New Application Form - Nia Association| Clarksville Disability Services

Online Application

Step 1 of 12

Nia Association

Applicant Name:

Date

Employment Application

Nia Association is a non-proﬁt organization that offers 24 hours day, 7 days a week support to persons with intellectual and developmental disabilities in a residential setting. In order to properly provide the required care required by Nia Association's Persons Supported, it is important that employees be ﬂexible in the hours they can work in the homes, as well as be able to meet minimum state guidelines.

PRE - EMPLOYMENT SURVEY

Please indicate your availability:

Full Time

Part Time

PRN (as needed)

Times Available:

Any

Weekdays

PRN (as needed)

Weekends

Evenings

Nights

Available to work overtime

Other

Are you able to provide copies of the following?

Valid Tennessee or Kentucky driver's license or valid photo ID

Yes

If no, list state

Social Security Card

Yes

Proof of high school education, GED or college education?

Yes

Do you meet these guidelines?

Are you at least 18 (eighteen) years of age?

Yes

Are you able to effectively read, write, and communicate verbally in English.

Yes

Are you legally eligible to work in the United States?

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Veriﬁcation "Form l-9" be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

Yes

If hired, can you produce documentation to verify this eligibility?

Yes

Are you willing to submit to pre-employment drug screening?

Yes

Will you consent to a pre-employment background check?

Yes

Have you ever been convicted of any felony?

Yes

Have you ever been convicted of a misdemeanor involving physical harm to a person including but not limited to neglect or abuse or a misdemeanor involving ﬁnancial harm/exploitation to a person including but not limited to theft, misappropriation of funds, fraud, or breach of ﬁduciary duty?

Yes

Have you ever been convicted of a misdemeanor involving illicit drugs, drug/alcohol misuse or sexual misbehavior (e.g. indecent exposure, voyeurism) within the last ten (10) years?

Yes

Have you ever been listed on any of the following: Sexual Offenders, Tennessee Felony Offender, Tennessee Department Health Elderly or Vulnerable Abuse Registry, or the Ofﬁce of Inspector General's List of Excluded Entities / Individuals?

Yes

To be eligible to drive any company vehicle, an employee must be at least 21 years of age and not have more than two moving violations within the last three years. Are you eligible?

Yes

If no, please explain

General Questions

Do you have any family members currently employed by Nia Association?

Yes

If yes, please provide the name and nature of your relationship.

Do you have experience assisting individuals with intellectual and developmental disabilities?

Yes

If yes, please explain

As an employee, you will be required to attend approximately 36 hours of training between 8am - 4pm Monday through Friday. Will you be able to attend all required training?

Yes

I certify that all my statements are true, correct and made in good faith.

Signature

Date

Applicant Name:

Date

APPLICANT INFORMATION

Last Name

First

M. I.

Section Break

Street Address:

Apartment/Unit #

City

State

Zip

Phone

E-mail Address

How long at current address :

Date Available

How did you hear about Nia Association ?

Position(s) Applied for:

Availability

Full time

Part time

When will you be available to begin work?

Have you ever worked for this company?

Yes

If YES, reason for leaving:

If YES, please provide dates of employment:

From

EDUCATION

High School

Address

Did you graduate?

Yes

Diploma or GED

College

Address

Did you graduate?

Yes

Degree

Other

Address

Did you graduate?

Yes

Degree

PROFESSIONAL LICENSES AND CERTIFICATIONS

Credential/License Type:

Credential/License Number:

Expiration Date:

Issuing Agency

Do you have valid/current certiﬁcation for any of the following:

Basic First Aid

CPR/Adult

Crisis Prevention Institute (CPI)

State of TN — DIDD Medication and Administration

RESIDENCE HISTORY

If Tennessee residence is one (1) year or less, provide residence history for the past seven (7) years or since the age of 18, whichever is fewer.

