Providing Long Term Care
Insurance, Private Pay & Medicaid Personal Care Services
 
 
 
 
 
 
 
 
 
Date:
 
 

New Employee Self-Identification Form


Federal laws and regulations require us to report on our workforce by race, gender, and veteran status and to offer the opportunity for self-identification as to disabilities. Please assist us by completing this form. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. Data which you provide shall be kept strictly confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work and duties of disabled individuals and/or disabled veterans; (ii) first aid and safety personnel may be informed, to the extent appropriate, if the condition might require emergency treatment; and (iii) governmental officials reviewing the Company's compliance status shall be informed.
 
 
 
 
 
Gender:
 Male 
 Female 
Veteran Status:
 I am not a disabled veteran. 
 I am a disabled veteran. 
 I am a recently separated veteran. 
 
Date of Discharge (MM/DD/YYYY)
 
 
 
Race/Ethnicity: Please choose one.
 Hispanic or Latino 
 Black or Afircan American (Not Hispanic or Latino) 
 Native Hawaiian or Other Pacific Islander(Not Hispanic or Latino) 
 American Indian or Alaska Native (Not Hispanic or Latino) 
 White (Not Hispanic or Latino) 
 Asian (Not Hispanic or Latino) 
 Two or More Races (Not Hispanic or Latino) 
 
 
 
 
 
Disability
 I do not have a disability 
 I am an individual with a disability. * 
 I have received the form and decline to provide the requested information 
* Categories consistent with 41 C.F.R. 60-300 & Form VETS-100A
If you need a definition of these terms, please see below.
SELF - IDENTIFICATION FORM DEFINITIONS

1. The term "Disabled Veteran" means -

A. a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability; or

B. a person who was discharged or released from active duty because of a service-connected disability.

2. The term "Recently Separated Veteran" applies to any veteran during the three-year period beginning on the date of discharge or release from active duty.

3. An "individual with a disability" means any person who (i) has a physical or mental impairment which substantially limits one or more of such person's major life activities; (ii) has a record of such impairment; or (iii) is regarded as having such impairment.

EMPLOYMENT APPLICATION

 
Date:
 
 
 
 
 
Position Applied For:
 
 
 
EDUCATIONAL BACKGROUND
 
Type of School
Grammar or Grade
High School
Community College
College
Post Graduate
Business or Trade
 
Name and City
 
Years Attended
 
Graduated
 
Course / Major
 
 
Other / Classes
 
 
SPECIALIZED EXPERIENCE ( Indicate number of years in each category)
 
 
Operating Room
Pediatrics
Labor / Delivery
Med / Surge
 
 
 
 
Critical care - Pediatrics
I. V. Experience
Psych
Telemetry
 
 
 
Are there any other experiences, skills, or qualifications which you feel are relevant to this job that have not already been mentioned?
MILITARY SERVICE BACKGROUND
 
 
 
 
Date
 
 
to
 
 
Rank at discharge
 
 
HISTORY (List in order, last or present employer first)
 
From
 
 
to
 
 
Position / Title
 
 
 
 
 
 
 
 
 
From
 
 
to
 
 
Position / Title
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
I hereby certify that the answers given by me to all the questions contained on this application form are true and correct. If employed by Caremed, Inc. I will comply with all rules, regulations, policies and procedures of the company. I authorize my former employers to give any information they have regarding me, whether or not it is on their records. I authorize Caremed, Inc. to run a background check. I hereby release them and Caremed, Inc. from all liability for any damage whatsoever for issuing same. If upon investigation, anything in this application is found to be untrue, I understand I will be subject to dismissal, and/or prosecution to the fullest extent
of the law.
 
 
Date
 
 
 
 
Date