APPLICATION FOR EMPLOYMENT

EMERGENCY CONTACT

EDUCATION

PROFESSIONAL

Speciality areas in which you have performed proficiently in the last two years:

EMPLOYMENT EXPERIENCE

PROFESSIONAL REFERENCES

SUBSTANCE ABUSE POLICY

Substance abuse in our society poses a threat of danger to us all. Advanced Healthcare Staffing Solutions, LLC, accepts its responsibility to all its employees to provide a safe working environment. Advance Healthcare Staffing Solutions, LLC, also recognizes its responsibility to its clients and to the public to ensure that their safety and trust in our organization is protected. In accordance with this, and in compliance with the federal Drug Free Workplace Act of 1988, Advanced Healthcare Staffing Solutions, LLC is committed to maintaining a Drug Free Workplace.

To ensure that the company meets its legal and ethical requirements, the following substance Abuse policy has been implemented and is effective immediately. Read the contents o f this policy carefully as you will be held responsible for understanding and complying with it. This policy explains your rights and responsibilities as they relate to Advanced Healthcare Staffing Solutions, LLC, Drug Free Workplace and Drug and Alcohol Testing programs. Compliance with this policy is required as a condition of employment.

1. Covered Employees

   This policy applies to employees and prospective employees of Advanced Healthcare Staffing Solutions, LLC. Who provides or will provide temporary services to the organization’s clientele? These employees include, but are not limited to: Registered Nurses, Licensed Practical, or Vocational Nurses, Certified Nurse’s Assistants, Home Health Aides, as well as ancillary service personnel.

2. Policy

   Advanced Healthcare Staffing Solutions, LLC, prohibits the use, possession, transfer, diversion, or sale of alcohol and /or illegal drugs or prescription drugs obtained illegally while working, or on any premises owned or operated by the company and its clients. It also prohibits reporting for work on behalf of Advanced Healthcare Staffing Solutions, LLC, under the influence of alcohol and / or illegal drugs.

   Violation of this policy may result in disciplinary action, up to and including termination. “Illegal drugs” mean illicit drugs and controlled substances and includes prescription medication that contains a controlled substance and are used for a purpose for which they were not prescribed or intended.

3. Consequences of Non-Compliance

   Employees who are found to be in violation of this policy will be subject to disciplinary actions including possible termination. Disciplinary actions may also include, but not be limited to formal reprimand, suspension without pay, or other actions as required by state and local regulatory authorities.

4. Drug/Alcohol Testing
   1. Pre-Employment Drug Testing

      Many of our clients require pre-employment drug testing of all temporary employees placed on assignment at their facilities. Therefore, when stipulated by service contract or agreement, and /or in accordance with law, Advanced Healthcare Staffing Solutions, LLC, will require its employees to comply with the client’s policies and procedure to be eligible for work assignments with the client.

      Advanced Healthcare Staffing Solutions, LLC also requires pre-employment drug testing of all travel Division employees. Furthermore, the company reserves the right to expand its pre-employment drug testing program at any time and without notice.

   2. Reasonable Suspicion Testing

      An employee may be requested or required to undergo a drug and /or alcohol test if there is a reasonable suspicion that the employees: (1) is under the influence of alcohol and /or illegal drugs, (2) has violated the policy statement above, or Advanced Hea lthcare Staffing Solutions LLC, Drug- Free Work Place Policy, (3) has caused himself/ herself or another person to sustain a personal injury, or (4) has caused a work - related accident.

   3. Notification

      Before requesting or requiring an employee to undergo dru g and or alcohol testing, the company will provide the employee with a copy of this Drug and Alcohol Testing Policy and an opportunity to read and sign the policy.

   4. Right to Refuse to Undergo Drug and Alcohol Testing and The Effect There of any employee has the right to refuse to undergo drug/ or alcohol testing. An employee who refuses to be tested or whose behavior prevents meaningful completion of drug and /or alcohol testing will be subject to termination or other disciplinary action in conformity with company policy.

   5. Rights In Case of a Positive Test

      Confirmatory Test- if the initial result on a drug test is positive, the sample tested will be subject to a second, confirmatory test. No employee will be terminated, disciplined, discriminated against solely based on an initial positive test result.

      Medical Review (MRO) - If the confirmatory test is also positive, the applicant or employee will be notified of the test results by an MRO and will be allowed to submit information to explain the positive test results. The MRO will either confirm the positive result or determine that the test result is negative. Secondary Confirmatory Test- If the employee is not satisfied with the positive test results he or she may, at his or her expense, request a second confirmatory retest of the original sample, conducted either by the original testing laboratory or by another licensed laboratory.

   6. Consequences Of a Positive Test Results

      If an applicant has a positive confirmatory test, any conditional job offer will be withdrawn immediately and the applicant will be ineligible for employment with Advanced Healthcare Staffing Solutions, LLC, until they successfully complete a rehabilitation or counseling program.

      If an employee has a positive confirmatory test, he or she will be required to participate in a drug and/ or alcohol counseling rehabilitation program as a condition of continued employment. The employee may be suspended during the period of rehabilitation but, will not be discharged unless he or she: (1) refuse rehabilitation; (2) does not successfully complete the rehabilitation program; or (3) tests positive for drugs or alcohol following completion of the program. An employee who com pletes a drug or alcohol counseling or rehabilitation program may be required to undergo drug or alcohol testing without prior notice during the evaluation or treatment period and for any period following treatment allowable by law. The employee will be responsible for all costs associated with the counseling or rehabilitation program.

   7. Additional Rights of Applicants and Employees

      An Applicant or employee who is requested or required to undergo drug testing will be provided with a copy of the test results upon request.