Street Address

From

City

State

Zip

Street Address

From

City

State

Zip

Street Address

From

City

State

Zip

Applicant Name :

Date

PREVIOUS EMPLOYMENT (Please begin with your most recent employment.) List Five years of Employment History to include periods of unemployment.

Box #1

Employer or School Attended

Check Appropriate Box

Employed

Unemployed

School

Phone

Supervisor

Address

City

State

Zip

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous employer for a reference ?

Yes

FOR OFFICE USE ONLY

Date Veriﬁcation Initiated:

Phone Veriﬁcation

Fax Veriﬁcation

Unable to Contact

Date Veriﬁcation Completed:

Dates of Employment:

Beginning:

Ending:

Position

Eligible for Rehire:

Yes

Unknown

Duties

Verified By:

Box #2

Employer or School Attended

Check Appropriate Box

Employed

Unemployed

School

Phone

Supervisor

Address

City

State

Zip

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous employer for a reference ?

Yes

FOR OFFICE USE ONLY

Date Veriﬁcation Initiated:

Phone Veriﬁcation

Fax Veriﬁcation

Unable to Contact

Date Veriﬁcation Completed:

Dates of Employment:

Beginning:

Ending:

Position

Eligible for Rehire:

Yes

Unknown

Duties

Verified By:

Box #3

Employer or School Attended

Check Appropriate Box

Employed

Unemployed

School

Phone

Supervisor

Address

City

State

Zip

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous employer for a reference?

Yes

FOR OFFICE USE ONLY

Date Veriﬁcation Initiated:

Phone Veriﬁcation

Fax Veriﬁcation

Unable to Contact

Date Veriﬁcation Completed:

Dates of Employment:

Beginning:

Ending:

Position

Eligible for Rehire:

Yes

Unknown

Duties

Verified By:

Box #4

Employer or School Attended

Check Appropriate Box

Employed

Unemployed

School

Phone

Supervisor

Address

City

State

ZIP

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for Leaving

May we contact your previous employer for a reference?

Yes

FOR OFFICE USE ONLY

Date Veriﬁcation Initiated:

Phone Veriﬁcation

Fax Veriﬁcation

Unable to Contact

Date Veriﬁcation Completed:

Dates of Employment:

Beginning:

Ending:

Position

Eligible for Rehire:

Yes

Unknown

Duties

Verified By:

LIST ADDITIONAL EMPLOYMENT HISTORY ON SEPARATE SHEET

Applicant Name :

Date:

REFERENCES: PLEASE LIST 3 REFERENCES - TWO PROFESSIONAL & ONE PERSONAL; ONE HAVING KNOWN YOU FOR AT LEAST 5 YEARS. PLEASE DO NOT INCLUDE FAMILY MEMBERS.

REFERENCES # 1

Full Name

Relationship

Month(s) / Year(s) Known:

Address:

Phone

Alternate Phone :

Best Time to Contact:

Morning (after 8am)

Afternoon (after 12pm)

FOR OFFICE USE ONLY

Call Status:

Date Initiated:

Msg (1) Time:

Msg (2) Time:

Date Contacted:

Unable to Contact

Relationship

Known For:

Recommended for Position:

Yes

Character Words :

Verified By:

REFERENCES # 2

Full Name

Relationship

Month(s) / Year(s) Known:

Address:

Phone

Alternate Phone :

Best Time to Contact:

Morning (after 8am)

Afternoon (after 12pm)

FOR OFFICE USE ONLY

Call Status:

Date Initiated:

Msg (1) Time:

Msg (2) Time:

Date Contacted:

Unable to Contact

Relationship

Known For:

Recommended for Position:

Yes

Character Words :

Verified By:

REFERENCES # 3

Full Name

Relationship

Month(s) / Year(s) Known:

Address:

Phone:

Alternate Phone :

Best Time to Contact:

Morning (after 8am)

Afternoon (after 12pm)

FOR OFFICE USE ONLY

Call Status:

Date Initiated:

Msg (1) Time:

Msg (2) Time:

Date Contacted:

Unable to Contact

Relationship

Known For:

Recommended for Position:

Yes

Character Words :

Verified By:

Applicant Name :

Date

Nia Association, Inc.

