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chamber SteGenPublicHealth
equal opportunity employer

 
Date: 08/01/2014
1) Position Applying For and Availability:
1st Choice:
2nd Choice:
full time     part time    PRN     any
Are you available to work: days    evenings    nights     any weekends holidays rotating shifts
Please indicate any days of the week or times during a particular day you are not available for work.
Date available for employment Minimum salary desired $
I understand that assignments and scheduling may vary to meet the needs of the hospital and I may be required to work other areas or shifts.


2) Your Information

Last Name
First Name
Middle Name
Present Address
City
State
Zip
Telephone Number
Alternate Number
E-Mail Address
SSN
- -
Are you legally eligible to work for employment in the United States? Yes No
Have you ever applied for work at Ste. Genevieve County Memorial Hospital System before? Yes No
Have you ever worked for Ste. Genevieve County Memorial Hospital System before? Yes No
If yes, when? What name were you employed under?
Do you have a reliable means of transportation to get to work? Yes No
Person to be notified in case of emergency:
Name:
Phone:


3) Education

Education Level School Address Degree/Diploma Major Field of Study Years Completed
High School
Vocational/
Technical Training
College(s) Attended
What profession/skill are you licensed/registered for?
Date first issued?   License No.    State


4) Experience
Please complete the following section even if a resume is enclosed. List all employers starting with most recent. List all employers for the past 10 years or the last four employers, whichever covers the longest period. You may list more employers on a separate sheet of paper if you desire. If previously employed under another or maiden name, please indicate so.

Company Name
Address City State Zipcode
Dates of Employment to    Name appearing in former employer's records
Last position held     Wage $ per
Describe job duties
Specific reason for leaving Voluntary
Involuntary
Name of last supervisor
Ph. #
May be contacted for references*:
Yes
No

Company Name
Address City State Zipcode
Dates of Employment to    Name appearing in former employer's records
Last position held     Wage $ per
Describe job duties
Specific reason for leaving Voluntary
Involuntary
Name of last supervisor
Ph. #
May be contacted for references*:
Yes
No

Company Name
Address City State Zipcode
Dates of Employment to    Name appearing in former employer's records
Last position held     Wage $ per
Describe job duties
Specific reason for leaving Voluntary
Involuntary
Name of last supervisor
Ph. #
May be contacted for references*:
Yes
No

Company Name
Address City State Zipcode
Dates of Employment to    Name appearing in former employer's records
Last position held     Wage $ per
Describe job duties
Specific reason for leaving Voluntary
Involuntary
Name of last supervisor
Ph. #
May be contacted for references*:
Yes
No



5) References
(Please exclude former employers and persons related to you)

Name & Occupation Address Email Phone


6) Resume
(PDF Format)




