95 Old Short Hills Road, West Orange, New Jersey 07052, PHONE: 1-888-724-7123

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Employment Status
* In order to process your application properly, please tell us your employment status.
Facility:
Employment includes full-time, part-time, per diem, any other status or employment as agency staff, independent contractor, or subcontractor working at one of our facilities.
 
General Information:
* First Name M.I. * Last Name
(NAME MUST MATCH SOCIAL SECURITY RECORDS)
* Home Phone: Work Phone:
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Cell Phone:
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* Email:
* Address:
* City: * State/Province: * Zip/Postal Code:
* Country:
* Where did you see this opportunity?:
 
Questionnaire:
 
Resume or Profile:
* Please paste a copy of your resume or profile below. Pasting a resume will allow us to consider you for future opportunities.
I do not have a resume.
 
Voluntary Affirmative Action Information
In compliance with federal regulations, Barnabas Health is required to gather and maintain statistics for use in completing our annual Affirmative Action Plans. To ensure that our statistics are accurate, we would like you to complete the information below.

This information will not be considered in evaluating your qualifications for employment. This information is immediately segregated from your application. Please also be assured that this information is voluntary and confidential.

We appreciate your assistance in providing us with this information. Thank you.
 
Gender
Female
Male
 
Ethnic Background
Hispanic or Latino
American Indian or Alaskan Native (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
White (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)
 
Protected Veterans - One or more of the four veteran categories click here

This employer is a Government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Right Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Veteran
Vietnam Veteran
Not a Veteran
 
Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 01/31/2017
Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.


How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:
  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy

  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy

  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs

  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below:
Yes, I Have a Disability (Or previously had a disability)
No, I Don't Have a Disability
I Don't Wish To Answer
 
 

 
Your Name   Date

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
 

I do not wish to provide the above EEO information.
 
 
Identification
Dates Applied/Edit Application:
 
* indicates required field
* Are you 18 years of age or older? Yes No
* Are you legally eligible to work in the United States? Yes No
* Do you understand that due to the nature of the services we provide, an exceptional work record of attendance, courtesy, promptness, and dependability is required for all Barnabas Health employees? Yes No
* What is your expected salary? $    Annual   Hourly
* Are you related to anyone currently working in the department to which you are applying? Yes No
Outline your career goals and objectives:
Do you have a relative currently employed within the Barnabas Health? Yes No
If yes:
Name:
Relationship:
Facility:
 
Employment History (Please list ALL previous employment)
No employment history at all.

1. Current or most recent employer
If so, may we contact them? Yes No
* Employer:
If different name used while employed:
Telephone:
 -   - 
* City:
State: (* if in US)
Country:
* Job Title:
* Supervisor:
Department:
* Final Salary:
* Dates Employed (mm/yyyy):
 to 
* Duties/Responsibilities:
If less than full-time, please explain:
Reason for leaving:

2. Current or most recent employer
If so, may we contact them? Yes No
* Employer:
If different name used while employed:
Telephone:
 -   - 
* City:
State: (* if in US)
Country:
* Job Title:
* Supervisor:
Department:
* Final Salary:
* Dates Employed (mm/yyyy):
 to 
* Duties/Responsibilities:
If less than full-time, please explain:
Reason for leaving:

3. Current or most recent employer
If so, may we contact them? Yes No
* Employer:
If different name used while employed:
Telephone:
 -   - 
* City:
State: (* if in US)
Country:
* Job Title:
* Supervisor:
Department:
* Final Salary:
* Dates Employed (mm/yyyy):
 to 
* Duties/Responsibilities:
If less than full-time, please explain:
Reason for leaving:

 
Education Information
No formal education.