Affirmative Action: Voluntary Self Identification Form

Nia Association is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as disabled, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please complete the information requested below. if you do not wish to Self-Identify, simply check the appropriate box and sign. Thank you for your cooperation.

Section 1: General Applicant Information

Name:

Date

Position applied for:

Section 2: Please check all that apply (See reverse for definitions)

Race or Ethnic Identity

Hispanic or Latino

White (not Hispanic or Latino)

Black or African American (not Hispanic or Latino)

Native Hawaiian or Pacific Islander (not Hispanic or Latino)

Asian (not Hispanic or Latino)

American Indian or Alaskan Native (not Hispanic or Latino)

Two or more Races (not Hispanic or Latino)

Gender

Male

Female

Veteran Status

Vietnam Era Veteran

Special Disable Veteran

Other Protected Veteran

Recently Separated Veteran

Armed Forces Service Medal Veterans

Other (Individual With Disabilities)

Untitled

I do not wish to Self - Identify

Signature

How did you hear of our opening(s)?

Current Employee

Newspaper Ad

Recruiter

Other - Explain Below :

Applicant Name :

Date

[** Editor's note: According to 41 CFR 60-741.42, there are only two circumstances when an employer may ask a disabled applicant to self-identify on a pre-offer basis:

(1) The invitation is made when the contractor actually is undertaking affirmative action for individuals with disabilities at the pre-offer stage: or (2) The invitation is made pursuant to a Federal, State, or local law requiring affirmative action for individuals with disabilities.

According to 41 CFR 60-250.42, there are only two circumstances under which an employer may ask applicants who are Special Disabled Veterans to self-identify on a pre-offer basis:

1) The invitation is made when the contractor actually is undertaking affirmative action for special disabled veterans at the pre - offer stage: or (2) The invitation is made pursuant to a Federal, State or local law requiring affirmative action for special disabled veterans.

EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (Not Hispanic or Latino)

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (Not Hispanic or Latino)

A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)

A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino)

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino)

A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino)

All persons who identify with more than one of the above five races.

Individual with Disabilities

Defined as a person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as having such impairment(s). For purposes of this definition, an individual with disability(s) is substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).

Veteran of the Vietnam - Era

Means a person who: (i) served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such active duty was performed: (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in all other cases; or (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service for a service connected disability if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in any other location.

Special Disabled Veteran

Means (i) a veteran of the U. S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans' Affairs for a disability (A) rated at 30 percent or more, or (B) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 38 U. S. C. 3106 to have a serious employment handicap or (ii) a person who was discharged or released from active duty because of a service connected disability.

Other Protected Veteran

Includes any veteran who served on active duty in the U. S. military, ground, naval or air service in a war, campaign or expedition in which a campaign badge has been authorized under laws administered by the Department of Defense.

Recently Separated Veteran

Any veteran who served on active duty in U. S. military, ground, naval or air service during the one year period beginning on the date of such veteran's discharge or release from active duty.

Armed Forces Service Medal Veteran

Includes any veteran who, while serving on active duty in the Armed Forces, participated in a United States military operation for which a service medal was awarded pursuant to Executive Order 12985.

NIA Association

375 Dover Road

Clarksvilie, TN 37042.

Phone : 931-906-3993

www.niaassociation.org

Fax : 931-503-0472

Availability Form

Today's date:

Name (please print clearly):

Please indicate below the shifts, hours, and days of the week that you will be available to work, each week.

Nia Association's policy regarding the following status/ position states:

Full Time status states the employee is placed on a 3-2-2-3 rotation (3 days on, 2 days off, 2 days on, 3 days off), with 36 hours worked one (1) week, 48 hours worked the other week. Part Time status states the employee must work a minimum of 24 hours per week. PRN (as needed) states that employees must work a minimum of 24 hours per pay period, every two (2) weeks. Failure to work the minimum number of hours, or to respond to work offers in any of the above status, violates this policy and may result in disciplinary action, up to and including termination.

