Application for Employment - Westways Staffing Services, Inc.

Transcription

Application for Employment
PLEASE PRINT
Equal access to programs, services, and employment is available to all persons. Those applications requiring reasonable accommodation to the
Application and/or interview process should notify a representative of the Human Resource Department.
Position(s) applied for
Date of Application
Name:
Last
First
Middle
Address:
Street
Telephone#: (
Apt. #
)
-
City
Mobile/Beeper/Other Phone#: (
State/Province
)
-
Zip Code
Social Security#:
Email Address: _______________________________________________________________________________________________________________
If necessary, best time to call you at home is …………………………………………………………………………………………………………
AM
PM
May we contact you at work?
Yes
If yes, work number and best time to call ………………………………………………………………………………………………………………
No
AM
PM
If you are under 18 and it is required, can you furnish a work permit? ……………………………………………………………………………………
Yes
No
Yes
No
In case of emergency, please contact
Telephone#:
If No, please explain
Have you submitted an application here before? ……………………………………………………………………………………………………………………
If Yes, give date(s) ………………………………………………………………………………………………………………………………… From
/
/
To
/
Are you legally eligible for employment in this country? …………………………………………………………………………………………………………
Yes
Date available for work ………………………………………………………………………………………………………………………………………………………
/
Type of employment desired ……………………………
Full-time
Will you relocate if job desires it? ……………………
Yes
Part-time
No
Shift …………………………………
Days
/
No
/
Nights
Will you travel if job requires it? ……………………………………
Yes
No
Are you able to meet the attendance requirement of the position? …………………………………………………………………………………………
Yes
No
Will you work overtime if required? ………………………………………………………………………………………………………………………………………
Yes
No
Yes
No
If No, please explain
Have you ever been convicted of a crime in the last seven (7) years? ………………………………………………………………………………………
If Yes, please explain
Conviction will not necessarily bar employment. Each instance & explanation will be considered in relation to the position for which you are applying.
Driver’s license number if driving is an essential job function
Referral Source
Online Advertisement
Online Search
Employee
State
Relative
Print Advertisement
Walk-in
Other
Name of source (if applicable)
An Equal Opportunity Employer
Westways Staffing Services, Inc. http://www.westwaysstaffing.com/
2010.02.22
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Employee History
Provide the following information for your past and current employees, assignments or volunteer activities, starting with the most recent (use additional
sheets if necessary). Explain any gaps in employment in comments section below.
Employer:
Type:
Tel #:(
Agency
)
Summarize the type of work performed and job responsibilities
Facility
Address:
Job Title:
Immediate Supervisor & Title:
Dates employed:
From:
To:
Reason for leaving:
Hourly Rate / Salary
$
May we contact for reference?
Employer:
Yes
Tel #:(
No
)
Type:
Agency
Facility
Address:
Job Title:
Dates employed:
From:
To:
Reason for leaving:
$
Yes
Employer:
Tel #:(
No
)
Type:
Agency
Facility
Address:
Job Title:
Dates employed:
From:
To:
Reason for leaving:
$
Yes
Employer:
Tel #:(
No
)
Type:
Agency
Facility
Address:
Job Title:
Dates employed:
From:
To:
Reason for leaving:
$
Yes
COMMENTS
No
INCLUDING EXPLANATION OF ANY GAPS IN EMPLOYMENT
2010.02.22
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SKILLS & QUALIFICATIONS – Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to
perform job-related functions in the position for which you are applying.
Educational Background – IF JOB-RELATED
A. List last three (3) schools attended, starting with most recent.
B. Dates attended.
D. Type of degree or diploma earned, if any.
E. Major field of study.
A. SCHOOL(S) ATTENDED
B. DATES
C. Year graduated, if completed.
C. YEAR
GRADUATED
D. TYPE OF
DEGREE
E. MAJOR
References:
List name and telephone number of 3 (three) business/work references who are not related to you.
NAME
TELEPHONE #
YEARS KNOWN
Additional Information:
Certifications:
CPR / BLS
PALS
ACLS
NRP
Advanced Fetal Monitoring
I have a MINIMUM OF ONE YEAR experience in the following units and I am prepared to care for patients in these specialties:
1. Medical
2.
Maternal Health
4.
Surgical
6.
Levels of Care
Genito-Urinary
Postpartum
Burns
General Medical / Surgical
Rehabilitation
Prenatal
Cardiac
Telemetry
Cardio-Vascular
Nursery II
Thoracic
Intensive Care / ICU
Respiratory
Labor / Delivery
Orthopedic
PICU
Gastro-Intestinal
NICU
ENT Surgery
Recovery Room
General Medicine
Couplet Care
Gastro-Intestinal
Operating Room
Genito-Urinary
Emergency Room
Gynecology
Out-Patient / Clinic
HIV
Infectious Disease
3.
Pediatrics
Metabolic
Burns
Neurology
Cardio-Vascular
Renal/Dialysis
Oncology
Hospice / Sub-Acute
Psychiatric
Cath Lab / Cardiology
Gastro-Intestinal
Chemical Dependency
Pre-Op Holding
Respiratory
Suicidal Precaution
GI-Lab
Orthopedic
General Psychiatric
General Medical
Adult
Metabolic
Adolescent
Neurology
Closed unit
5.
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I understand that if I am employed, any misinterpretation or material omission made by me on this application will be sufficient cause for cancellation
of this application or immediate discharge from the employer’s service, whenever it is discovered.
I give the employer the right to contact and obtain information from all references, employers, educational institutions, and to otherwise verify the
accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering, and
using such information and all other persons, corporations or organizations for furnishing such information.
The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any
applicant from consideration for employment on a basis prohibited by local, state or federal law.
This application is current for 60 (sixty) days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for
employment, it will be necessary to fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same
right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does
not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the
employer, other than an authorized officer, has the authority to make any assurance to the contrary. I further understand that any such assurances
must be in writing and signed by an authorized officer.
I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable
accommodation as required by the ADA.
I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.
I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.
Signature of applicant
______
Date:
2010.02.22
/
/
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WESTWAYS STAFFING SERVICES, INC.
