Evaluator’s Name (Please print): __________________________
REQUIRED QUALITIES AND QUALIFICATIONS(As outlined in the Position Posting)
Please rate the candidate on the qualifications and characteristics listed below on a scale of 1-3 as follows: 1 – Below Expectations 2 – Meets Expectations 3 – Exceeds Expectations 0 -- Not Applicable
Evaluator Rating
Qualification/Experience/Characteristic 1 2 3 0-N/ADemonstrates superb communication skills NOTES:
Possess education/training required for position NOTES:
Knowledge of basic technical skills NOTES:
Applicable work experience NOTES:
Effective leadership & solid decision making skills NOTES:
Shows interest in position & Augusta University NOTES:
Demonstrates customer service excellence NOTES:
Shows strong initiative & attentiveness NOTES:
NOTES:
ADDITIONAL COMMENTS:
RECOMMENDED ACTION (CONSIDER OR DON’T CONSIDER), PLEASE CHECK ONE: YES OR NO
EVALUATOR’S SIGNATURE:
Position Title/Job ID: _____________________
lacanderson
Typewritten Text
SECTION ONE – TO BE COMPLETED BY CANDIDATE
Candidate’s Name: Maiden Name or N/A:
Recruiter Name: Position Title Applied For:
(Check One) Medical Center: University: Employer:
Dates Employed: From: To: Employer E-mail/Phone Number:
Reason for Leaving (if previous employer): (Check One)Voluntary: Involuntary:
Information Provided By: Title:
SECTION TWO – TO BE COMPLETED BY REFERENCE
1. How long have you known the candidate and in what capacity did/do you work with them (co-worker, supervisor, subordinate, etc.)?
2. Describe this candidate’s overall work performance in the following areas.
Poor Good Excellent Comment
Customer Service / Integrity
Interpersonal Skills / Inclusivity
Technical Skills
Productivity
Dependability / Excellence
Initiative
Leadership
Teamwork / Collegiality
Attendance
3. Major Responsibilities: What was/is the nature of his/her duties?
4. Do you think he/she would be a good fit in the unit? Why?
5. (If previous employer) Is he/she eligible for rehire and if so, would you rehire? Yes No (Check One) If no, why?
6. Additional Comments:
This reference was completed by: Date:
Revised 02.2016 LSA
Candidate Pre-Employment Reference Form
Verified by: _____________________
Organization:____________________
Date:__________________________
Education Verification Form (PLEASE PRINT LEGIBLY THROUGHOUT THE FORM)
Name of Candidate:___________________________________________________________________ (First) (Middle) (Last) (Maiden)
Social Security Number:____________________________Date of Birth: ________________________
Name of High School:__________________________________________________________________
Attended From: _____/_____ (month/year) Attended To: _____/_____(month/year) Degree Obtained:_____________________________________Major:___________________________
I authorize Augusta University to conduct an investigation of my personal, employment, and education history and further release the University, companies, schools, or persons from liability or damages for providing information. I hereby state that the information on this form is true and complete. In the event of employment, I understand that false, misleading, or omitted information given in the application documents or employment interviews may result in dismissal. I affirm I have not committed Medicare/Medicaid fraud. I understand my employment status will be contingent upon the satisfactory completion of a post offer medical assessment and drug screen and acceptable results of criminal background check. If accepted for employment, I understand my employment will be for no definite time period, regardless of the period of payment of my wages. In addition, I agree to abide by the rules and policies of Augusta University.
I understand that as a new hire my nursing license will be checked for sanctions and restrictions through the Georgia Secretary of State Licensing website. I understand the following and attest to the accuracy of these statements:
____ I understand that I must self-report to the Georgia Board of Nursing any state in which I currently or have previously been granted a nursing license.
____ I understand that I must self-report violations of the Georgia Nursing Act to the Georgia Board of Nursing immediately.
____ I understand that I must self-report sanctions or restrictions placed on my license by the Georgia Board of Nursing to my immediate supervisor.
____ I understand that failure to self-report sanctions and restrictions on my license is subject to disciplinary action up to termination.
____I attest that the above statements are true to the best of my knowledge.
TO: GCHC Director of Human Resources FROM: _______________________________ DATE: ________________________________ Facility Name & HSA: _________________________________________________________________ Applicant Name: __________________________________ Position Title: _______________________ The attached candidate is interested in employment at our facility. Please validate an appropriate rate of pay for the above position. A copy of the applicant’s resume is attached. Please make sure that the applicant has completed the on-line application that can be found at www.augusta.edu/jobs/university Any special considerations are listed below: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SALARY DETERMINATION RESPONSE FORM
(TO BE COMPLETED BY HUMAN RESOURCES ONLY)
DATE: ______________________ TO: _________________________ FROM: ______________________ In response, the validated rate of pay for the above candidate in the above position is: $______________ per _______________ Explanation: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Validated by: ______________
*Make sure to include the candidate’s resume.*
Use this form when you have already interviewed your candidate and you want to make them an offer. Fax it to Human Resources along with the resume. A salary offer will be emailed back to you in most cases within 24 hours. Revised 10/16
AJG 01/09/20
I accept the salary of $ per hour/year for the position of at . I understand this is not my official appointment letter. My target date of hire will be . I am aware that my official date of hire will be determined by DCHC Human Resources, based on satisfactory/approved 1) GCIC Criminal History/Accurate Background check 2) Drug Screen 3) Education Verification 4) Credential verification 5) Corrected and complete original hire packet
Applicant Date Staff Date • Please forward this document to DCHC Human Resources
along with the new hire, promotion & transfer document.
