Clinical Staff Employment Application

Please check this box to indicate that you agree to the RSBCIHI employment application policies.

I agree.

Email *

Name *

First

Middle

Last

Date of Birth *

Social Security Number

Drivers License Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Are you Native American / Alaskan Native? *

YES
NO

Are you fully vaccinated with booster? *

YES
NO

Are you authorized to work in the USA? (copy)

YES
NO

If employed and under 18, can you furnish a work permit?

YES
NO

Have you filed an application here before?

YES
NO

Have you ever been employed here before?

YES
NO

Can you travel if the job requires it?

YES
NO

Are you available to work nights and weekends if required?

YES
NO

Are you employed now?

YES
NO

Are you on a lay-off and subject to recall?

YES
NO

May we contact your previous/present employer(s)?

YES
NO

Are you a member of the Reserves, and subject to recall?

YES
NO

To your knowledge, are you an immediate relative of any member of the Board of Directors of Riverside-San Bernardino County Indian Health, Inc.?

YES
NO

Have you been convicted of or plead guilty to or no contest (no lo contendre) to an offense involving crimes of violence?

YES
NO

If YES, please explain.

Date you can start:

List professional, trade, business or civic activities and offices held. (Exclude those which indicate race, color, religion, sex or national origin):

Can you perform the essential functions of this job with or without accommodations?

YES
NO

1. Education Record

High School

Graduation Date

Degree

Address

Address Line 1

Address Line 2

City

State

Zip Code

_______________________________________________

Business or Technical School

Date Attended

Degree / Major

Address

Address Line 1

Address Line 2

City

State

Zip Code

_______________________________________________

Undergraduate College

Date Attended

Degree / Major

Address

Address Line 1

Address Line 2

City

State

Zip Code

_______________________________________________

Graduate School

Dates Attended

Degree / Major

Address

Address Line 1

Address Line 2

City

State

Zip Code

2. Premedical Education

College or University Name

Degree / Major

Address

Address Line 1

Address Line 2

City

State

Zip Code

3. Professional Education

College or University Name

Graduation Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Practice Name

Graduation Date

Degree, Subject

Address

Address Line 1

Address Line 2

City

State

Zip Code

4. Post Graduate Training

(specify internships, residencies, fellowships)

Internship Institution / Hospital Name

Dates of Service

Address

Address Line 1

Address Line 2

City

State

Zip Code

_______________________________________________

Residency Institution / Hospital Name

Dates of Service

Address

Address Line 1

Address Line 2

City

State

Zip Code

_______________________________________________

Additional Residency Institution / Hospital Name

Dates of Service

Address

Address Line 1

Address Line 2

City

State

Zip Code

Board

Expires

Address

Address Line 1

Address Line 2

City

State

Zip Code

_______________________________________________

Boards Taken Results Pending

Date Taken

If not boarded, state current status.

9. Licensing

California Board License Number

Expiration Date

Name

Relationship

_______________________________________________

Name

Relationship

14. Employment Experience

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, sex, or national origin.

Employer Name

Supervisor

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates Employed

Hourly Rate / Salary

Work Performed

Reason for Leaving

_______________________________________________

Employer Name

Supervisor

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates Employed

Hourly Rate / Salary

Work Performed

Reason for Leaving

_______________________________________________

Employer Name

Supervisor

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates Employed

Hourly Rate / Salary

Work Performed

Reason for Leaving

Special Skills and Qualifications

Summarize any special skills and qualifications that you have aquired from employment or other experience.

Paragraph Text

_____________________________________________________

Has your clinical license to practice ever been limited, suspended, or revoked in any jurisdiction, or is any such action pending?

Yes
No

Have your privileges at any health care organization ever been suspended, diminished, revoked, or not reviewed, or is any such action pending?

Yes
No

Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any medical organization, or is any such action pending?

Yes
No

Have any judgments or settlements been made against you in professional liability cases, or are such cases pending?

Yes
No

If your answer to any of the above four questions is "YES", please provide full details in the space below.

I understand that the Program is responsible for the evaluation of my professional competence and qualifications, and has the obligation to inquire into my professional training, experience, professional conduct and judgment, and to make appropriate recommendations to the governing body of this Program.

By filing an application for employment and privileges, and in connection with this application, I agree to be bound by the policies of the Program, and the bylaws, rules and regulations of the professional staff, as adopted by the board and the applicable laws of the State of California.

I agree that it is my duty and ethical responsibility as an individual and as an employee of this Program to cooperate with and assist the Program in evaluating not only my professional qualifications but also those of my colleagues. I agree to appear before the Executive Director, Clinical Services Director and Committees for interview or inquiry at reasonable times and places. I consent to the communication of information and documents between this professional staff and other professional staffs, schools, training programs, societies, professional associations, professional liability insurance companies, national practitioner data bank, and licensing authorities in the jurisdiction in which I have trained, resided, or practiced, for the evaluation of my professional training, experience, character, conduct and judgment.

I release from any liability all individuals and organizations who provide information in good faith and without malice concerning my competence, ethical conduct, character and other qualifications for staff appointment and clinical privileges, including otherwise privileged information.

Evaluation and inquires into my professional competence and qualifications shall be accomplished in a professional manner. I hereby affirm that the information furnished by me is true to the best of my knowledge and is furnished in good faith. I understand that willful and substantial omissions or misrepresentations may result in denial, modification, or revocation of my privileges or termination of employment.

Signature