By submitting this form, I hereby authorize Dental and Medical Staffing Inc. to make such investigations and inquiries into my employment, educational history and other related matters, as may be necessary in arriving at an employment decision. I HEREBY release employers, schools, and other persons from all liability in responding to inquiries connected with my application and for employment and I specifically authorize the release of information by any schools, individuals, services, and other entities. I HEREBY AFFIRM: That all information given by me on the pre-employment application and this employee data and work history card is true and complete. If my answers are false or misleading, you have the right to dismiss me immediately. If selected for employment, I agree to provide documentation showing I am authorized to work in the United States of America. You may contact my former employers for references and release the information herein to your clients and insurance company. In the event of an "on the job" injury, I will submit to a post accident drug test. I will notify you when the assignment is ending and my availability for work.
IF I DO NOT NOTIFY DMSI OF THIS INFORMATION THE ASSUMPTION MADE BY DMSI IS: I AM NO LONGER AVAILABLE FOR WORK AND THEREFORE QUIT DMSI.
ATTENTION: All healthcare workers must provide proof of Hepatitis B Virus (HBV) vaccination or submit a signed Hepatitis B Vaccine Declination form. This policy ensures compliance with occupational health and safety guidelines to protect against HBV exposure in the workplace.
If you have not yet been vaccinated against Hepatitis B, you will be given the opportunity to receive the vaccination series at no cost to you. Should you choose to decline the vaccine, you must complete and submit the Hepatitis B Vaccine Declination form. Thank you for your understanding and cooperation in this matter.
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; however, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
I HEREBY AFFIRM: That all information given by me on this Skills Check List is true and complete. If my answers are false or misleading, you have the right to dismiss me immediately.