If you indicate a time and day you are available, you will be expected to work, if you are contacted to come in. If you are contacted to work during a time that you have submitted as being available and you do not report to the shift, or refuse to come in, it will be documented. Continuing to refuse a shift or failure to report to a shift during times you have indicated you are available could result in disciplinary action, to include suspension and/ or dismissal. If you have any changes to your availability, after the date on this form, you are responsible to notify the Human Resources Department, in writing, of the changes. A new availability form will also need to be filled out.

Morning

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Evening

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Night

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Employee Signature :

Date

FOR SUPERVISOR USE ONLY

Record of Refusal to Work

Date

Time

Hours

Minutes

AM/PM

Reason

Supervisor's Initials

NIA Association

375 Dover Road

Clarksvilie, TN 37042.

Driver Information & Questionnaire

Please answer all questions as they pertain to both on & off the job !

Driver's Name as it appears on your Driver's License/State ID:

Driver's License/State ID No:

State of Issue:

Expiration Date:

Date of Birth:

Driver's License Restrictions:

Please note: An incorrect answer, intentional or not, to any questions below may jeopardize continuing coverage. If the answers to any of the following are "YES", give requested details (attach additional sheet if necessary).

Has the Driver:

A. Had any auto insurance refused, cancelled or expired in the past 5 years or been excluded or restricted on a policy in the past 5 years?

Yes

Give company name and reason:

B. Been required to file an evidence of financial responsibility in the past 5 years?

Yes

Give date and reason:

C. Had their driver's license or driving privileges revoked or suspended in the past 5 years?

Yes

Give date and reason:

D. Received a ticket for any vehicle code violation within the past 5 years?

Yes

Give date and reason and speed if speeding violation:

E. Ever been arrested for any reason?

Yes

Give date, place and reason for arrest. If convicted, give penalty:

F. Had a physical or mental impairment or disability or other medical infirmity?

Yes

Give details of condition and treatment:

G. Had any comprehensive losses (deer, fire, glass breakage, theft, etc.) in the past 5 years?

Yes

Give company name and reason:

H. Been involved in an accident - regardless of fault - during the past 5 years?

Yes

Give description and include date, location, and dollar amount of damages:

I certify I have given true and correct answers to the above questions. You have my permission to obtain a copy of my motor vehicle driving record for purpose of determining my eligibility for coverage under this policy. You also have my permission to release detailed information - including a copy of my motor vehicle driving record - to my employer/potential employer if it is requested.

Signature

Nia's Tennessee Bureau of Investigations Background Check Process for all Applicants

Non-Criminal Justice Applicant's Privacy Rights

Welcome to Nia Association! Nia Association makes it a priority to provide each applicant with the full disclosure on the processing or your personal information. TBI, Tennessee Bureau of Investigations, is used to conduct all background checks for Employees, Contractors, and Family Model Residential Provider Providers. If you are reading this, you have been interviewed or screened to become a part of Nia Association. As an applicant, Nia Association is mandated to provide you with TBI Non-Criminal Justice Agency Individual Applicant Privacy Act.

As an applicant who is the subject of a national fingerprint-based criminal history record check for a non-criminal justice purpose, you have certain rights, which are discussed below.

1) Applicant's fingerprints will be used to check their criminal history records of the FBI.

2) Applicant's Privacy Act will be given to each applicant to sign after the interview.

3) If an applicant has a criminal history record, The Executive Team will determine their suitability for employment, license, or other benefit. The applicant must be provided the opportunity to complete or challenge the accuracy of the information in the record. The Executive Team must advise you of the procedures for obtaining a change, correction or update of your criminal history record set forth in title 28, Code of Federal Regulations (CFR), Section 16.34. If an applicant has a criminal history record, they will be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the Executive Team denies them the employment, license, or other benefit based on information in the criminal history record.