Affirmative Action Questionnaire
Westways Staffing Services, Inc. is required to report the composition of its employment force to the government. The form allows individuals to self-identify
their ethnicity and race and to select more than one race and/or ethnicity. This allows individuals to more accurately reflect their racial and ethnic
background by not limiting them to only one racial or ethnic category. The information on this form will be filed separately from the main application form
and will not be accessible to those processing your application. Safeguards are used to prevent the discriminatory abuse of this information. It will be
available only to the person responsible for government reporting purposes. Your voluntary cooperation will be appreciated.
Last Name:
First:
Position Applying For:
Gender:
Ethnicity:
Non-Hispanic/Latino
MI:
 Male
 Female
Date of Birth:
 Hispanic/Latino. If “yes”, choose one:
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Other Hispanic or Latino – Please specify:
The question above is about ethnicity, not race. If you marked “Non-Hispanic/Latino”, please continue to answer the following by marking one or
more boxes to indicate what you consider your race to be.
What is your race? (Choose one or more)
Black or African American
Caucasian/White
American Indian or Alaska Native
American Indian – Please specify tribe:
 Other Native American – Please specify:
Asian
 Chinese
 Filipino
 Cambodian
Japanese
 Korean
Vietnamese
 Laotian
Other Asian – Please specify:
Native Hawaiian or other Pacific Islander
 Native Hawaiian
 Pacific Islander – Please specify:
VETERAN STATUS: Are you a veteran of the U.S. armed forces:
If YES, please check one of the following
 Disabled Veteran/Vietnam-era
Yes
No
 Vietnam-era Veteran
Other Veteran
 Spouse of Disabled Veteran
 Disabled Veteran
Newly Separated Veteran: Discharged from active duty within the last 12 months (Date of Discharge __/__/____).
DISABILITY STATUS: Do you have a physical, sensory, or mental impairment which substantially limits one or more life activities?
Yes
No
If yes, please check one of the following:
Ambulatory/Mobility
Mental/psychological
Visual
Multiple disabilities
Hearing
Other
Do you have a physical, mental, or health condition that has lasted six or more months which limits the kind or amount of work you can do at a job?
Yes
No
Disabilities. For Affirmative Action purposes, people with disabilities are persons with a permanent physical, mental, or sensory impairment which
substantially limits one or more major life activities. Physical, mental, or sensory impairment means: (a) any physiological or neurological disorder or
condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems or functions; or (b) any mental or psychological disorders
such as mental retardation, organic brain syndrome, emotional or mental illness, or any specific learning disability. The impairment must be material rather
than slight, and permanent in that it is seldom fully corrected by medical replacement therapy or surgical means.
REFERRAL INFORMATION: How did you find out about this opening?
Walk-in
Newspaper – Print name:
Announcement
Friend
Signature of Applicant
Internet – Please specify site:
Other – please specify:
Date
2011.01.31
DISCLOSURE AND AUTHORIZATION TO OBTAIN INFORMATION
In connection with my application for employment at Westways Staffing Services, Inc., I hereby authorize Westways Staffing Services,
Inc. (“Company”) and ScreeningOne, Inc. to perform a pre-employment background screening check (including future screenings for
retention, reassignment or promotion, if applicable, and unless revoked by Applicant in writing). I understand and agree to the following:
1.
2.
3.
4.
5.
6.
A background check is not only for the benefit of Westways Staffing Services, Inc. as a sound business practice, but also for the
benefit of all employees. It is no reflection on an applicant. I have read, understand and signed the Disclosure concerning my rights.
All reports are confidential, and provided to Westways Staffing Services, Inc. for employment decisions only. Consumer credit
information including credit reports are obtained in strict compliance with the Fair Credit Reporting Act, the Americans with Disabilities
Act (ADA), anti-discrimination and privacy laws and all other applicable federal and state laws.
I may review or obtain a copy of my report as provided by law. ScreeningOne may be contacted by writing to: ScreeningOne, Inc.,
2233 W. 190th Street, Torrance, CA 90504.
I authorize and release people, companies, references, current and former employers, schools, credit bureaus, municipal, county,
state and federal agencies and courts, and agencies that provide motor vehicle records, to provide all information that is requested to
Westways Staffing Services, Inc. or ScreeningOne.
I further release all of the above, including Westways Staffing Services, Inc. and ScreeningOne, to the full extent permitted by law,
from any liability or claims arising from retrieving and reporting information concerning me.
I agree that a copy or fax of this document shall be as valid as the original.
For the benefit of Westways Staffing Services, Inc. and employees, Westways Staffing Services, Inc. has a policy of performing preemployment background screening on job applicants as a condition of employment. This policy is a business practice that protects everyone by
helping to promote a safe and profitable workplace. All pre-employment inquiries are limited to information that affects job performance and
the workplace. It is conducted in accordance with applicable federal and state laws, including the Fair Credit Reporting Act (FCRA). The
screening will be conducted by ScreeningOne, Inc., an outside agency. Westways Staffing Services, Inc. may obtain a consumer credit report
and/or an investigative consumer report on you as an applicant or during the course of employment.
1.
The report consists of information deemed to have a bearing on job performance, and may include information from public and private
sources, public records, former employers and references. The scope of the report may include information concerning driving record,
civil and criminal court records, credit, worker’s compensation records, education, credentials, identity, past addresses, social security
number, previous employment and personal references.
2.
The report may also include reference checks from former employers, co-workers or references. Any past employment reference check is
limited to job related information. These are known as an “investigative consumer report.” This type of report is legally defined as a
report based upon interviews that may contain information relating to my character, general reputation, personal characteristics or mode
of living. You have the right to request additional disclosures of the nature and scope of the investigation and a statement of your rights.
To receive this information or to inspect any files concerning such a report or to determine if a report on you has been requested, you
may contact Westways Staffing Services, Inc. or ScreeningOne, Inc. at (888) 327-6511, or at 2233 W. 190th Street, Torrance, CA 90504.
3.
In using a report for employment purposes, before taking any adverse action based in whole or in part on the report, the person intending
to take such adverse action shall provide to the consumer to whom the report relates a copy of the report and a description in writing of
the rights of the consumer under the title, as prescribed by the Federal Trade Commission section 609(c) (3).
4.