• Please give a copy to the candidate
AUGUSTA UNIVERSITY PRE-EMPLOYMENT DRUG SCREEN REQUEST
This form must be complete, signed, dated and returned with your application of employment. Upon an offer of employment, information regarding pre-employment drug screening procedures for interns, residents and fellows entering training programs at Augusta University will be provided prior to the start date . MY SIGNATURE BELOW INDICATES MY CONSENT AND AUTHORIZATION TO HAVE MY URINE SCREENED FOR ILLEGAL DRUGS AS A PRECONDITION OF MY EMPLOYMENT BY AUGUSTA UNIVERSITY AND AS REQUIRED BY GEORGIA LAW. I HEREBY CONSENT TO HAVE THE RESULTS OF MY URINE DRUG SCREENING REPORTED TO APPROPRIATE PERSONNEL AT AUGUSTA UNIVERSITY. I UNDERSTAND THAT IN THE EVENT THAT I TEST POSTIVE FOR ILLEGAL DRUGS, I WILL BE INELIGIBLE FOR EMPLOYMENT AT AUGUSTA UNIVERSITY.
(Please Print or Type)
NAME:
First/Middle/Last Jr. /Sr., etc. ADDRESS:
Street
City/State/Zip Code
Social Security Number
Signature of Applicant
Date
(10/2018) RETURN WITH APPLICATION
Department of Correctional Healthcare 699 Broad St./ OR-6000 Augusta, Georgia 30901
SECURITY QUESTIONNAIRE NOTICE TO EMPLOYEES: The Sedition and Subversive Activities Act of 1953 (Ga. Laws, 1953), as amended, requires each employee to complete and sign, prior to his/her employment by the State of Georgia, a questionnaire which is designed to establish that there are no reasonable grounds to believe that he/she is a subversive person. A subversive person is defined as one who commits acts, advocates, or teaches the overthrow of the government of the United States or government of the State of Georgia by force or violence or who is a knowing member of a subversive organization. INSTRUCTIONS: Prepare in original only. Fill in all items. If more space is needed for any item, or explanation, continue under Item 5. Please type or print in ink. 1. Name Social Security No. Other Names Used: (Maiden name, names by former marriages, former names changed legally or otherwise: Aliases, nicknames, etc. Specify which, and show dates used.)
2. Address Street and No. City State County Phone No.
3. Are you now or have you been within the last ten (10) years a member of any organization which to your knowledge at the time of membership advocates or has as one of its objectives, the overthrow of the government of the United States or the government of the State of Georgia by force or violence? Yes No If “Yes,” state the name of the organization and your past and present membership status including any offices held therein.
NOTE: If the answer to Question 3 is “yes” and the employing authority deems further inquiry is necessary, you will be notified of such
determination. No action adverse to your application will be taken because of an affirmative answer until after such an inquiry, with notice to you and an opportunity for you to present evidence, and only if the results of such inquiry bring your application within the prohibition within the Sedition and Subversive Activities Act of 1953, as amended.
4. (A) Have you ever been convicted or are any charges now pending against you by Federal, State, or other law-enforcement
authorities, for any violation of any federal law, state law, county or municipal law, regulation, or ordinance? (Do not include anything that happened before your sixteenth birthday. Do not include minor traffic violations for which a fine of $35.00 or less was imposed. All other convictions must be included even if they were pardoned.)
Yes No (B) If the answer to 4 (A) is “yes,” state the reason convicted, the date convicted, and the place where convicted.
REASON CONVICTED DATE PLACE WHERE CONVICTED
5. SPACE FOR CONTINUING ANSWERS OR EXPLANATIONS: (Show item numbers to which answers or explanations apply. Attach a separate sheet if more space is needed.)
USO Page 2
NOTE: Before signing this form, check all answers and explanations to see that you have answered all questions fully and correctly. This form is to be executed under oath subject to the penalties of false swearing as prescribed in Code Section 16-11-14 of the Criminal Code of Georgia.
AFFIDAVIT OF VERIFICATION State of County Personally appeared before the undersigned attesting officer, duly authorized to administer oaths, (Print your Name) who, after being sworn, deposes and says and declares under penalties of false swearing that he or she is the person who executed the foregoing instrument; that he or she has read and completed the same and knows and understands the contents thereof; that the matters stated therein and the answers and information furnished by him or her in the foregoing questionnaire, including any attachments thereto, are true and correct. SWORN TO AND SUBSCRIBED BEFORE ME
(Signature of Employee) This day of ,
Month Year ____________________________________________________
Notary Public
County of My commission expires day of , month year
(Affix seal)
INFORMATION TO BE FURNISHED BY EMPLOYING UNIT
INSTRUCTIONS TO UNIT: If this questionnaire is executed by applicant, insert “APPL” in the space for date of appointment, and show date of application. If this questionnaire is executed by an individual who has been offered employment or who is already employed, provide the information requested.
DATE OF APPOINTMENT
TITLE OF POSITION UNIT AND DEPARTMENT DUTY STATION
University System Office
Board of Regents University System of Georgia
LOYALTY OATH
STATE OF COUNTY OF I, (Print your Name) , a citizen of
State / Country and being an employee of the University System of Georgia and the recipient of public funds for services rendered as such employee, do hereby solemnly swear and affirm that I will support the Constitution of the United States and the Constitution of the State of Georgia. This day of ,
Month Year Signature of Employee Sworn to and subscribed before me this day and year above set out.
Notary Public (Affix Seal)
PLEASE NOTE THAT EACH OF THE ABOVE DOCUMENTS, THE SECURITY QUESTIONNAIRE AND THE LOYALTY OATH, MUST BE SIGNED AND NOTARIZED.