7) Ste Genevieve County Memorial Hospital Behavior Standards

As a Ste. Genevieve County Memorial Hospital employee, I am here to serve our customers (patients, visitors, co-workers). I am committed to providing the highest quality of caring service and to meeting our customers’ needs in a courteous and respectful manner. This commitment is reflected in my behavior.
Attitude: I have a positive attitude and show enthusiasm at work:
  • I greet all customers with a smile. I express a positive attitude and avoid negative comments.
  • I smile and laugh frequently with a sense of humor, when appropriate.
  • I apologize for problems and inconveniences.
  • I provide personable and compassionate care to all I come in contact with.
Appearance: I take pride in my appearance, my workspace, our hospital and our physician clinics:
  • I wear my ID Badge at chest level and I follow the dress code policy.
  • I understand that my appearance communicates to each customer that "I respetct you and myself".
  • I decrease clutter by returning equipment and supplies to their proper place.
  • I pick up trash when I encounter it, inside and outisde the facility.
Communication: I communicate effectively:
  • I use AIDET and TeamSTEPPS tools and standards. I speak in a calm, clear voice; and confirm that others understand my message. I make eye contact; use positive body language; use a pleasant tone of voice; and say please and thank you.
  • I listen carefully and avoid unnecessary interruptions. I address customers by name when possible.
  • I promptly answer and respond to all written, verbal, and electronic requests/concerns. I avoid using all capital letters in my emails.
  • I avoid discussing staffing issues with customers.
  • I answer the phone in a professional manner with a smile on my face. I introduce myself and my department using the hospital name when necessary. I ask callers for permission to hold; then wait for their response before placing them on hold. I give a handoff to the next department when transferring calls.
Privacy: I respect privacy and confidentiality:
  • I discuss private matters in a private place. I do not access employee or patient records, unless necessary for my job.
  • I knock before entering and close doors for privacy. I explain what I’m doing to protect privacy.
  • I confidentially maintain electronic and written information by turning over papers on my desk and protecting my computer screen when others are around. I also avoid reading other’s computer screens and information while in their work space.
  • I treat all co-worker’s personal information as confidential.
Accountability: I am Ste. Genevieve County Memorial Hospital. I take pride in what I do:
  • I recognize my work is a reflection of who I am as a person and as a health care professional.
  • I accept responsibility for my job and for the outcomes of my efforts.
  • I am a team player. I am flexible with my schedule and workload as needed.
  • I use resources (ie: time, supplies, equipment) wisely to keep costs down.
  • I am accountable for meeting our standards of behaviors. I am encouraged to “politely and respectfully” hold others accountable for meeting our standards of behavior.
  • I support a culture that makes people feel appreciated, included and valued.
  • I stay informed by reading hospital and departmental communications (ie: Grapevine, Memos, etc) each shift.
  • I follow appropriate reporting and chain of command policies when addressing concerns or comments.
  • I arrive to meetings on time, come prepared (if applicable), and avoid distractions.
Excellence: I pursue excellent performance:
  • I keep my customers safe and comfortable by being patient and creating a healing environment.
  • I provide a productive work environment. I limit personal business (ie: cell phone calls, text messages, internet use, etc) to breaks and lunch, unless it is an emergency.
  • I seek out learning opportunities to enhance my skills and ability to serve. I share my knowledge with others.
  • I follow all policies and procedures.
  • I recognize that change is necessary and I comply with new processes.
  • I ask for help if something is beyond my knowledge, ability, or scope of authority.
  • I prioritize my work to exceed customer’s needs.
If employed, will you uphold the Behavior Standards?    Yes  No


8) Miscellaneous

Please list any friends or relatives working for Ste. Genevieve County Memorial Hospital.
Have you ever been convicted or plead guilty to a misdemeanor or felony charge (other than minor traffic offenses) including any suspended imposition of sentence, any suspended execution of sentence or any period of probation or parole? Yes No  
If yes, please explain
I understand that a prior conviction may not necessarily disqualify me for employment but will be a factor which may be considered in the hiring process. Yes No  
The hospital conducts criminal background checks on all new employees in accordance with Missouri and Federal law.
Occasionally the form of an application blank makes it difficult for an individual to adequately summarize their complete background. To assist us in finding the proper position for you in our hospital, use the space below to summarize any additional information necessary to describe your full qualifications.
What prompted your application? Own Accord Employee Internet
Newspaper Employment Service
Other


APPLICANT AUTHORIZATION AND CONSENT 
FOR RELEASE AND DISCLOSURE OF INFORMATION

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements, misleading statements, or omissions on this application shall be considered sufficient cause for dismissal. You are hereby authorized to conduct an investigation of any information provided on this application.

I understand that Ste. Genevieve County Memorial Hospital (SGCMH) participates in E-Verify and will provide the Social Security Administration (along with the Department of Homeland Security, if necessary) information from my Form I-9 to confirm my work authorization. All new employees are required to undergo blood and/or urinalysis screening for drug use as part of their pre-employment health screening. If I am accepted for employment, I agree to take a drug and/or alcohol test(s) when requested by SGCMH. I understand that taking such tests is a condition of my employment.

Also, as a requirement of the employment application process, I consent to the release of my criminal records to my employer. My prospective employer will consider material contained in my criminal history records solely for the purposes of determining my suitability for the position(s) for which I applied. I do not authorize release of this information for any purposes beyond this employment decision. I understand this application does not create an employment relationship or a contract of employment with Ste. Genevieve County Memorial Hospital.

Should I become employed as a result of my application inquiry, my employment will be “at will” and SGCMH will have the right to terminate my employment without notice or cause. This application is active for only 90 days. At the conclusion of this time, if I have not heard from SGCMH and still wish to be considered for employment, it will be necessary to fill out a new application.

I agree to these terms:    Yes  No
Digital Signature


 
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