California Provisions: In California, any report concerning a consumer’s character, general reputation, personal characteristics or mode of
living is defined as an Investigative Consumer Report. In addition to your rights under federal law, you have the following additional
rights: You have the right to inspect ScreeningOne’s files during normal business hours and on reasonable notice; the inspection may be
in person, by certified mail, or by telephone if the individuals shows proper identification and pays for any copying charges; the applicant
may be accompanied by one other person who must show proper identification; and trained ScreeningOne personnel will explain any of
the information in the report and will provide written explanation for any coded information.
***************************************************************************************************************************************************************
COURTS AND OTHER ENTITIES REQUIRE THE FOLLOWING INFORMATION FOR INDENTIFICATION WHEN CHECKING PUBLIC RECORDS. IT IS
CONFIDENTIAL AND IS USED FOR INDENTIFICATION ONLY.
LAST NAME: _________________________________
SOCIAL SECURITY NUMBER
FIRST NAME: ___________________________
DRIVER’S LICENSE NUMBER OR STATE ID#
FOR IDENTIFICATION PURPOSES, PLEASE PROVIDE:
FULL DATE OF BIRTH
STATE ISSUE
MIDDLE NAME: ___________________
E-MAIL ADDRESS
____________________________________
HAVE YOU USED ANY NAMES OR SOCIAL SECURITY NUMBERS OTHER THAN ABOVE?
Please List Other Names Used: ________________________________________
YES
N
 O
Please List Other SS Number Used: _______________________
Signature Authorizing the Procurement of the Consumer Report and/or Investigative Consumer Report
TODAY’S DATE
I understand that in CALIFORNIA, MINNESOTA, or OKLAHOMA if a Consumer Report/Investigative Consumer Report (including any Credit Report) was requested, I may order
a copy of such report and it will be mailed to me:
Yes please send me a copy of my Report.
PLEASE PROVIDE ALL ADDRESSES WHERE YOU HAVE LIVED
FOR THE PAST SEVEN YEARS INCLUDING ZIP CODES
Current Address: __________________________________________________________________________
City: ________________________
County: _________________
State: _________
Zip: __________
Former Address: __________________________________________________________________________
City: ________________________
County: _________________
State: _________
Zip: __________
Former Address: __________________________________________________________________________
City: ________________________
County: _________________
State: _________
Zip: __________
Former Address: __________________________________________________________________________
City: ________________________
County: _________________
State: _________
Zip: __________
Former Address: __________________________________________________________________________
City: ________________________
County: _________________
State: _________
Zip: __________
Former Address: __________________________________________________________________________
City: ________________________
County: _________________
State: _________
Zip: __________
Former Address: __________________________________________________________________________
City: ________________________
County: _________________
State: _________
Zip: __________
EDUCATION REFERENCE
Name: ________________________
SS#: _________________
Date of Birth: __________
Address: _____________________________________________________________________
_____________________________________________________________________
School/College/University: ______________________________________________________
Address: _____________________________________________________________________
_____________________________________________________________________
Telephone #: ____________________
Graduated:
Yes/No
Dates of Attendance: From: ________ To: ________
Highest Degree Received: ___________________________________
Address: _____________________________________________________________________
_____________________________________________________________________
Telephone #: ____________________
Graduated:
Yes/No
Address: _____________________________________________________________________
_____________________________________________________________________
Telephone #: ____________________
Graduated:
Yes/No
Signature: __________________________
Date: ______________________
School Name (Registrar): _______________________________________________________
Authorized Signature: __________________________________________________________
Date Verified: ____________________
Employment Reference
Name:
SS#:
Date:
Employed by:
Reference Name:
Title:
Phone#:
Address:
From:
To:
Position:
The above named individual has made an application with our company for temporary assignments. Because
careful screening is of the utmost importance to rendering quality service, we ask your cooperation in answering
the following questions. Your answers will be held in strictest confidence.
Are dates given correct?
Attendance
Punctuality
Quality of Work
Competence to perform duties
Appearance
Attitude
Honesty
If not, give correct dates: From:
excellent
excellent
excellent
excellent
excellent
excellent
excellent
good
good
good
good
good
good
good
fair
fair
fair
fair
fair
fair
fair
To:
poor
poor
poor
poor
poor
poor
poor
Reason for leaving?
Would you re-hire?
Additional information:
Department:
Signature:
Please return by:
I hereby authorize Westways Staffing Services to request, and also authorize and request each former person, firm
or corporation given as a reference to answer all questions that may be asked, and give all information that may be
necessary in connection with this application concerning me or my work habits, character, or skills.
Signature:
Date:
2010.2.22
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Employment Reference
Name:
SS#:
Date:
Employed by:
Reference Name:
Title:
Phone#:
Address:
From:
To:
Position:
The above named individual has made an application with our company for temporary assignments. Because
careful screening is of the utmost importance to rendering quality service, we ask your cooperation in answering
the following questions. Your answers will be held in strictest confidence.
Are dates given correct?
Attendance
Punctuality
Quality of Work
Competence to perform duties
Appearance
Attitude
Honesty
If not, give correct dates: From:
excellent
excellent
excellent
excellent
excellent
excellent
excellent
good
good
good
good
good
good
good
fair
fair
fair
fair
fair
fair
fair
To:
poor
poor
poor
poor
poor
poor
poor
Reason for leaving?
Would you re-hire?
Additional information:
Department:
Signature:
Please return by:
I hereby authorize Westways Staffing Services to request, and also authorize and request each former person, firm
or corporation given as a reference to answer all questions that may be asked, and give all information that may be
necessary in connection with this application concerning me or my work habits, character, or skills.
Signature:
Date:
2010.2.22
1 of 1
Authorization and Release
To the employee:
From time to time Westways Staffing Services’ client facilities will request to audit the employee files of
employees who have worked in their facility. These audits are intended only to verify that Westways
Staffing Services and consequently their employees are, and have been, in compliance with Regulations
and Accepted Industry Standards with regard to, but not limited to, annual in-services and health exams.
In order for Westways Staffing Services to comply with these hospital audits the employee (you) must sign
an Authorization allowing these facilities access to your Personnel file. Since compliance by Westways
Staffing Services with these audit requests are mandatory, it is necessary for Westways Staffing Services to
require that ALL EMPLOYESS sign this Authorization and Consent as a condition of employment. This
Authorization is required due to the “AMERICAN DISABILITY ACT” which prohibits employers from
disclosing medical information about their employees without their knowledge and consent.