Nia Association will use personal information given by the TBI Background for authorized purposes and will not retain or disseminate it in violation of Federal Statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and privacy Act.

Nia Association is not obligated to provide any applicant, employee, or contractor with a copy of their TBI Background Check. If any persons listed would want to obtain their TBI Background, they will be provided the background by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbigov/services/cjis/identity-history-summary-checks.

If the applicant decides to challenge the accuracy or completeness of their FBI criminal history record, they should send their challenge to Nia Association. Alternatively, you may send the challenge directly to the FBI. The FBI will then forward the challenge to Nia Association and request to verify or correct the challenged entry. Upon receipt of an official communication from Nia, the FBI will make any necessary changes/ corrections to their record in accordance with the information supplied by Nia Association.

By signing below, you are confirming that you have read and understood the Non-Criminal Justice Applicant's Privacy Rights.

Print First and Last Name

Signature

Date

Nia Association, Inc.

375 Dover Road

Clarksville, TN 37042

Acknowledgement Of Non-Abuse and Statment for Release of Information

Date

Name of Agency and region:

Full Name of Employee:

Previously used name (nicknames, aliases, maiden names, etc.):

Last Four of Social Security Number:

Driver's License Number:

State of Driver's License:

I, certify and affirm that to the best of my knowledge and belief. I have/have not(circle one) had or received a finding or a substantiated case of abuse, neglect, mistreatment or exploitation against me. In order to verify this affirmation, I further release and authorize Nia Association, the Tennessee Division of Intellectual Disabilities Services, and the Bureau of TennCare to have full and complete access to any and all current or prior personnel or investigative records as pertains to any substantiated allegations against me of abuse, neglect, mistreatment or exploitation.

Signature of employee:

Date

HR Manager:

Date

Please provide all requested information completely, as it is necessary to schedule your required finger print appointment.

Date of Birth:

SSN:

Full Address:

Phone Number:

Email Address:

Height

Weight

Race:

Hair Color:

Eye Color:

Place of Birth

City:

State:

County:

You will be called with the date and time of your appointment. It is very important that you do not miss your scheduled appointment. If you need to reschedule your appointment, you will need to contact the Indentogo location to set up a new date and time, as well as notify HR of your new appointment date and time. HR is unable to make any changes to your appointment once it has been scheduled. If you miss your scheduled appointment, it is your responsibility to set up a new appointment as well as make any payments necessary for your missed appointment.

Signature of employee:

Date

Nia Association

375 Dover Road

Name

This field is for validation purposes and should be left unchanged.

LET'S CHAT

Online Application

PRE - EMPLOYMENT SURVEY

Are you able to provide copies of the following?

Do you meet these guidelines?

General Questions

APPLICANT INFORMATION

Section Break

EDUCATION

PROFESSIONAL LICENSES AND CERTIFICATIONS

RESIDENCE HISTORY

Box #1

FOR OFFICE USE ONLY

Box #2

FOR OFFICE USE ONLY

Box #3

FOR OFFICE USE ONLY

Box #4

FOR OFFICE USE ONLY

LIST ADDITIONAL EMPLOYMENT HISTORY ON SEPARATE SHEET

REFERENCES: PLEASE LIST 3 REFERENCES - TWO PROFESSIONAL & ONE PERSONAL; ONE HAVING KNOWN YOU FOR AT LEAST 5 YEARS. PLEASE DO NOT INCLUDE FAMILY MEMBERS.

REFERENCES # 1

FOR OFFICE USE ONLY

REFERENCES # 2

FOR OFFICE USE ONLY

REFERENCES # 3

FOR OFFICE USE ONLY

Section 1: General Applicant Information

Section 2: Please check all that apply (See reverse for definitions)

Has the Driver:

Contact Details

375 Dover Road Clarksville, Tennessee 37042

Phone: +1 (931) 906-3993

Mon - Fri: ( 8am - 4pm ) Sat & Sun: CLOSED

Core Services

Book Appointment

LET'S CHAT

Email US