Fillable Printable Application for Employment of Local Health Departments of Kentucky
Fillable Printable Application for Employment of Local Health Departments of Kentucky
Application for Employment of Local Health Departments of Kentucky
CH-36 (Revised 02/2011)
1
APPLICATION FOR EMPLOYMENT
Local Health Departments of Kentucky
(Excluding Lexington-Fayette, Louisville Metro, and Northern Kentucky which include Boone, Kenton, Campbell and Grant Counties)
Department for Public Health
Division of Administration & Financial Management
Local Health Personnel Branch
Phone number (502) 564-6663
INFORMATION SHEET
We appreciate your interest in employment with the Local Health
Department. In order to receive full consideration for employment opportunities an
“Application for Employment” must be completed and returned to the local health
department where employment is being sought for proper consideration.
*
General Instructions for completing the application for employment:
Type or print this application clearly in dark ink in its entirety.
Job Announcements may contain special instructions and requirements.
Do not substitute a resume’ or other application form for this application.
Write the exact job title as specified on the job announcement.
If a closing date for filing is shown in the job announcement, your application
and any required information, such as a copy of transcript(s) and any other
supporting documentation, must be submitted to the office listed on the job
announcement by the date indicated.
Applications that are received unsigned, incomplete, or after the closing date,
shall be eliminated from consideration.
Change of name or address should be reported in writing to the health
department where you applied.
Applications should be returned to the local health department where
employment is being sought for proper consideration.
CH-36 (Revised 02/2011)
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EEO Survey
Although the following information is not mandatory, it is requested to aid the Department
for Public Health and the local health department in their commitment to Equal
Employment Opportunity. The information in this section will not be used in making any
decision affecting potential employment or any personnel action following employment,
should you be employed.
POSITION TITLE FOR WHICH YOU ARE APPLYING:
Gender: Male Female
Ethnicity (Check Only One)
White (Non-Hispanic) Black (Non-Hispanic) Hispanic or Latino
Asian or Pacific Islander Native American Other
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LOCAL HEALTH DEPARTMENTS OF KENTUCKY
APPLICATION FOR EMPLOYMENT
.
Social Security - -
Number SSN Required for Record Keeping and Data Processing only Date:
Name
Last First Middle (Maiden)
Present
Address
Street City State Zip Code County
Telephone ( ) - ( ) -
Home or where you can be reached Business
POSITION (S) APPLIED FOR
Local Health Department Local Health Department
Title of Position Title of Position
Counties of Interest Counties of Interest
Minimum Acceptable Salary Minimum Acceptable Salary
PERSONAL INFORMATION
If under 18 years of age please provide proof of eligibility to work.
Yes No Have you ever applied for a position with a Kentucky local health department before?
If yes, when?
Yes No Have you ever been employed with a Kentucky local health department before?
Yes No Are you currently employed with a Kentucky local health department?
If no, when were you last employed with a Kentucky local health department?
Which health department? Under what name?
Yes No Do you have a relative employed with a Kentucky local health department?
If yes, who?
Which health department?
Yes No May we contact your present employer?
Yes No May we contact your previous employer(s)?
Equal Opportunity Employer. No question on this form is asked for the purpose of limiting or excluding
any applicant’s consideration because of race, color, sex, national origin, age, marital status, religion, or
status with regard to public assistance, or disability. Thank you for your interest in employment with us.
Agency use only-----
________Class # ________
________Class # ________
________Class # ________
________Class # ________
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LACK OF REQUESTED INFORMATION IS BASIS FOR REJECTING AN APPLICATION.
Criminal Conviction/Traffic Violations: Have you ever been convicted of;
(1) A misdemeanor? Yes No If yes, you must provide the following for EACH conviction:
Conviction: Date: County: (Use space below for additional convictions)
(2) A felony? Yes No If yes, you must provide the following for EACH conviction:
Conviction: Date: County: (Use space below for additional convictions)
(3) A moving traffic violation within the last 5 years? Yes No (Use space below to explain)
You will be asked, if offered employment, to verify that you are a citizen of the United States or provide
proof that your immigration status permits you to work.
On what date will you be available for work?
Full-time Part-time Temporary
Yes No Do you have a valid drivers’ license?
Yes No Are you available for travel?
Yes No Are you available to work on call (after normal work hours?