I hereby authorize Westways Staffing Services, and its employees and representatives to provide any
information it deems appropriate regarding me to all hospitals and any of their employees, representatives,
and agents. This information may be provided either verbally or in writing. In addition to authorizing the
release of any information, I hereby fully waive any rights or claims I have against Westways Staffing
Services, its employees, or representatives from any and all liability, claims, or damages that may directly
or indirectly result from the disclosure or release of any information, whether such information is favorable
or unfavorable.
Date
Signature
Print Name
2010.02.22
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In-Service Acknowledgement
ACKNOWLEDGEMENT OF RECEIPT OF HIRING POLICY AGREEMENT
I have received, reviewed and understand my job description for Westways Staffing Services, Inc. given to
me at the time of orientation. I agree to abide by the job description as terms of my continued employment
with Westways Staffing Services.
Initials
Date:
ACKNOWLEDGEMENT OF RECEIPT OF PERSONNEL MANUAL
This is to acknowledge that I have received a copy of the Personnel Manual and understand that it contains
important information on Westways Staffing Services, Inc.’s general personnel policies and my duties and
obligation as an employee. I will familiarize myself with the manual and understand that I am governed by
its contents. I further understand that the company may change, rescind or add any policies, benefits, or
practices described in the handbook from time to time in its sole and absolute discretion with or without
prior notice.
Initials
Date:
ACKNOWLEDGEMENT OF RECEIPT OF FACTS ABOUT WORKERS COMPENSATION BENEFITS
BROCHURE
I have received, reviewed and understand Facts about Workers Compensation Benefits Brochure given to at
the time of my application. I have been informed that I have the right to choose a personal physician to
treat me in the event of an injury occurring while providing services for Westways Staffing Services, Inc. I
agree to abide by the Worker Compensation policies and procedures outlined in the personnel manual.
Initials
Date:
ACKNOWLEDGEMENT OF RECEIPT OF JCAHO AND OSHA CORE COMPETENCIES
I have received, reviewed and understand the JCAHO and OSHA Core Competencies. Westways Staffing
Services, Inc. strives to keep all staff updated on current health care practices and encourages all staff to
become familiar with these competencies and to implement them in their daily practice.
Initials
Date:
Employee
Signature:
Date:
2010.02.22
1 of 1
Acknowledgement of Receipt of BrightCureSM MPN Information
I acknowledge that I have received information regarding my employer’s use of a
Medical Provider Network for Workers’ Compensation claims
Employee’s Name (please print)
_______________________________________
Employee’s Signature
_______________________________
Today’s Date
Health Examination Form
Name:
Classification:
The following information is required by the TITLE XXH of the Health Code of the State of California for all persons working in
acute care hospitals. In order to maintain compliance with the Laws of the State please provide Westways Staffing Services, Inc.
with your physical prior to employment and ANNUALLY THEREAFTER.
PPD SKIN TEST:
CHEST X-RAY:
Date given:
Mm of induration:
Interpretation:
Date read:
negative
positive
Date Taken:
Date Read:
Results:
Signature of RN reading results:
PPD Positive Date:
Date:
RUBELLA:
Date Titers drawn:
Titer IGG results:
Status:
immune
Immunization date if not immune:
Date:
HEPATITIS B / IMMUNIZATION:
not immune
Hepatitis Vaccine:
1st dose
2nd dose
3rd dose
Or waiver signed:
MUMPS:
HEPATITIS C / IMMUNIZATION
Date Titers drawn:
Titer IGG results:
Status:
immune
Date:
Date Titers drawn:
Titer IGG results:
Status:
immune
Date:
not immune
RUBEOLA:
Date Titers drawn:
Titer IGG results:
Status:
immune
Date:
TETANUS / DIPTHERIA /ACELLULAR PERTUSSIS:
not immune
Date given:
Or WAIVER signed:
Notes:
Date:
VARICELLA:
Date Titers drawn:
Titer IGG results:
Status:
immune
Date:
not immune
COLOR BLIND:
Date:
Results:
not immune
The above patient has been examined by me and found to be in good physical and mental health. There is no evidence of
communicable disease and is able to carry out the functions as RN, LVN, LPT, CNA, or TECH without limitations.
Physician’s Name
Physician’s Signature
Date
2010.02.22
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Declination of the Influenza Vaccination
I decline to accept the influenza vaccine. I understand that if I am refusing to be vaccinated, I may endanger my
health, the health of my family and loved ones, and the patients that I may come in contact with. I am declining
the vaccine for the following reason(s) check all that apply

I have already received the influenza vaccine for this flu season

I intend to receive the influenza vaccine from my own healthcare
Provider

I have a contra-indication to receiving the vaccine and/or my
physician has advised me not to be vaccinated

I do not believe the vaccine is necessary or will prevent me from
getting the flu

I do not have time to be vaccinated and/or it is too inconvenient to
get vaccinated

Other:
_____________________________________________________________
______________________________________
Employee Signature
________________________
Date
______________________________________
Westways Representative
________________________
Date
2011.10.05
1 of 1
WESTWAYS STAFFING SERVICES, INC. Tuberculosis Annual Screening Questionnaire
Employee Name:
Date:
Positive TB Skin Test (PPD) Date Given
Date Read:
Last Chest X-Ray Date:
Please indicate if you are having any of the following problems for three to four weeks or longer:
1.
Chronic Cough (greater than 3 weeks)
Yes___ No___
2.
Production of Sputum
Yes___ No___
3.
Blood Streaked Sputum
Yes___ No___
4.
Unexplained Weight Loss
Yes___ No___
5.
Fever
Yes___ No___
6.
Fatigue/Tiredness
Yes___ No___
7.
Night Sweats
Yes___ No___
8.
Shortness of Breath
Yes___ No___
Employee Signature
Date
I have examined the above patient and find no evidence of Pulmonary Tuberculosis or Contagium.
