you been previously employed here? Yes    No
If yes, give dates
Have you been convicted of a criminal offense or been released from prison within the past ten (10) years?
Yes    No
If yes, explain fully
Have you been debarred, excluded, or otherwise ineligible for participation in federal health care programs?
Yes    No
If yes, explain fully
Work Skills
List training and/or experience which may qualify you for the position(s) desired:

Check "T" if you have training in the skill
Check "E" if you have experience in the skill
Check "B" if you have both training and experience

Business
T  E  B Typing W.P.M.
T  E  B Transcription
T  E  B Bookkeeping
T  E  B Ten-Key Adding
T  E  B Key Punch
T  E  B Reception
T  E  B Insurance Billing
T  E  B Word Processing
Software
T  E  B Shorthand W.P.M.
T  E  B Medical Terminology
T  E  B Accounting
T  E  B Calculator
T  E  B Invoicing/Inventory
T  E  B Phone Switchboard
T  E  B Medicare/Medicaid
T  E  B Computers
T  E  B Data Entry
Other:

General
T  E  B Floor Care (Manual)
T  E  B Linen Packing
T  E  B Sterilizer (Steam/Gas)
T  E  B Dishwasher (Industrial)
T  E  B Maintenance (General)
T  E  B Small Power Tools
T  E  B Maintenance (Craft):
Electrical
Plumbing
Building
Electronics
T  E  B Floor Care (Machines)
T  E  B Autoclave
T  E  B Dishwasher (Manual)
T  E  B Sewing
T  E  B Driving
Other:

Patient Care
T  E  B Sterile Technique
T  E  B Pre-Op Preps
T  E  B Catheterization
T  E  B Monitor: Type
T  E  B Orthopedic
T  E  B Geriatric
T  E  B Surgical
T  E  B Oncology
T  E  B Vital Signs
T  E  B Isolation Technique
T  E  B Coronary Care
T  E  B Intensive Care
T  E  B Pediatric
T  E  B Medical
T  E  B Obstetrics
Other:

Comments

Optional
List any foreign language(s) and check the box that best describes your skill level.
Language 1
Read/Write/Speak Read/Write Read/Speak Read Only Speak Only
Language 2
Read/Write/Speak Read/Write Read/Speak Read Only Speak Only
Language 3
Read/Write/Speak Read/Write Read/Speak Read Only Speak Only

Job Performance Ability
Given your knowledge, skills, education, are you able to perform all the essential functions of the position for which you are applying, with or without reasonable accomodation, as set forth in the job description?
Yes    No

Education
High School
Name of School Location (City, State) Diploma or GED
1 Yes No
2 Yes No
College or Schools after High School (include any job related education or training in military services)
Name of School Location
(City, State)		 Academic Major, Skill, or Trade Dates Attended
(ex. Sept 1999)		 Did you graduate?
1 Yes No
2 Yes No
3 Yes No

Work Experience
List most recent employer first. Include at least past five (5) years, and account for any time gaps in your employment history, including any military service.
1.
Name of Employer
 Location (City, State)
Dates employed (ex. Sept 1999)
From To 		Final Salary
Your last job title & description
Name under which employed
Name of supervisor
 Phone Number (123-456-7890)
Reason for leaving
May we contact? Yes No
2.
Name of Employer
 Location (City, State)
Dates employed (ex. Sept 1999)
From To 		Final Salary
Your last job title & description
Name under which employed
Name of supervisor
 Phone Number (123-456-7890)
Reason for leaving
May we contact? Yes No
3.
Name of Employer
 Location (City, State)
Dates employed (ex. Sept 1999)
From To 		Final Salary
Your last job title & description
Name under which employed
Name of supervisor
 Phone Number (123-456-7890)
Reason for leaving
May we contact? Yes No
4.
Name of Employer
 Location (City, State)
Dates employed (ex. Sept 1999)
From To 		Final Salary
Your last job title & description
Name under which employed
Name of supervisor
 Phone Number (123-456-7890)
Reason for leaving
May we contact? Yes No

Attendance
Do you now have or do you anticipate having any activities, commitments, or responsibilities that may prevent you from meeting your work attendance requirements? Yes    No
If yes, please explain

Professional Registration/Licensure
Type of Registration or License State Number Date of Expiration
(ex. Sept 1999)
If you do not have a required registration or license, have you applied for one? Yes No
If an examination is required, what date are you scheduled to take the examination?
If not licensed in Washington state, have you applied for reciprocity? Yes No
DISCLOSURE STATEMENT

SUMMARY:   RCW 43.43.830 and .840 are statutes which require facilities in the State of Washington involved in the provision of services to children, vulnerable adults or developmentally disabled person, to obtain information from prospective employees of Kittitas Valley Community Hospital relating to past problems with child abuse or conviction of certain crimes.    Kittitas Valley Community Hospital ensures that the information provided in this disclosure form is correct by conducting a Washington State Patrol Criminal History check at the time the new employee completes their new hire paperwork. 

