Lane Regional Medical Center is an Equal Opportunity Employer. All applications for employment are considered without regard to an individual's race, religion, national origin, sex, age, or physical or mental disability.
Employment applications are kept active on file for sixty (60) days and then destroyed. After 60 days, it will be necessary for an applicant to reapply in order to be considered for a position of employment.
Employment at Lane Regional Medical Center is at will. Successful completion of this application or hiring does not imply or mean that employment is anything other than at will.
When filling out this form, there are restricted words that our web server will not allow in the form for security reasons. The following list represents words to avoid
Select
Script
Insert
Union
Update
Delete
Drop
In addition please do not use the following symbols
> <
Current Address:
Street Address
City
State
Zip
E-Mail:
Phone:
Are you over 18 years of age?
Yes
No
Have you worked for Lane Regional Medical Center before?
Yes
No
If yes, when?
Have you ever been involuntarily discharged from a job?
Yes
No
If yes, explain and give dates:
Have you ever been convicted of a crime other than a minor traffic violation?
Yes
No
If yes, explain:
Have you ever been sanctioned, suspended, or barred from Medicare/Medicaid?
Yes
No
If yes, explain:
Have you ever had a professional license denied,suspended, or revoked?
Yes
No
If yes, explain:
Have you ever been suspended or debarred from doing business with any government or government agency or participating in any government program?
Yes
No
If yes, explain:
List any relatives employed by the hospital:
Name
Relationship
Department
Employment Desired
Date Available For Employment:
Position Applied For:
Salary Requested:
Desired Status:
(Select at least one)
Full Time
Part Time
Temporary
PRN (as needed basis)
Pool
Summer
Available to Work:
(Select at least one)
Days
Evenings
Nights
Rotation
Weekends
Referred By
Referral Name
Education
School
Name & Location of School
Start Year
End Year
Diploma/Degree
High School
College
Major:
Technical
School
Major:
Graduate
School
Major:
Other
School
Major:
Professional Registration / Certification / License
Type
Number
State
Military Experience
Were you in the U.S. Armed Forces?
Yes
No
Dates Of Duty: From
Through
Rank At Separation:
Briefly describe your duties:
Skills/Experience
Experience In:
Emergency Room
Home Health
Intensive Care Unit
Nursing Home
Skilled Nursing Unit
Office Skills:
Typing 35+ WPM
Medical Transcription
Windows
Word Processing
Spreadsheet
Presentations
Languages:
Sign Language
French
Spanish
German
Italian
Vietnamese
List any computer software or office equipment you can use beyond those indicated above:
Please identify skills you believe you have that are relative to the job which you are applying:
Indicate any honors, professional societies, and related professional activities that you feel might be helpful in considering your application:
Employment History
List all places of employment that you have held since graduating or otherwise leaving high school. Start with your present or most recent employer, and work back to high school. You should include any applicable volunteer work. You must include all places of employment or volunteer work. Any omissions will be cause to void your application or terminate your employment when discovered.
Current / Most Recent Employer
Employer
Address:
Street Address
City
State
Zip
Phone Number
Supervisor
Phone
Pay Rate
Full Time
Part Time
Principal Job Duties
Employed
From
(MM/DD/YYYY)
To
(MM/DD/YYYY)
Reason For Leaving
May this employer be contacted at this time for a reference?
Yes
No
If no, please explain why not:
Previous Employer
Employer
Address:
Street Address
City
State
Zip
Phone Number
Supervisor
Phone
Pay Rate
Full Time
Part Time
Principal Job Duties
Employed
From
(MM/DD/YYYY)
To
(MM/DD/YYYY)
Reason For Leaving
May this employer be contacted at this time for a reference?
Yes
No If no, please explain why not:
Previous Employer
Employer
Address:
Street Address
City
State
Zip
Phone Number
Supervisor
Phone
Pay Rate
Full Time
Part Time
Principal Job Duties
Employed
From
(MM/DD/YYYY)
To
(MM/DD/YYYY)
Reason For Leaving
May this employer be contacted at this time for a reference?
Yes
No If no, please explain why not:
Previous Employer May this employer be contacted at this time for a reference?
Yes
No If no, please explain why not:
Additional Previous Employers If you have additional previous employment that has not been listed, please enter all relevant information into the space below for any remaining employers:
References
Give name(s) of persons we may contact to verify your qualifications for the position. (Other than relatives)
Name:
Occupation:
Phone:
Organization:
Address:
Name:
Occupation:
Phone:
Organization:
Address:
Name:
Occupation:
Phone:
Organization:
Address:
Applicant Agreement Please Read Carefully
Selected applicants will be required to undergo a medical examination as a means of determining ability to perform job duties. This examination may include, but is not limited to, a physical examination, screening for infectious diseases and alcohol and drug abuse. Failure to undergo such examinations or screenings at the time specified by Lane Regional Medical Center may result in disqualification from employment. Also, selected applicants will be subject to a criminal background and Medicare exclusion check.
The employment relationship between you and Lane Regional Medical Center is completely at will and may be terminated by either party at any time.
AFFIDAVIT
I certify that the answers given by me to the foregoing statements are true and correct without omissions of any kind whatsoever. I understand and agree that Lane Regional Medical Center reserves the right to terminate my employment, or retract an offer of employment at any time with or without reason, but including if it determines that I have falsified, omitted any information from, or included any extraneous information in this application.
I am aware that Lane Regional Medical Center requires pre-employment drug screens and that in order to become employed and remain employed, my pre-employment drug screen must be negative. I am not an illegal drug user and at this time I can pass a drug screen. I understand that if I am put to work prior to receipt of the results of a drug test showing the presence of illegal drugs in my body, I will be immediately discharged for deliberately falsifying employment information. The above action will be based on the statement signed by me certifying to my drug free condition.
I also understand that a discharge from employment for filing a fraudulent employment application will jeopardize my right to receive unemployment insurance benefits which are based on my previous employment.
The giving of false information on the application or in any part of the employment process may result in forfeiture of workers' compensation rights.
I agree that the schools, employers, police, and/or persons named above are free from all liability as a result of information released by them in verifying the accuracy of the information I have provided.
I certify also that within the past two years I have not been employed in a managerial, accounting, auditing, or similar capacity by an agency or organization which currently serves or has served as a Medicare fiscal intermediary for Lane Regional Medical Center.
I understand that employment offers are conditional on the results of a medical examination and criminal background and Medicare exclusion check. In addition, if accepted for employment, I hereby agree to abide by the rules, procedures, and policies of Lane Regional Medical Center.
Items in RED are required.
