First Name:*

Last Name:*

Email Address:*

CTHires Username:

City/Town:*

State:*

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AMS Guam PR UMOI VI

Zip:*

Home Phone:*

Cell Phone:*

Date of Birth:* (MM/DD/YY format)

Employment Status:*

Not Provided Employed Unemployed - Receiving Unemployment Compensation Unemployed - NOT Receiving Unemployment Compensation Employed - Part Time Applied and awaiting approval Applied and denied Benefits exhausted

If employed, how many hours per week, on average, do you work?:*

Temporary employee:*

No Yes

If temporary, when does job end:*

If employed, hourly wage:*

If employed, what benefits does the company provide:*

Veteran:*

No Yes

Current/most-recent Job title:*

Currently In School?*

Yes No

Highest Grade Completed:*

8th Grade 9th Grade 10th Grade 11th Grade Highschool Diploma Some college Associates Degree Bachelors Degree Some Post-bachelors college Masters Degree PhD or other Doctorate

Describe any Special Training:*

Prior Healthcare Experience:*

Yes No

If yes, please explain:*

Do you have experience in any of the following activities?*

Scheduling

None

0-5 years

5-10 years

10+ years

Billing/Coding

None

0-5 years

5-10 years

10+ years

Pharmacy

None

0-5 years

5-10 years

10+ years

Data Entry

None

0-5 years

5-10 years

10+ years

Nursing

None

0-5 years

5-10 years

10+ years

Home Healthcare (professionally)

None

0-5 years

5-10 years

10+ years

Caring for Family or Friend in Need

None

0-5 years

5-10 years

10+ years

Childcare (Paid or Unpaid)

None

0-5 years

5-10 years

10+ years

Customer Service

None

0-5 years

5-10 years

10+ years

Medical Assistant

None

0-5 years

5-10 years

10+ years

Counseling Others

None

0-5 years

5-10 years

10+ years

Positions Requiring First-Aid Knowledge

None

0-5 years

5-10 years

10+ years

Other Healthcare-Related

None

0-5 years

5-10 years

10+ years

Microsoft Office

None

0-5 years

5-10 years

10+ years

Patient Care

None

0-5 years

5-10 years

10+ years

Administrative Experience

None

0-5 years

5-10 years

10+ years

How did you find out about this opportunity?*

Attached to my UI status/ UI Orientation
Session or phone call from the local American Job Center
Poster in the community
CTHires
School Administration
Social Media
Other

If other, please explain

 

I consent for representatives of the Eastern CT Healthcare Pipeline Initiative to contact me via email, voice or text.