 

HAVE YOU EVER BEEN CONVICTED OF ANY OF THE FOLLOWING CRIMES AGAINST CHILDREN OR OTHER

PERSONS:

 

  YES NO   YES NO
Aggravated Murder    Murder (First or Second Degree) 
Kidnapping (First or Second Degree) Assault (First, Second or Third Degree)
Rape (First, Second or Third Degree)   Robbery (First or Second Degree)
Assault of a Child (First, Second or Third Degree) Burglary (First Degree)
Arson (First Degree)  Manslaughter (First or Second Degree)
Incest Indecent Liberties
First Degree Promoting Prostitution Vehicular Homicide
Communication with a Minor  Unlawful Imprisonment
Criminal Mistreatment (First or Second Degree) Simple Assault
Child Abuse or Neglect (as defined in RCW 26.44.020) Sexual Exploitation of Minors
Custodial Interference (First or Second Degree) Malicious Harassment
Child Molestation (First, Second or Third Degree) Rape of a Child (First or Second Degree)
Sexual Misconduct with a Minor Patronizing a Juvenile Prostitute
Selling or Distributing Erotic Material to a Minor Child Abandonment
Violation of Child Abuse Restraining Order Promoting Pornography
Child Buying or Selling Custodial Assault
Felony Indecent Exposure Prostitution
Extortion (First or Second Degree) Forgery
OR ANY OF THESE CRIMES AS THEY MAY BE RENAMED

Have you ever been convicted of any crime related to the manufacture, delivery, or possession with intent to manufacture or deliver a controlled substance?      

Have you ever been found in any dependency action to have sexually assaulted or exploited any minor or to have physically abused any minor?  
Have you ever been found in a court in a domestic relations proceeding to have sexually assaulted or exploited any minor or to have physically abused any minor?
Have you ever been found in any disciplinary board final decision to have abused or financially exploited any person 60 years of age or older who has a functional, mental, or physical inability to care for himself/herself or who is a patient in a state hospital?       
Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person.
Have you ever been found by a court in a protection proceeding under Chapter 74.34 RCW  to have abused or financially exploited a person 60 years of age or older who has a functional, mental, or physical inability to care for himself/herself or who is a patient in a state hospital?
 

If your answer is “yes” to any of the above, please describe and provide the date(s) of the
conviction(s) and the sentence(s) imposed.

UNDER PENALTY OF PERJURY, I certify that the above information is true and correct and complete.  I understand that if I am employed by Kittitas Valley Community Hospital, my employment may be terminated for any misrepresentation or omission in the above statement.  I also understand that my employment is conditioned upon receipt of a satisfactory report from IntelliSense. 

 

We shall request from IntelliSense a report of criminal convictions for offenses against person, civil adjudications or child abuse, and disciplinary board final decisions.  If you are employed by Kittitas Valley Community Hospital before that report is available, YOUR EMPLOYMENT WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT.

I agree   I disagree



Kittitas Valley Community Hospital
Code of Excellence

As a prospective employee of Kittitas Valley Community Hospital we feel it is important for you to know in advance a little about who we are as it relates to our work culture. The hospital upholds a Code of Excellence, developed by the employees, with the expectation that we all hold each other accountable to the code. Please take a few minutes to review these behavioral standards. Alignment with these principles is an essential part of becoming a KVCH team member.

  • Treat each other as equals.

  • Come to work with a positive attitude and a smile.

  • Appreciate that others are busy by asking, “Do you have time?”

  • Treat others as you would want to be treated.

  • Verify the facts, make no assumptions.

  • Help each other out, lend a hand without being asked.

  • Maintain a sense of humor.

  • Acknowledge the customer instantly.

  • Speak positively about the hospital and your co-workers – on and off the job.

  • Never say, “That’s not my job”.

  • Ask “May I help you” when you notice someone who may need assistance.

  • Address people by their name.

  • Keep the hospital immaculate – see what needs to be done and do it.

  • Identify yourself, wear your nametag.

I understand that by submitting my application to Kittitas Valley Community Hospital, I am acknowledging my personal commitment to the KVCH Code of Excellence as the guiding principle for my behavior as a KVCH team member.