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Human Resources Service

Seale, Alabama, 36875, United States
May 20, 2018

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Medical Center

*** ***** **** ******

Rugby, ND *8368-2118


701-***-**** TDD

701-***-**** FAX

701-***-**** Surgical Clinic

Johnson Clinics

Rugby – 701-***-****

Dunseith – 701-***-****

Maddock – 701-***-****

Thank you for your interest in employment opportunities at the Heart of America Medical Center, Heart of America Johnson Clinics and the Haaland Estates


Online listings of employment opportunities are available on our website: and on the North Dakota Job Services website: Onsite listings of employment opportunities are available on our official bulletin boards, near the employee time clocks at both the Heart of America Medical Center and the Haaland Estates and near the Human Resources Department. To apply for any of the positions currently open, please complete the employment packet which contains: Application Form, Standards of Behavior, and Reference Request Form.

Complete the Application Form and specifically fill in the section which reads: This application is for the position of:

Please list any other positions in which you are

interested as well as the department in which the opening exists. Please read the Standards of Behavior: the Good Samaritan Hospital Association’s goal of excellent service to all customers.

On the Reference Request Form, please leave the top portion of the page uncompleted. Just sign and date in the signature spaces provided below the solid black line. To maintain the confidentiality of your paper employment application, please place in an envelope and mail to the Human Resources Department or hand deliver to the Human Resources Offices, located on 1st floor.

Directions to Human Resources: Take elevator #1 (by the Admissions Desk) to the 1st floor; take 2 left turns, 1 right turn and 1 left turn to the 1B corridor. The Human Resources offices are located midway down the corridor. Our office hours are 8:00 a.m. to 4:30 p.m. Monday through Friday. Again, we welcome you to apply for any open positions at the Heart of America Medical

Center, the Heart of America Johnson Clinics and the Haaland Estates. EMPLOYMENT APPLICATION

Good Samaritan Hospital Association

800 South Main Avenue

Rugby, North Dakota 58368-2118

EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER M/F/H/V MISSION: To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service.

VISION: To be the provider of choice for healthcare within our communities. This application is for the position of:

List other positions of interest:

Name Date

(Last) (First) (Middle)

Street Address City State Zip Code Social Security # Telephone # Email address: Other Telephone numbers where you can be reached or message can be left: How did you learn of this opening? (choose one) Newspaper HAMC Website ND Job Service Website Employee Radio Friend Walk-In Other I am applying for: Full time Part time Temporary Summer Shifts for which I am available: Days Evenings Nights Weekends These are the hours/days/shifts I CANNOT work: If hired, date I am available to begin employment: Have you ever filed an application with the GSHA? If so, when? Have you previously been employed by the GSHA? If so, when and department? Do you have relatives working at the GSHA? Have you ever used another name (maiden, previously married)? List all others here: Are you eligible to work in the United States? Yes No If Yes, VISA Type Are you at least 16 years of age? Yes No (If Applicable) Have you ever been convicted of a crime other than a traffic offense: YES NO Indicate dates, location and outcome(s):

Criminal convictions are not an absolute ban to employment but will be considered in relationship to specific job requirements. IF APPLICABLE

North Dakota Registration Number: Original Current Expiration Date

(i.e., RN, LPN, CNA, etc.)

Other states in which you are licensed: State License Number Expiration Date HR USE ONLY: Application Routed to: Dept. & Date Dept. & Date Application Routed to: Dept. & Date Dept. & Date HR RESPONSE: E-Mail Card Date: EDUCATION

Name of School and Location Circle Highest Grade Diploma/Degree Year Completed Completed at Each Level

1 2 3 4

Elementary 5 6 7 8

High School 9 10 11 12

Vocational 1 2

1 2 3

College 4 5 6

Other/Specialized Training


Company Name and Address Phone Position Held From To Salary Time Time Reason for Leaving PERSONAL REFERENCES - NOT RELATIVES

Name Address Phone Occupation

Please read and sign below:

I hereby acknowledge that this application does not constitute an employment contract and that any employment relationship with Good Samaritan Hospital Association (GSHA) is of an "AT WILL" nature. It is further understood that this "AT WILL" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by the Chief Executive Officer of the GSHA. I certify that the statements on this form are true and complete to the best of my knowledge. During my employment I agree to support all policies of GSHA. I authorize investigation of all statements contained in this application, including a legal background check. I agree that all former employers or any other persons may furnish GSHA with all information regarding their record of my service, character and reason for leaving. I hereby release such former employers and persons from all liability on account of providing such information. I understand that misrepresentation or omission of information on my part in connection with my application will be sufficient cause, in and of itself, for denial of employment whenever discovered. I understand that I may be required to successfully complete a medical exam for initial or continued employment to determine if I am physically and mentally capable of performing my job. I also understand that I will be required to submit to a pre-employment drug test. GSHA will provide reasonable accommodations for known qualified individuals with disabilities. Should I accept an offer of employment, I understand that the work schedule, hours, shifts, status and job responsibilities may be subject to change at any time. At no time, as an employee of GSHA will I reveal any information regarding clients, staff, physicians, finances or other information sensitive to the operations of GSHA to anyone unless I have been specifically instructed to do so by GSHA.

By my signature below, either written or electronic, I certify the information I provided on and in connection with this application is true, correct, and complete. I agree that this form in original, faxed, photocopied or electronic will be valid for any background reports that may be required by or on behalf of GSHA. I certify that by signing my name on the line or by inserting my name electronically constitutes my signature.

Date Signature of Applicant

To complete application please read Standards of Behavior. Check box to acknowledge. We believe that a culture of EXCELLENT SERVICE is the foundation of who we are and what we do; thus we incorporate these STANDARDS OF BEHAVIOR into our daily attitudes and actions. 1. Appearance


• I will understand my dress is a direct reflection of my care and service to my patient/resident and reflects my respect for my patient/resident and for me. My dress will always be professional, tasteful, and tidy. Good personal hygiene is expected.

