Revised Sept ****

CANDIDATE BACKGROUND CHECK

FOR EMPLOYMENT

CentraState Healthcare System contracts with TABB, Inc. to conduct a thorough and extensive background investigation (including references from current/former employers, criminal background check, verification of license, certification and education, and an OIG check for employment candidates.

An offer of employment is conditional upon substantiation of information provided on the application and upon medical clearance.

CentraState will investigate all statements made in your application. Any misrepresentation of fact or material commission of fact will be cause for rejection from consideration or, if employed, for immediate termination upon discovery. Candidates with conflicting information between their background checks and employment applications will be notified of such as required under the Fair Credit Reporting Act.

By signing this document, you acknowledge receiving an information sheet summarizing your rights under the Fair Credit Reporting Act.

Print Applicant Name

Applicant Signature

Date

Revised Sept 2021

IMPORTANT INFORMATION YOU MUST KNOW

Thank you for considering CentraState Healthcare System as a possible next step in your career! Before you proceed with the interview process for employment consideration, there are some things we want you to know. CentraState is dedicated to quality and excellence. To that end, we seek employees who not only support our mission, but also actively contribute their talents and abilities while seeking opportunities to excel and make a difference. It is essential that all of our employees possess and demonstrate excellent customer service skills. Due to the nature of the services we provide, CentraState contracts with TABB, Inc. to conduct an extensive background investigation (including references from all current/former employers, criminal background check, verification of license, certification, education and an OIG check) for all candidates. An offer of employment is conditioned upon substantiation of information requested on the application and medical clearance. Candidates are expected to complete a full application, in addition to any resume provided, which will include all prior employment and education. Additionally, CentraState must be able to verify all statements made on the application and obtain good quality references for all prior employment education. A post offer physical/medical exam is required for all candidates who accept a position with us. Our medical assessment includes a drug screening urinalysis. It is the policy of CentraState that all prospective employees be immune to Measles, Mumps, Rubella and Chicken Pox. Those determined to be susceptive by titer will receive the appropriate vaccination prior to employment, unless they provide physician documentation of the necessity for medical exemption. Additionally, all employees must be fully vaccinated for the Covid 19 virus. Immunity to Measles, Rubella and Chicken Pox, as well as full vaccination for Covid 19, are considered conditions of employment. Failure to successfully complete the required medical assessment will result in a withdrawal of an offer. Requests for medical and religious exemptions must go through CentraState’s interactive process and will be considered accordingly. Because you are now interviewing for a position with CentraState, we ask that you answer the two questions below: Have you ever plead guilty or been convicted of a crime or disorderly persons offense which has not been annulled or sealed by a court?

Yes No

This question refers to instances where you have been convicted, plead guilty, plead no contest or “nolo contendere,” paid a fine, or had some negative legal result from the charge. For CentraState’s purposes, the term “crime” is defined as any:

• First, second, third or fourth degree criminal offenses (such as assault and battery),

• Disorderly persons offense or petty disorderly offense (such as shoplifting), or

• Criminal motor vehicle violation (such as drunk driving, assault by auto, death by auto),

• Other than a parking ticket, or

• Violation of a municipal ordinance involving aggressive, violent or assaultive behavior, financial offenses

(such as passing a bad check), theft, or any drug related offenses Whether the charge was handled in Federal, Superior, or Municipal Court. Additionally, Do you have any open, pending or unresolved criminal matter (including, but not limited to, a conditional discharge or diversionary program, such as pre-trial intervention) that has not yet been completed?

Yes No

Revised Sept 2021

It is very important that you understand these questions and answer them truthfully. If you do not understand these questions you must discuss it with a representative from Human Resources. Answering “yes” to either of these questions does not mean that your consideration for employment will automatically be denied. However, failing to disclose information discovered during the background check or falsifying your application is automatic grounds for withdrawing our employment offer or dismissal.

You will be asked to provide additional information if you checked YES to either of the questions above. To avoid potential conflict of interest issues, CentraState representatives may not have any employment, consulting or other business relationship with a competitor, customer, supplier or provider who may influence business transactions with CentraState unless written permission is granted from a Compliance Officer. As such, employees must disclose any outside employment relationships, current or future, while employed by CentraState Healthcare System.

By signing the bottom of this page, you authorize CentraState to investigate all statements made in this application. Any misrepresentation of fact or material omission of fact will be cause for rejection from consideration or, if employed, for immediate termination upon discovery. CentraState is an Equal Opportunity Employer. Employees are selected on the basis of qualifications without regard to race, color, religion, sex, sexual orientation, age, national origin, ancestry, physical or mental disability, marital status or veteran status.

Employees are subject to a six-month introductory period. CentraState can terminate employment at any time. Employees retain that same right. Your application does not constitute a contract of employment. I have read the above information, have had the opportunity to ask questions, and fully understand what I have read.

Print Applicant Name

Applicant Signature

Date

Revised Sept 2021

DATA PRIVACY, CONFIDENTIALITY, AND SECURITY STATEMENT I am aware of the CentraState Healthcare System confidentiality policy and State and Federal laws governing the privacy and confidentiality of information. I understand that it is my responsibility to become familiar with the State, and/or Federal laws regarding confidentiality that is applicable to the scope of my responsibility within the CentraState Healthcare System. http://www.nj.gov/health/njhit/patients/privacy/

http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/ 2. Further, I understand that any violation of my responsibilities by unauthorized disclosure of patient information, electronic protected health information, financial, or business sensitive information will result in termination of my employment/volunteer relationship and may result in charges for Invasion of Privacy. 3. Furthermore, failure to close out patient or resident information screens, log off of the computer system before leaving the workstation and the sharing of individual computer passwords may result in termination of my employment/volunteer relationship.

4. I understand that under the Federal Health Insurance Portability and Accountability Act (HIPAA}, any person who maliciously accesses, alters, deletes, damages or destroys any computer system, network computer program or data shall be guilty of a felony.

5. I understand that my access to computer systems constitutes my "signature" and I will be responsible for all entries made under my access.

6. I understand that all data and information on either electronic communication systems, non-electronic systems, or media is the property of CentraState Healthcare System, and may be reviewed only by me on a "need to know" basis and that it is only that information which is "minimally necessary" for me to serve the patient, the institution, and the community. I will be granted the installation and access to systems upon the approval of my Department Head/Designee. 7. I understand that the electronic systems are solely to be used for job related purposes and not for personal use. I agree to use code, access, file or retrieve any stored communication unless authorized. I may not use these systems in any way that may be seen as insulting, disruptive, or offensive by other persons. 8. I am advised that my failure to comply with these policies and regulations may result in corrective action up to and including termination. Violation of State of New Jersey or Federal Statutes may carry the additional consequence of prosecution under the law, where judicial action may result in specified fines or imprisonment or both; plus the costs of litigation or the payment of damages or both; or all. 9. I understand that I have no expectation of privacy in connection with the use of E-mail, Voice Mail, or Internet and associated equipment or with the transmission, receipt or storage of information in these systems. I acknowledge and consent to System monitoring of my use of these systems and associate equipment at any time. Such monitoring may include listening to, printing and reading all E-mail, Voicemail, and Internet communications entering, leaving or stored in these systems in the ordinary course of business.

10. Clicking below is an acknowledgment that I understand this document is enforced for the duration of my employment/volunteer relationship with CentraState Healthcare System and my confidentiality obligations as described above survives this relationship with CentraState Healthcare System. Print Applicant Name Applicant Signature Date

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