   8. Confidentiality

      The fact that an employee has been requested or required to take a drug and/ or alcohol test, the result of the test, and information acquired in the alcohol and / or illegal drug testing process shall be treated in a manner consistent with the companies’ treatment of other private and confidential information concerning employees. Voluntary disclosure by an employee of the excessive use of alcohol and/ or illegal drugs before being confronted, tested, or otherwise involved in drug and /or alcohol- related discipline or proceedings will also be treated in a manner consistent with the company’s treatment of other private and confidential information concerning employees.

5. Acknowledgement

   have read and understand the policies of Advanced Healthcare Staffing Solutions, LLC, herein and acknowledge the specific clients of Advanced Healthcare Staffing Solutions, LLC, may require pre-employment drug testing and that I will be expected to comply with these requirements to be eligible for assignment with such facilities. Furthermore, I understand that I may be subject to other subjects to other types of drugs and/ or alcohol testing outlined in the policy.

Employments of AHSS, LLC are expected to always conduct themselves in a professional manner. “Professionalism” refers to dependability and reliability in arriving for assignments on time and in appropriate attire. It also refers to providing quality services consistent with the job description for the position to which you are assigned and in accordance with the policies and protocol of the client facilities as well as those of AHSS, LLC. AHSS LLC employees recognize that the role of temporary employees is to provide competent, skilled support to the client. Every effort must be made to meet the needs of the client. Unacceptable conduct will result in disciplinary action including up to termination of employment.

Unacceptable conduct includes, but is not limited to the following:

1. No Call No Show “Automatic Termination”
2. Excessive Usage of any Electronic Device including cell phones, tablets, mp3 players, etc.
3. Excessive Unexcused Issues Clocking in/out
4. Performance on assignment, which results in clients’ complaints
5. Chronic Tardiness
6. Not in Proper Uniforms (Scrubs Only)
7. Inordinate number of cancellations or late cancels.
8. Theft
9. Noncompliance with AHSS, LLC substance abuse policy
10. Insubordination (Refusal or failure to follow instructions/directions by supervisor/management personnel)
11. Taking unauthorized person(s) to client’s home
12. Sleeping while on assignment
13. Failure to follow Occupational Health and Safety Standards including Universal Precautions
14. Unprofessional Behavior
15. Falsification of records
16. Racial intolerance
17. Violence on premises
18. Sexual Harassment and other discriminatory behavior
I have received a copy of AHSS, LLC policies and procedures. I agree to abide by the Policies and Procedures as well as the following:

1. To notify AHSS, LLC when a client schedules me for additional hours
2. To accept responsibility for learning each facility’s emergency procedures, including orientation if required. To receive orientation, pay, you will have to do at least 1 service day. Training hourly rate varies.
3. I am responsible for working in a professional manner while on duty. I am also responsible for the filing of the appropriate tax forms. I release AHSS, LLC from any all liability arising from this form.
4. I agree to never leave my assignment without notifying my supervisor.
5. I agree to accept patients without regard to race, color, national origin, or medical treatment and will strive to provide services of the highest quality.
6. I agree to notify AHSS, LLC of address or telephone changes within 72 hours.
7. Any employee injuries should be reported by the end of the shift to the immediate supervisor.

Advanced Healthcare Staffing Solutions, LLC will not offer work assignments to an employee who:

1. Does not show for an accepted shift
2. Presents a work performance or an attitude that draws complaints for the client
3. Is chronically tardy
4. Has an inordinate amount of cancelled shifts day period

Written warning will be given with a request for an office consultation concerning any attendance record in question.


Additional Information:

1. All Referrals: The worker or client must be with the company for 30 days to receive payment disbursement.
Availability of Work

AHSS, LLC does not guarantee the availability of work. It is understood that work is assigned on an “as needed” basis as determined by our clientele. The flexibility and availability of the employee greatly enhances the likelihood that she/he will be offered an assignment. AHSS, LLC is an equal opportunity employer and will not discriminate against any individual based on gender, race religion, ethnic background, sexual orientation, disability, marital status, political affiliation, or veteran status.

Acknowledgement:

I have read and fully understand the policies stated above. I have also reviewed and understand the content of the applications information provided to me. Provided that an offer of employment is given to me, I will accept employment on these conditions.

SOUTH CAROLINA LAW ENFORCEMENT DIVISION

A fee of twenty –five dollars will be deducted from your first payroll check to cover the cost of your criminal record check. For A.H.S.S., LLC to process your criminal record check you must complete this form in its entirety. Failure to do so will disqualify you as a candidate for employment.

RANDOM DRUG TESTING

As an Employee of Advanced Healthcare Staffing Solutions, LLC you will undergo a random drug test. You will be required to report to Lab Corp located on 1508 North Cashua Dr. Florence, SC 29501 or Advanced Healthcare Staffing Solutions, LLC 611 S. Dargan Street. Florence, SC 29506. You must show up to the collection site and present your identification. You will be presented with a consent form if you have not signed one. You will receive the results within 5 minutes. Anyone who fails the drug test will be terminated immediately. If you disagree with the results, you can request another test from one of the two testing centers and if the second test comes back positive the employee will be terminated indefinitely. If you fail to report for test by the established deadline, refuse testing, or test positive for one or more illegal drugs, you will be separated from employment with Advanced Healthcare Staffing Solutions, LLC.

ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I certify that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity. I acknowledge that this Accident Waiver and Release of Liability Form will be used by Advanced Healthcare Staffing Solutions, LLC

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: The Soil Ecology Society, (SES) and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers;

(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from all liabilities or claims made because of participation in this activity, whether caused by the negligence of release or otherwise. I acknowledge that SES and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL