ONLINE APPLICATION FOR EMPLOYMENT

Johnson County Hospital is an Equal Opportunity Employer. JCH does not discriminate against any employee or applicant on the basis of race, color, national origin, sex, disability, religion, marital status, age or any other protected status in employment decisions.

Applicants who need a reasonable accommodation during the selection process may contact Human Resources for assistance.

All applications are kept on file for 180 days.

If you have any questions in completing the employment application, please call Human Resources at 402-335-3361. 

Thank you for your employment interest at Johnson County Hospital.

EEO Employer/Vet/Disabled

APPLICANT INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

ADDITIONAL INFORMATION

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I understand that this application is not a contract of employment and I understand that if hired my employment at JCH is At-Will. This means that, if hired, either JCH or I can end the employment relationship at any time and for any or no reason. Johnson County Hospital and all its physician clinics are a no smoking campus as of January 1, 2014.

I authorize investigation of all statements contained in this application for any employment related purpose. I release the listed references and all employers to provide you with any and all applicable information they may have. I hereby release these references and former employers from all liability for any information they may give you.

JOHNSON COUNTY HOSPITAL

APPLICANT’S BACKGROUND CHECK ACKNOWLEDGEMENT

Johnson County Hospital is committed to providing a safe and secure environment for its customers and employees. Reference and background checks will be conducted in order to:

• Prohibit the employment of personnel who have been convicted of a crime or who have a conviction of a prior history of child or adult abuse, neglect, or mistreatment, in accordance to state and federal law and organizational policy.

I understand that, as a condition of my employment, verifications and reference and background checks will be conducted, which may include but are not limited to:

• NE Department of Health and Human Services Adult/Child Protective Services Central Registries
• NE State Patrol Criminal Records
• NE State Patrol Sex Offender Registry
• State Licensing Records
• Officer of Inspector General Exclusions Report
• Employment Reference
• Personal Reference
• Nurse Aide Registry

Johnson County Hospital

202 High St, Box 599
Tecumseh, NE 68450
402-336-3362
Fax: 402-335-6342

APPLICANT INFORMATION FORM

Johnson County Hospital is an Affirmative Action/Equal Opportunity Employer and does not
discriminate on the basis of race, color, religion, sex, age, sexual orientation, gender identity,
national origin, disability, veteran status, or any other classification protected by Federal, state,
or local law.

This information will be used strictly for statistical record-keeping purposes and will be kept
confidential. Providing—or not providing—the gender/race/ethnic/veteran’s status information
on this form will neither impact whether or not you are hired, nor will it affect your employment in
any manner if you are hired. If you choose not to self-identify, you must select the declination
box below to move forward with the application process. The person(s) making hiring and
personnel decisions will not see this form.

Johnson County Hospital is a federal contractor or subcontractor subject to the Vietnam Era
Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002,
38 U.S.C. 4212 (“VEVRAA”), which requires federal contractors/subcontractors to take affirmative
action to employ and advance in employment: (1) disabled veterans; (2) recently separated
veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal
veterans. These classifications are defined as follows:

1. A “disabled veteran” is one of the following:
   1. A veteran of the U.S. military, ground, naval or air force 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 Secretary of
      Veterans Affairs; or
   2. A person who was discharged or released from active duty because of a
      service-connected disability.
2. A “recently separated veteran” means any veteran during the three-year period
   beginning on the date of such veteran’s discharge or release from active duty in
   the U.S. military, ground, naval, or air service.
3. An “active duty wartime or campaign badge veteran” means a veteran who
   served on active duty in the U.S. military, ground, naval or air service during a
   war, or in a campaign or expedition for which a campaign badge has been
   authorized under the laws administered by the Department of Defense.
4. An “Armed Forces service medal veteran” means a veteran who, while serving
   on active duty in the U.S. military, ground, naval or air service, participated in a
   United States military operation for which an Armed Forces service medal was
   awarded pursuant to Executive Order 12985.

If you believe you are a member of any of the categories of protected veterans listed above,
please indicate by checking the appropriate box below. As a federal contractor or subcontractor
subject to VEVRAA, we request this information to measure the effectiveness of the outreach
and positive recruitment efforts we undertake pursuant to VEVRAA. Your decision to provide the
relevant information is purely voluntary on your part, and refusal to provide such information will
not subject you to any adverse treatment. The information will not be used in a manner
inconsistent with VEVRAA, as amended.

The information will be kept confidential, except that (i) supervisors and managers may be
informed regarding restrictions on the work or duties of disabled veterans, and regarding
necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the
extent appropriate, if you have a condition that might require emergency treatment; and (iii)
Government officials engaged in enforcing laws administered by the Office of Federal Contract
Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.