High School
* Institution Name:
* City:
State: (* if in US)
Country:
* Did you graduate?
Yes No
* Grade completed:
9 10 11 12

College/University
* Institution Name:
* City:
State: (* if in US)
Country:
* Did you graduate?
Yes No
* Years completed:
1 2 3 4
* Degree, certificate, or diploma:
* Major or field of study:
Major concentration:
Minor:

Graduate/Professional School
* Institution Name:
* City:
State: (* if in US)
Country:
* Did you graduate?
Yes No
* Degree, certificate, or diploma:
* Major or field of study:
Major concentration:
Minor:

Technical/Other
* Institution Name:
* City:
State: (* if in US)
Country:
* Did you graduate?
Yes No
* Degree, certificate, or diploma:
* Major or field of study:
Major concentration:
Minor:

 
Military
Branch:
Rank:
Dates served: (mm/yyyy)
 to 
Specialty, if any, related to medical or nursing services:
 
Licensure and Certification
Are you currently registered, certified, or licensed in your specialty? Yes No

* Type of license:
* Date of issue (mm/yyyy):
New Jersey professional license number:
* Date of expiry (mm/yyyy):
Certification Number:
In what other states are you registered?
(To select mulitple states, hold the "ctrl" key down and select the applicable states.)
Certification:

 
Skills
List all equipment (office, trade laboratory) that you are able to operate:
Additional certifications and/or relevant coursework:
Typing (W.P.M.):
Software:
List all foreign languages in which you are fluent:
 
Personal Information
* Have you ever been disciplined or discharged for theft, unauthorized removal of company property or related offenses?
Yes No
If yes, please explain:
* Have you ever been discharged for fighting, assault or related offenses?
Yes No
If yes, please explain:
* Have you ever been disciplined or discharged for being under the influence of alcohol or drugs or for possession or use of alcohol or drugs on the job?
Yes No
If yes, please explain:
* Have you ever been disciplined or discharged for violating safety rules?
Yes No
If yes, please explain:
* Have you ever been disciplined or discharged for insubordination?
Yes No
If yes, please explain:
* Have you ever been disciplined or discharged for unsatisfactory performance?
Yes No
If yes, please explain:
* Have you ever been disciplined or discharged for incompetent practice or a related offense?
Yes No
If yes, please explain:
If you possess a license or certification, has your license or certification ever been suspended or revoked?
Yes No
If yes, please explain:
If you possess a license or certification, is your license or certification currently under review by the credentialing agency?
Yes No
If yes, please explain:
* Are you currently or have you ever been listed on the Office of Inspector General List of Excluded Individuals/Entities (Cumulative Sanctions List), General Services Administration List of Parties Excluded from Federal Programs?
Yes No
* Have you currently or ever been excluded or debarred or subject to any other action that rendered you ineligible to participate in Federally funded health care programs?
Yes No
* Are you now or have you ever been employed by the Barnabas Health or one of its affiliates?
Yes No
 
Authorization
* I certify that the information contained in this application is correct, and I understand that if an offer of employment is made to me it will be contingent upon the results of a post-offer medical examination which includes a background check, drug and alcohol testing, and receipt of satisfactory references. I realize that misrepresentation of facts called for in this application may result in a revocation of an offer of employment or dismissal after employment. I hereby authorize my present and past employers to furnish Barnabas Health with records of my employment.
I Agree
 
Notice
* I also realize that nothing contained in this application or any handbook, policy manual, policy statement or hospital practice shall constitute a contract of employment or a contract or agreement for a defined or specific term of employment. The employment relation is by mutual assent and may be terminated by Barnabas Health or its employee at any time, with or without cause, except as may be provided to the contrary by a written contract or written agreement governing the terms and conditions of my employment. I understand that no officer or representative of Barnabas Health, other than the top Executive of Barnabas Health, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement to the contrary to the foregoing.
I Agree 

 
Barnabas Health is an equal opportunity/affirmative action employer. It is committed to the recruitment, employment and promotion of all individuals without regard to race, color, religion, creed, ancestry, affectional or sexual orientation, sex, genetic information, a typical hereditary cellular or blood trait, age, national origin, martial status, pregnancy, disability or handicapped status, gender identity or expression or for services in the United States Armed Forces.
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95 Old Short Hills Road, West Orange, New Jersey 07052
PHONE: 1-888-724-7123