• I will care for my equipment and my environment. I will preserve cleanliness of my immediate work environment and throughout the facility.

• I will understand my patient/resident and my personal safety is my responsibility. If I see a safety hazard, I will correct it immediately (if possible) and report the event completely and promptly.

2. Commitment/Approach


• I will be honest, polite, and respectful in all my interactions and greet my co-workers with a smile and verbal acknowledgement. When dealing with conflict, I will go directly to the person involved to seek a solution.

• I will encourage my co-workers to be accountable for upholding our standards of behavior, policies and procedures.

• I will remember our goal is to provide a warm, caring, supportive, and fun environment in which to work. I will be loyal to my co-workers and never undermine the work or decisions of my co- workers. I will conduct myself in a positive, approachable manner and have an appreciative attitude toward my co-workers.

• I will be patient when interacting with my co-workers and understand that tension may exist in a busy environment. Being busy is a sign of a successful organization, and we intend to stay successful. I will recognize that we each have an area of expertise that has been brought together to serve our patients/residents.

Patient/Resident or Internal Customer as applies to your area

• I will greet all patients/residents with a smile, make eye contact, and introduce myself. I will acknowledge him/her by their name when appropriate.

• I will treat everyone as an important person in our organization. I will listen carefully and compassionately to what the patient/resident has to say and avoid interruptions. Being rude is never acceptable.

• I will seek opportunities to offer encouragement and hope to my patient /resident by showing empathy and understanding. I will not rush or be in a hurry as I deliver my services.

• I will include my patient/resident in decisions regarding their care by providing explanations before beginning procedures and asking if they have questions.

• I will have an attitude of appreciation for my patient/resident and for the opportunity to provide service. I will thank them for choosing our service and trusting us with their care.

• I will recognize that my patient/resident has a sense of urgency, and I will show them that I value their time. My patients/residents are not an interruption of my work; they are the reason I am here. If there is a delay, I will communicate this whenever possible. I will not allow anyone to feel ignored.

Heart of America Medical Center

Heart of America Johnson Clinics

Haaland Estates

• I will meet my patient/resident immediate needs or find someone who can. I will take them where they need to go whenever possible and I am committed to exceeding the expectations of my patient/resident.

3. Phone Etiquette

• I will answer all phone calls in a professional, friendly, clear and concise manner, remembering if I smile when I speak, my voice will reflect a cheerful positive attitude.

• I will attempt to answer all calls within three rings, identifying myself by name and department, followed by, “How may I help you?”

• I will ask permission before placing a caller on hold, and wait for a response, then thank them for holding. When transferring a call, I will give caller the name and extension of the person to whom the caller is being transferred.

4. Privacy


• I will respect the privacy of co-workers and will be honest in all my interactions. I will not criticize or embarrass co-workers in the presence of others.

• I will be sensitive to my conduct and speech while on my breaks, in the hallway, or in an elevator. I realize that family, patients, and residents are ever present, and I will refrain from discussing personal and inappropriate information. Patient/Resident or Internal Customer as applies to your area

• When discussing health or personal information with my patient/resident (whether in person or on the phone) I will assure I have taken all measures to assure privacy, and assure I am not in proximity to others where information will be overheard.

• I will always knock and ask to enter before entering a patient’s/resident’s room. I will not enter until I have received acknowledgement to enter, as appropriate to my patient’s/resident’s abilities to respond.

5. Work Ethic

• I will look for ways I can help beyond my assigned tasks. I understand flexibility is important and usually my responsibility does not end where my co-workers begins. In most situations responsibilities merge and blend for the purpose of “meeting our patients’/residents’ needs.”

• I will complete my duties on time and I understand what I do, or fail to do, often has a direct impact on other staffs’ abilities do their jobs; realizing our patients’/residents’ care is interrelated and requires each of us being accountable to deliver excellent service.

• I will share appropriate information freely to enhance the services provided. I will be prepared and resourceful and respond timely when my input or services have been requested or are needed.

• I will practice self-awareness, and I am productive with usage of company time, remembering our core values include accountability and trustworthiness.

• I will be committed to continual learning to improve and develop my professional and personal skills in order to deliver excellent service and exceed the expectations of my patient/resident. I acknowledge I have received my personal copy of the Service Standards of Behavior. I understand that as a colleague, I am responsible for knowing and adhering to these standards. Signature: Print Name: Date:


Good Samaritan Hospital Association

800 South Main Avenue

Rugby, North Dakota 58368

Phone 701-***-**** Fax 701-***-****

Applicant Name: S.S. #

The above named person has made application with the Heart of America Medical Center for employment and has authorized the release of information regarding his/her education, employment record, and/or character. Personal Reference Notes:

Previous Employment Reference:

Dates of Employment:

Position Held:

Would you Rehire? Yes No If not, why?

Why did the applicant leave your employ?

Please check the appropriate box:

YES NO Excellent Good Fair Poor

Courteous Quality of Work

Cooperative Quantity of Work

Of Good Habits Attendance & Punctuality

Honest General Ability

Ambitious Able to Accept Criticism

Entitled to Full Confidence & Trust,

Able to Preserve Confidentiality

Able to Make Practical


Need for Supervision: Occasionally Frequently Constantly Additional Remarks:

Signature: Date:

Title: Organization:

By my signature below, either written or electronic, I certify the information I provided on and in connection with this application is true, correct, and complete. I agree that this form in original, faxed, photocopied or electronic will be valid for any background reports that may be required by or on behalf of GSHA. I certify that by signing my name on the line or by inserting my name electronically constitutes my signature.

Applicant Signature: Date:

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