Saturdays, Sundays)? *Some positions may require that you be on call on a rotating
basis to provide service after normal working hours or on the weekends.
Yes No Are you available to work overtime during the week?
Yes No Are you available to work overtime on weekends?
EDUCATION
High School Graduate Yes No If no, please indicate highest grade completed
Passed High School Equivalency Tests/GED Yes
College Graduate Yes No Please indicate the highest level of college completed:
College Freshman College Sophomore College Junior College Senior
Associate’s Degree Bachelor’s Degree Master’s Degree Ph D
Are you currently attending school? Yes No If yes, anticipated graduation or completion
date:
Social Security No - -
For identification in case pages become separated
AVAILABILITY:
EDUCATION AND TRAINING
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Name
Location
Dates of
Attendance
(Month and
Year)
From To
Number of
Credits
Qtr. Sem.
Degree
Rec’d
AA.,BS.
Etc.
Date
Major
Minor
TRANSCRIPTS MUST BE PROVIDED AT TIME OF APPLICATION FOR THOSE
JOB ANNOUNCEMENTS THAT REQUIRE POST-SECONDARY EDUCATION OR
WHEN EDUCATION CAN BE SUBSTITUTED FOR EXPERIENCE.
Business, Correspondence,
Trade, Technical, or
Vocational School
Name and Location
Dates of
Attendance
(Month and
Year)
From To
Total Hours
Completed
Hours Required
for Certification
Courses/Subjects
Taken
Certificates Received
LICENSES OR CERTIFICATES:
Please indicate if you have a license, certificate, or other authorization to practice a trade or profession.
*A COPY OF LICENSURE VERIFICATION IS REQUIRED FOR POSITIONS, E.G. NURSE,
PHYSICAL THERAPIST, ARNP, ETC.
Name of Trade or Profession
Certificate/License:
License
Number
Current License
Expiration Date
Name and Address of Licensing
Agency
Verified
*
KNOWLEDGE / SKILL/ ABILITIES (KSAs)
List KSAs you possess and believe relevant to the position you seek, such as operating a computer, fluency in language, etc.
Social Security No - -
For identification in case pages become separated
College, University or Professional School: List all undergraduate and graduate work.
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EMPLOYMENT HISTORY
Describe your work experience in detail, beginning with your current or most recent job. Include military
service (indicate rank) and job-related volunteer work, if applicable. Use a separate block to describe each
position or gap in employment. If needed, attach additional sheets, using the same format as on the
application. The information provided will be used to determine if you meet the minimum requirements of
education, training, and experience for the position. List your present or most recent experience first. List
each job (including promotions) separately, even if in the same organization. Under “Description of work”
describe your job in sufficient detail so that we can determine not only your tasks but also the level of
responsibility. Indicate number of employees supervised. If the number of hours on a job varied or was
PRN, use the average number of hours per week. Part time experience is pro-rated according to the
number of hours worked, using 37.5 hours for the workweek.
Social Security No - -
For identification in case pages become separated
1. Employer Address Phone
Job Title Supervisor’s Name and Title No. Supervised by You
Date Employed (Mo./Year) Starting Salary: $
Date Separated (Mo./Year) Ending Salary: $
Full Time Hrs/Week # Years # Months Part Time Hrs/Week # Years # Months
Description of Work:
Reason for Leaving/Wanting to Leave:
2. Employer Address Phone
Job Title Supervisor’s Name and Title No. Supervised by You
Date Employed (Mo./Year) Starting Salary: $
Date Separated (Mo./Year) Ending Salary: $
Full Time Hrs/Week # Years # Months Part Time Hrs/Week # Years # Months
Description of Work:
Reason for Leaving/Wanting to Leave:
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Social Security No - -
For identification in case pages become separated
3. Employer Address Phone
Job Title Supervisor’s Name and Title No. Supervised by You
Date Employed (Mo./Year) Starting Salary: $
Date Separated (Mo./Year) Ending Salary: $
Full Time Hrs/Week # Years # Months Part Time Hrs/Week # Years # Months
Description of Work:
Reason for Leaving/Wanting to Leave:
4. Employer Address Phone
Job Title Supervisor’s Name and Title No. Supervised by You
Date Employed (Mo./Year) Starting Salary: $
Date Separated (Mo./Year) Ending Salary: $
Full Time Hrs/Week # Years # Months Part Time Hrs/Week # Years # Months
Description of Work:
Reason for Leaving/Wanting to Leave:
5. Employer Address Phone
Job Title Supervisor’s Name and Title No. Supervised by You
Date Employed (Mo./Year) Starting Salary: $
Date Separated (Mo./Year) Ending Salary: $
Full Time Hrs/Week # Years # Months Part Time Hrs/Week # Years # Months
Description of Work:
Reason for Leaving/Wanting to Leave:
CH-36 (Revised 02/2011)
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Social Security No - -
For identification in case pages become separated
CERTIFICATION: I am aware that any omissions, falsifications, misstatements, or misrepresentations
above may disqualify me for employment consideration and, if I am hired, may be grounds for termination at
a later date. I understand that any information I give may be investigated as allowed by law. I consent to the
release of information about my ability, employment history, and fitness for employment by employers,
schools, law enforcement agencies, and other individuals and organizations to the local health department for
which I am applying and authorized individuals in the Department for Public Health. This consent shall
continue to be effective during my employment if I am hired. I certify to the best of my knowledge and
belief all of the statements contained herein and on my attachments are true, correct, complete, and made in
good faith.