Physician Signature
Date
PHYSICIAN’S OFFICE:
PLEASE PLACE YOUR OFFICIAL STAMP
HERE. THANK YOU. >>>>>>>>>>
2010.02.22
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Employee Health Survey
Emergency Notification
Should I be involved in an accident or emergency situation, please notify:
Last Name:
First Name:
Address:
Street
City
State
Zip
Telephone:
Home
Business
Physician Designation
I authorize the following physician who has my medical records and history to be contacted should I incur an
illness or work related injury while on assignment and in the employ of Westways Staffing Services, Inc. Should my
physician change, I assume responsibility for notifying Westways Staffing Services, Inc.
Health Clearance
Date of last physical exam:
The name and address of the physician and/or facility that performed the physical exam:
Name:
Address:
City
State
Zip
Telephone:
TB Status
Date of last PPD:
Date read:
Results:
Date of last Chest X-ray:
Results:
Allergies
Adhesive Tape
Latex
Any food:
Alcohol preparations
Aspirin, or other pain medications
Hay fever or seasonal allergies
Iodine or other cleaning solutions
Morphine, Codeine, Demerol or other narcotics/controlled
Novocaine, Xylocaine, or other anesthetics
Penicillin or other antibiotics
Sulfa Drugs or medications
Tetanus Antitoxin or other Sera
Any other drug group or medication: Name
Do you have any physical condition which precludes or would limit your ability to perform
certain tasks or responsibilities of the job for which you are applying?
Yes
No
Are you presently pregnant?
Yes
No
Is there pending, or have you applied for a pension, or compensation for any existing disability?
Yes
No
2010.02.22
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Are you now being treated or have you ever sought treatment for:
Alcohol abuse
Allergies
Arthritis
Asthma
Back Strain
Back Surgery
Broken Bones
Bronchitis
Cancer
Cardiovascular Disease
Diabetes
Dislocations
Epilepsy
Fainting Spells
Hay Fever
Yes
No
Hepatitis A
Hepatitis B
Hepatitis C
Hernia
High Blood Pressure
Immune System Disorder
Jaundice
Kidney Disease
Kidney Stone
Liver Disease
Malaria
Migraine Headaches
Pneumonia
Psychological Condition
Rheumatoid Arthritis
Have you ever been:
Yes
No
Seizures
Sinus Problems
Skin Disease
Small Pox
Sprains
Stomach Disorders
Tuberculosis
Urinary Tract Infection
Ulcers: Peptic
Venereal Disease
Other:
Other:
Other:
Other:
Other:
Yes
No
Have you ever:
Refused Employment?
Unable to hold a position for health reasons?
Unable to hold a position for medical reasons?
Unable to work due to medical reasons?
Hospitalized in the last five years?
Advised to have diagnostic tests that were not
completed?
Advised to have a hospitalization that was not
completed?
Advised to have a surgery which was not
completed?
Yes
No
Worked with cytoxic drugs?
Worked with radioactive materials?
Had any serious illness in the last five years?
Had your work restricted for health reasons?
Had a surgical procedure?
Procedure:
Date:
Procedure:
Date:
Had treatment or consultation for
musculoskeletal injury?
Yes No
Have you ever received/ had:
German Measles
Measles
Mumps
Rubella
Diptheria
Pertussis
Small Pox
BCG
X-ray
Vaccine
Vaccine
Vaccine
Vaccine
Vaccine
Vaccine
Vaccine
Vaccine
Chest
Titer
Titer
Titer
Titer
Titer
Titer
Titer
Titer
Spine
Tetanus?
Vaccine
10 yr Booster
Steroids?
Yes
No
Gamma Globulin?
Yes
No
Hepatitis B Vaccine Series (3) completed?
Yes
No
If yes, list date: Month/Year:
If no, check those completed:
1 Date: (Month/Year)
2 Date: (Month/Year)
Are you taking any medication or substance (prescription or otherwise) that may cause a positive result on a drug
test?
I certify that the information provided in this health survey is true, correct and complete. I understand that any
misinterpretation, omission or falsification on this documentation may result in my failure to receive an offer of
employment or, if I am hired, my immediate dismissal from employment.
Print Name
Signature
Date
2010.02.22
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Diphtheria Vaccination Request or Waiver
Name:
________________________________________
Facility:
________________________________________
Position:
________________________________________
Please indicate if employee requests or waives the diphtheria vaccination. If the employee waives
the vaccination the employee must indicate the reason for the waiver.
____
Employee waives the diphtheria vaccination.
___________________________________
Employee Signature
_________________
Date
___________________________________
_________________
Date
2010.02.22
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Hepatitis B Vaccination Declination
Employee Name:
___________________________________________
Employee SSN:
___________________________________________
I understand that due to my occupational exposure to blood or other potentially infectious
material I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the
opportunity to be vaccinated with Hepatitis B vaccine. However, I decline the vaccine at this
time. I understand that by declining the vaccine, I continue to be at risk of acquiring Hepatitis B,
a serious disease. If, in the future, I continue to have occupational exposure to blood or other
potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can
receive the vaccination series at my request. I understand that it is my responsibility to request
the vaccination if I choose to receive it after this initial refusal.
Employee’s reason for refusal:
________________________________________________________________________
Employee requests Hepatitis B vaccination series: _______________________________
______________________________________
Employee Signature
________________________
Date
______________________________________
________________________
Date
2010.02.22
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Measles Waiver
I have received information on recommendations from the Orange Country Health Department as
to the advisability of receiving an additional Measles, Mumps, and Rubella (MMR) vaccine for
protection against infection.
Westways Staffing Services is consistent with recommendations that all employees be immunized
for Measles, Mumps, and Rubella especially in light of the current epidemic in Orange County.
In the event, having refused the immunization, that I should contract the Measles, the choice to
waiver the vaccine will be considered along with all other circumstances in determining hospital
liability. I am aware that if I am pregnant or become pregnant this could be a risk to my unborn
child. I decline to receive the Measles, Mumps, and Rubella (MMR) vaccine due to one of more of
the following reasons:
____
I know I have had Measles
____
I have enclosed documentation of having received two immunizations in my lifetime.
____
I have serological evidence of immunity to Measles (documentation enclosed)
____
I am pregnant or plan to become pregnant in the next three months.
____
I am allergic to eggs and/or Neomycin
____
Other, please explain below:
_______________________________________________________________
_______________________________________________________________
____________________________________
Signature
_____________________
Date
2010.02.22
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Consent for Respiratory Fit Testing
I, ____________________________________, give my consent to receive a respiratory fit test prior to being
hired for employment with Westways Staffing Services. I understand the need for this test prior to working at
the facility assigned to me.
