N.J. Admin. Code § 13:45B-14.2

Current through Register Vol. 56, No. 24, December 18, 2024

Section 13:45B-14.2 - Application form; minimum information required

(a) An agency shall create an application form for each applicant seeking placement or employment by or through the agency. The application form shall require the following minimum information:

1. The applicant's name, address and telephone number;

2. The applicant's Social Security Number;

3. The type of license held (R.N., L.P.N., H.H.A., N.A.);

4. The license-issuing authority or board;

5. The license number;

6. The license expiration date;

7. The names and addresses of all institutions, patients and agencies worked for within the one year period preceding the date of application, a statement of reasons for leaving each employer and the name(s) of all supervisors having knowledge of the applicant's performance at each location. If the applicant has been employed by more than five employers within the stated one year period, the applicant shall be required to disclose only the five employers immediately preceding the date of application;

8. Areas of actual working experience and period of time during which experience was acquired (for example, I.C.U.--one year, med surg--one year, private residence--one year);

9. The applicant's education (diplomas/degrees held);

10. The applicant's malpractice insurance carrier (name and address), where applicable; and

11. The applicant's malpractice insurance policy number, where applicable.

(b) An application form shall contain the following duly executed authorization:

I, ... (Applicant) ..., hereby authorize ... (agency) ... to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination.

N.J. Admin. Code § 13:45B-14.2

Recodified from N.J.A.C. 13:45B-15.2 by R.2008 d.92, effective 4/21/2008.
See: 40 N.J.R. 91(b), 40 N.J.R. 2118(a).
Former N.J.A.C. 13:45B-14.2, Definitions, recodified to N.J.A.C. 13:45B-13.2.
Amended by R.2008 d.254, effective 8/18/2008.
See: 40 N.J.R. 1762(a), 40 N.J.R. 4819(a).
Recodified (c) as (b).