Signature: Date:
6. Employer Address Phone
Job Title Supervisor’s Name and Title No. Supervised by You
Date Employed (Mo./Year) Starting Salary: $
Date Separated (Mo./Year) Ending Salary: $
Full Time Hrs/Week # Years # Months Part Time Hrs/Week # Years # Months
Description of Work:
Reason for Leaving/Wanting to Leave:
7. Employer Address Phone
Job Title Supervisor’s Name and Title No. Supervised by You
Date Employed (Mo./Year) Starting Salary: $
Date Separated (Mo./Year) Ending Salary: $
Full Time Hrs/Week # Years # Months Part Time Hrs/Week # Years # Months
Description of Work:
Reason for Leaving/Wanting to Leave:
Social Security No __ __ __ __ __ __ __ __ __
For identification in case pages become separated
CH-36 (Revised 02/2011)
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EMPLOYMENT HISTORY SUPPLEMENTAL-SKILLS
For each skill/task you possess check those that you have experience in and write the years or months
accumulated for each and write the corresponding number(s) associated from the employment history
section of the application. If you have a skill not listed which you consider important, please write it at the
bottom section and indicate the number of years of experience you have.
COMPUTER SKILLS
MS Word
Outlook
Excel
PowerPoint
MAINFRAME/WORK-
STATION SOFTWARE
(SPECIFY)
KEYBOARDING SKILLS
Correspondence/Forms
Newsletters/Manuscripts
Medical/Scientific/Legal
Terminology
OFFICE EQUIPMENT
Photocopy/Fax Machine
RECEPTIONIST/FRONT
DESK/SCHEDULING
Moderate Phone Contact
(3+ hours/day)
Heavy Phone Contact
(6+ hours/day)
Screen/Direct
Volume of Traffic
( /hour)
MAIL
Sort/Screen/Distribute
Date Stamp/Log
FILING
Develop Systems
Maintain Files/Archive
ADDITIONAL SKILLS
Take minutes
FISCAL OPERATIONS
ACCOUNTING/
BOOKKEPING
Accounts Receivable and/or
Payable (system)
Financial Systems (“)
Deposits
Expense Report Preparation
BUDGET
Collect Data
Proposal Preparation
Prepare Budget
Assist Only
Monitor Expenditures
Contract/Grant Proposals
BILLING AND
CASHIERING
Medical Coding & Billing
Billing/Invoicing
Cash Handling
ADMINISTRATION
PURCHASING/INVENTORY
Expenditure Control
Vendor Liaison
Purchase Orders/Requisitions
PAYROLL (For # & System
Used)
STAFF PERSONNEL
Interpret Policies &
Procedures
Develop P&P
Provide Benefits Counseling
SUPERVISORY SKILLS
No. of Employees:
Interview and Select
Train
Schedule Assignments
Review Work
Evaluate Performance
Take Disciplinary Action
SURVEY SKILLS
Data Collection
Phone Interviews
In-Person Interviews
Coding
SECONDARY LANGUAGES
Specific
Speak
Write
Translate
ADDITIONAL SKILLS:
Social Security No - -
For identification in case pages become separated