Name:
Signature:
Date:
Witness:
Signature:
Date:
2010.02.22
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Respiratory Fit Declination Form
Please choose one area for signature
I have been fit tested within the past year.
Date:
Signature:
(Please submit evidence of Fit Testing)
I understand that by declining the Respiratory Fit Test, I am potentially exposing myself to the tuberculosis
bacteria and the risk of acquiring the disease.
I have been given the opportunity to receive the Respiratory Fit Test but decline Respiratory Fit Testing at this
time. I do understand by declining this, I will continue to be at risk of acquiring Tuberculosis while caring for
patients with this disease or suspected of having the disease.
Date:
Signature:
2010.02.22
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Varicella Questionnaire
It is recommended that healthcare workers, teachers of the young, daycare workers, college students, and
those who travel internationally, are confined to institutional settings and in the military obtain the vaccine
introduced in 1995.
Chickenpox is an infectious disease caused by the Varicella, a virus of the herpes family. The transmission is
spread by coughing, sneezing, direct contact and considered highly contagious.
An individual is contagious for 1-2 days followed by 10-21 days before symptoms appear. Individuals who may
not be able to take the vaccine have a preventative treatment called Varicella Zoster Immune Globulin(VZIG).
For more information, contact the National Immunization Hotline.
•
It is my belief that I have had Varicella (chickenpox).
Y
Date
N
•
As a child I lived with a sibling who had chickenpox.
Y
Date
N
•
I have cared for a child in my home who had chickenpox.
Y
Date
N
•
Acyclovir is a medication I have taken for herpes viruses.
Y
Date
N
•
My medical history includes having herpes zoster (shingles).
Y
Date
N
•
A blood test to establish my titer has been determined.
Y
Date
N
•
A copy of the results is available and I have/can provide.
Y
N
If no or you cannot provide the results you may be asked to establish a titer by blood test.
If yes, the results can be provided within ten (10) business days and are available from:
Facility Full Name:
Address:
City, State and Zip:
Telephone Number:
E-mail Address:
EMPLOYEE INFORMATION
Print Name:
Employee Signature:
Date:
WSS Representative Signature:
Date:
2010.02.22
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Consent for Drug Screening
I, ______________________________, give my consent to be screened for drugs prior to being hired for
employment with Westways Staffing Services. I understand the need to screen for use of drugs or illegal
substances to ensure that only the highest quality of nurses are hired by Westways Staffing Services.
I likewise consent to be screened for drugs any time and at any hospital that I shall be assigned to by
Westways Staffing Services.
I am fully aware that if my Drug Screen Result is positive, I will be ineligible to work with Westways Staffing
Services.
I hold Westways Staffing Services free from any liability should results of my drug screening influence future
employment.
Name:
Witness:
Signature:
Signature:
Date:
Date:
2010.02.22
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Latex Allergy Questionnaire
EMPLOYEE NAME: ___________________________________________
_______
I do have a latex allergy.
_______
I do not have a latex allergy.
_______
I have sensitivity to powder and require powder free gloves.
My signature below indicates that the above information is correct and I give permission for this
information to be shared with Westways Staffing Services’ clients for the purpose of working at
their client facilities.
______________________________________
Employee Signature
________________________
Date
2010.02.22
1 of 1
Form W-4 (2011)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal
income tax from your pay. Consider completing a
new Form W-4 each year and when your
personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign
the form to validate it. Your exemption for 2011
expires February 16, 2012. See Pub. 505, Tax
Withholding and Estimated Tax.
Note. If another person can claim you as a
dependent on his or her tax return, you cannot
claim exemption from withholding if your income
exceeds $950 and includes more than $300 of
unearned income (for example, interest and
dividends).
Basic instructions. If you are not exempt,
complete the Personal Allowances Worksheet
below. The worksheets on page 2 further adjust
your withholding allowances based on itemized
deductions, certain credits, adjustments to
income, or two-earners/multiple jobs situations.
Complete all worksheets that apply. However,
you may claim fewer (or zero) allowances. For
regular wages, withholding must be based on
allowances you claimed and may not be a flat
amount or percentage of wages.
Head of household. Generally, you may claim
head of household filing status on your tax return
only if you are unmarried and pay more than
50% of the costs of keeping up a home for
yourself and your dependent(s) or other
qualifying individuals. See Pub. 501, Exemptions,
Standard Deduction, and Filing Information, for
information.
Tax credits. You can take projected tax credits
into account in figuring your allowable number of
withholding allowances. Credits for child or
dependent care expenses and the child tax
credit may be claimed using the Personal
Allowances Worksheet below. See Pub. 919,
How Do I Adjust My Tax Withholding, for
information on converting your other credits into
withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using
Form 1040-ES, Estimated Tax for Individuals.
Otherwise, you may owe additional tax. If you
have pension or annuity income, see Pub. 919 to
find out if you should adjust your withholding on
Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to
claim on all jobs using worksheets from only one
Form W-4. Your withholding usually will be most
accurate when all allowances are claimed on the
Form W-4 for the highest paying job and zero
allowances are claimed on the others. See Pub.
919 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
amount you are having withheld compares to
your projected total tax for 2011. See Pub. 919,
especially if your earnings exceed $130,000
(Single) or $180,000 (Married).
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.
• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible
child plus “1” additional if you have six or more eligible children . . . . . . . . . . . . . . . . . .
G
Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
• If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
worksheets
$40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
that apply.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
{
B
C
D
E
F
G
H
}
{
Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-2159
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Type or print your first name and middle initial.
2
Last name
Home address (number and street or rural route)
3
Single
Married
2011
Your social security number
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2011, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date ▶
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
Cat. No. 10220Q
10
Employer identification number (EIN)
Form W-4 (2011)
Page 2
Form W-4 (2011)
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
2
3
4
5
6
7
8
9
10
Enter an estimate of your 2011 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . .
$11,600 if married filing jointly or qualifying widow(er)
Enter:
$8,500 if head of household
. . . . . . . . . . .
$5,800 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Enter an estimate of your 2011 adjustments to income and any additional standard deduction (see Pub. 919)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
Withholding Allowances for 2011 Form W-4 Worksheet in Pub. 919.)
