Health Information Management Team Onboarding Packet

Final PagePLEASE PRINT. USE BLACK INK ONLY. READ CAREFULLY. COMPLETE ALL SECTIONS.Last Name First Middle Social Security #We are an equal opportunity employer and will not unlawfully discriminate on the basis of race, color, sex, religion, national origin, age, height,weight, marital or veteran status, or the presence of a medical condition or disability.Michigan and Federal law require employers to make accommodations to persons with a disability if the disability can be accommodated withincertain guidelines, and the individual can perform the essential job duties with or without such accommodation.Persons with a disability may request an accommodation of their disability by notifying the organization in writing of the need for anaccommodation. Failure to properly notify the employer in writing of the need for an accommodation within 182 days from the date the personwith a disability knows or should know that an accommodation is needed will preclude any State claim that the employer failed to accommodatethe person with a disability. This 182 day requirement does not apply to a claim filed under the Americans with Disabilities Act.It is a violation of the DMC Nepotism Policy for an employee to work permanently under the supervision(indirect or direct) of a relative. In your new position, will anyone in department supervision/managementto which you were hired be your relative? Yes NoIf yes, Relative Name:Relationship:Person to be notified in case of an accident or emergency:Name:RelationshipAddress: Phone #: ( )Are you in the military reserves? Yes No If yes, date obligation ends:Foreign Language: Read Write Speak SignI certify that all of the information I have given in this document is accurate and complete and is subject to verification by the Detroit MedicalCenter. I hereby authorize investigation of all statements contained in this application, the submitted resume, and full disclosure of my presentand prior work record. I grant permission to the organization to obtain information concerning my general reputation, character, conduct andwork quality. I authorize any person or organization contacted to furnish information and opinions concerning my qualifications for employment,whether same is a matter of record or not, including personal evaluation of my honesty, reliability, carefulness and ability to take orders from mysuperiors. I understand that this may include a record of disciplinary action assessed by previous employers. I hereby release the organizationand any person or other organization from any and all liability which may result from furnishing such information or opinion, exclusive of statutoryclaims, where applicable. I hereby release the organization and any person, organization or prior employer from any obligation to provide mewith written notification of such disclosure.I understand that employment is contingent upon this investigation and, if employed, misrepresentation or falsification of material facts in thisapplication and the submitted resume, or the omission of any information shall be considered sufficient grounds for dismissal. I understand andagree that if, in the opinion of the organization, the results of the investigation are unsatisfactory, that an offer of employment that has beenmade may be withdrawn or my employment with the organization may be terminated. I further understand that this offer is contingent uponsuccessful completion of 1) a pre-placement physical examination, including a drug screen and TB test; 2) reference verification; 3) abackground check; 4) pre-employment eligibility verification. (Completion of the I-9 Form requires that you provide documentation whichsupports your legal right work in the U.S.); and 4) completion of Net Learning Training, all prior to the start date. I further understand that myoffer is also contingent on the DMC having a continuing need for personnel in the position offered as of my start date.I note this application and the submitted resume is not an offer for a contract of employment I understand and agree that if I am employed bythe organization my employment shall be subject to the following conditions: 1) I may be terminated at any time with or without notice and withor without cause, 2) I will receive wages and benefits pursuant to the organization’s rules and regulations and the organization may change suchrules and regulations at any time, without notice to me, 3) My assigned work hours may be modified by the organization, and if requested, I willbe required to work overtime, 4) Upon accepting any offer of employment made by the organization, I will execute an Acknowledgment andAcceptance of Employment as requested by the organization. Further, in cases where job specifications require certain credentials, educationand/or experience, I understand that I must be able to submit documentation to the DMC to support these requirements.I have read, understand and agree to the above statements and conditions of employment.Signature:Date:1/23/12 HR Employment application page 6-Rev 1-12 non-employee.doc13