. . . . . . . . . . .
{
}
Enter an estimate of your 2011 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $3,700 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
1
2
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .
3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional
withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2011. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . .
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
6
7
8
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
Married Filing Jointly
Enter on
line 2 above
$0 - $5,000 0
$0 - $8,000 0
1
8,001 - 15,000 1
5,001 - 12,000 2
15,001 - 25,000 2
12,001 - 22,000 3
25,001 - 30,000 3
22,001 - 25,000 4
30,001 - 40,000 4
25,001 - 30,000 5
40,001 - 50,000 5
30,001 - 40,000 6
50,001 - 65,000 6
40,001 - 48,000 7
65,001 - 80,000 7
48,001 - 55,000 8
80,001 - 95,000 8
55,001 - 65,000 9
95,001 -120,000 9
65,001 - 72,000 10
120,001 and over
10
72,001 - 85,000 11
85,001 - 97,000 12
97,001 -110,000 13
110,001 -120,000 14
120,001 -135,000 15
135,001 and over
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to
carry out the Internal Revenue laws of the United States. Internal Revenue Code sections
3402(f)(2) and 6109 and their regulations require you to provide this information; your employer
uses it to determine your federal income tax withholding. Failure to provide a properly
completed form will result in your being treated as a single person who claims no withholding
allowances; providing fraudulent information may subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal litigation, to
cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in
administering their tax laws; and to the Department of Health and Human Services for use in
the National Directory of New Hires. We may also disclose this information to other countries
under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to
federal law enforcement and intelligence agencies to combat terrorism.
If wages from HIGHEST
paying job are—
$0
65,001
125,001
185,001
335,001
- $65,000
- 125,000
- 185,000
- 335,000
and over
Enter on
line 7 above
$560
930
1,040
1,220
1,300
All Others
If wages from HIGHEST
paying job are—
$0
35,001
90,001
165,001
370,001
- $35,000
- 90,000
- 165,000
- 370,000
and over
Enter on
line 7 above
$560
930
1,040
1,220
1,300
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
OMB No. 1615-0047; Expires 06/30/09
Form I-9, Employment
Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Read instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)
Print Name: Last
First
Middle Initial Maiden Name
Address (Street Name and Number)
City
State
Apt. #
Date of Birth (month/day/year)
Zip Code
Social Security #
I attest, under penalty of perjury, that I am (check one of the following):
I am aware that federal law provides for
imprisonment and/or fines for false statements or
use of false documents in connection with the
completion of this form.
A citizen of the United States
A noncitizen national of the United States (see instructions)
A lawful permanent resident (Alien #)
An alien authorized to work (Alien # or Admission #)
until (expiration date, if applicable - month/day/year)
Employee's Signature
Date (month/day/year)
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under
penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
Preparer's/Translator's Signature
Print Name
Address (Street Name and Number, City, State, Zip Code)
Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and
expiration date, if any, of the document(s).)
List A
OR
List B
AND
List C
Document title:
Issuing authority:
Document #:
Expiration Date (if any):
Document #:
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
and that to the best of my knowledge the employee is authorized to work in the United States. (State
(month/day/year)
employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative
Print Name
Title
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)
Section 3. Updating and Reverification (To be completed and signed by employer.) A. New Name (if applicable)
B. Date of Rehire (month/day/year) (if applicable)
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.
Document Title:
Document #:
l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented
document(s), the document(s) l have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Form I-9 (Rev. 02/02/09) N Page 4
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be unexpired
LIST A
LIST B
Documents that Establish Both
Identity and Employment
Authorization
OR
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien
Registration Receipt Card (Form
I-551)
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machinereadable immigrant visa
Documents that Establish
Employment Authorization
Documents that Establish
Identity
AND
1. Driver's license or ID card issued by
a State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height,
eye color, and address
2. ID card issued by federal, state or
local government agencies or
entities, provided it contains a
photograph or information such as
name, date of birth, gender, height,
eye color, and address
4. Employment Authorization Document
that contains a photograph (Form
I-766)
3. School ID card with a photograph
5. In the case of a nonimmigrant alien
authorized to work for a specific
employer incident to status, a foreign
passport with Form I-94 or Form
I-94A bearing the same name as the
passport and containing an
endorsement of the alien's
nonimmigrant status, as long as the
period of endorsement has not yet
expired and the proposed
employment is not in conflict with
any restrictions or limitations
identified on the form
5. U.S. Military card or draft record
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association
Between the United States and the
FSM or RMI
LIST C
4. Voter's registration card
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
1. Social Security Account Number
card other than one that specifies
on the face that the issuance of the
card does not authorize
employment in the United States
2. Certification of Birth Abroad
issued by the Department of State
(Form FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
5. Native American tribal document
8. Native American tribal document
9. Driver's license issued by a Canadian
government authority
For persons under age 18 who
are unable to present a
document listed above:
10. School record or report card
11. Clinic, doctor, or hospital record
6. U.S. Citizen ID Card (Form I-197)
7. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
8. Employment authorization
document issued by the
Department of Homeland Security
12. Day-care or nursery school record
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)
Form I-9 (Rev. 02/02/09) N Page 5
W-11
Form
(April 2010)
Department of the Treasury
Internal Revenue Service
Hiring Incentives to Restore Employment (HIRE) Act
Employee Affidavit
▶
Do not send this form to the IRS. Keep this form for your records.
To be completed by new employee. Affidavit is not valid unless employee signs it.
I certify that I have been unemployed or have not worked for anyone for more than 40 hours during the 60-day period ending on the
date I began employment with this employer.
Your name
First date of employment
Social security number ▶
/
/
Name of employer
Under penalties of perjury, I declare that I have examined this affidavit and, to the best of my knowledge and belief, it is true, correct,
and complete.
Date
Employee's signature ▶
Instructions to the
Employer
Section references are to the Internal
Revenue Code.
Purpose of Form
Use Form W-11 to confirm that an
employee is a qualified employee under
the HIRE Act. You can use another
similar statement if it contains the
information above and the employee
signs it under penalties of perjury.
Only employees who meet all the
requirements of a qualified employee
may complete this affidavit or similar
statement. You cannot claim the HIRE
Act benefits, including the payroll tax
exemption or the new hire retention
credit, unless the employee completes
and signs this affidavit or similar
statement under penalties of perjury and
is otherwise a qualified employee.
A “qualified employee” is an employee
who:
• begins employment with you after
February 3, 2010, and before January 1,
2011;
• certifies by signed affidavit, or similar
statement under penalties of perjury, that
he or she has not been employed for
more than 40 hours during the 60-day
period ending on the date the employee
begins employment with you;
▶
/
/
your sibling or stepsibling, your parent or
an ancestor of your parent, your
stepparent, your niece or nephew, your
aunt or uncle, or your in-law. An
employee also is related to you if he or
she is related to anyone who owns more
than 50% of your outstanding stock or
capital and profits interest or is your
dependent or a dependent of anyone
who owns more than 50% of your
outstanding stock or capital and profits
interest.
• is not employed by you to replace
another employee unless the other
employee separated from employment
voluntarily or for cause (including
downsizing); and
If you are an estate or trust, see
section 51(i)(1) and section 152(d)(2) for
more details.
• is not related to you. An employee is
related to you if he or she is your child or
a descendent of your child,
CAUTION
Cat. No. 10744F
!
▲
Do not send this form to the IRS.
Keep it with your other payroll
and income tax records.
Form W-11 (4-2010)
Employee Benefits
Enrollment Information
Welcome to Westways Staffing Services, Inc.:
At Westways Staffing Services, Inc. we strive to provide
our employees the best possible coverage at the most
affordable rates. We offer our employees Medical,
Dental, Vision, Life/AD&D and Voluntary products.
Westways Staffing Services, Inc. also provides employees
with an Employee Assistance Program (EAP). At no cost
to you, this program assists with:
Consultation and resource service with up to six faceto-face assessments and counseling sessions per issue.
Unlimited 24/7 telephonic support services
Legal and financial consultation
Will preperation And more…
Once you reach your eligibility date, contact Khristine Matias to activate your Insurance
Enrollment UserName/Password.
Once you become eligible you will have the opportunity to:
Enroll in Medical, Dental, Vision, Life/AD&D and Voluntary coverage
Enroll dependents
Choose the plan that enhances you and/or your family’s quality of life
For plan information and
online enrollment
Go to Your
EMPLOYEE BENEFIT CENTER
www.westwaysstaffing.com
Click on “Sign In”
Company Code Login:
mywestways
For benefit questions feel free to contact
our Broker’s office: Sherrie Wilson [email protected]
(800)451-8037 x237 or
Westways/Benefits Coordinator:
Khristine Matias [email protected] (800)575-9674 x1008
Once your elections take effect, you are not able to make changes until the next Open Enrollment period.
Certain exceptions may be allowed during the year for Qualifying Events such as: marriage, birth, adoption
or loss of existing group coverage.
Benefit Eligibility Requirements
Full-Time Eligibility: 132 hours per month. Eligible 1st of the month following 3 consecutive
months of full-time status. Once you reach your full-time eligibility, contact Khristine Matias
for your username/password so you can “ENROLL” on benefits.
Employee Benefit Center (EBC)
www.westwaysstaffing.com Click on “Sign In”
EBC Login: mywestways
“My Benefits” View all your benefit options,
summaries, doctor search and more.
“Enroll Now” Direct link to your secure online
benefit enrollment system. (Personal Username/
Password Required from HR)
View the
“Employee Benefits Booklet”
through the EBC or contact
HR for a copy.
SeaBright Insurance Company
(800) 597-2755
The Employee Implementation Notice of SeaBright BrightCure Customized MPN
Westways Staffing Services participates in the SeaBright BrightCure Customized MPN. Unless you predesignate a physician or medical group, your new work injuries arising on or after October 8, 2010 will be
treated by providers in a new Medical Provider Network, SeaBright BrightCure Customized MPN. If you have
an existing injury, you may be required to change to a provider in the new MPN. Check with your claims
adjuster. You may obtain more information about the MPN from the workers’ compensation poster or from
your employer. The following language may be provided in writing to injured covered employees to give the
required notice of the change of MPN coverage:
SeaBright BrightCure Customized MPN website: www.sbic.com
Current MPN’s toll free number: 800-597-2755
El Aviso de Ejucación del Empleado de SeaBright BrightCure Customized MPN
Westways Staffing Services participa en la MPN SeaBright BrightCure Customized MPN. A menos que usted
tenga una designación previa de un medico o grupo medico, las lesions que surgen a partir del October 8, 2010
en su trabajo serán tratados por los proveedores en una mueva red de proveedores medicos, SeaBright
BrightCure Customized MPN. Si usted tiene una lesion existente, puede ser necesario cambiar a un proveedor
de la MPN Nuevo. Consulte con su ajustador de reclamos. Usted puede obtener más informacion acerca de la
MPN del cartel de compensación de los trabajadores o de du empleador:
Pagina web de la MPN: www.sbic.com
Número gratuito de la MPN vigente: 800-597-2755
Change of MPN Coverage Notice
This section applies to you if you have an existing injury with a different MPN:
Unless you pre-designate a physician or medical group prior to injury, your new work injuries arising on or
after October 8, 2010 will be treated by providers in a new Medical Provider Network, SeaBright BirghtCure
Customized MPN. If you have an existing injury, you may be required to continue care under your prior MPN
or may be required to change to a provider in the new MPN. Check with claims adjuster. For periods when you
are not covered under MPN, you may choose a physician 30 days after you’ve notified your employer of your
injury. You may obtain information at:
Cambio de la Comunicación de la cobertura del MPN
A menos que usted tenga una designación previa de un médico, las lesiones que surgen a partir del October 8,
2010 serán tratados por los proveederos en una nueva red de proveedores médicos, SeaBright BrightCure
Customized MPN. Si usted tiene una lesión existente, puede ser necesario continuar la atencion en virtud de su
previa MPN o usted puede ser requerido cambiar a un proveedor de la MPN Nuevo. Consulte con su ajustador
de reclamos. Durante los periodos en que no están cubiertos por la MPN, usted puede escoger un medico 30
dias después de haber notificado su empleador de su lesion. Usted puede obtener más información acerca de la
MPN en: