Policy Manual sample

MDT Home Health Care Agency, Inc. HOME HEALTH CARE AGENCY INTERVIEW INFORMATION I. General information Application name: ________________________________________________________ Position applicant interviewed for:_________________________________________________ Interview date: ________________________________ Hours desired: ____________________ No. of work days/week desired: _________________ No. of work hours/week desired: ________________ II. Interview discussion highlights: ____________________________________________________________________________ ____________________________________________________________________________ III. Response to case study questions: ____________________________________________________________________________ ____________________________________________________________________________ IV. Interview outcome ____________________________________________________________________________ ____________________________________________________________________________ Prospective home health care staff members offered position. __ Yes __ No (Explain) ____________________________________________________________________________ If item I above checked no, has a completed Outcome of Application/Interview for Home Health Staff Position letter been mailed? __ Yes __ No (Explain) ____________________________________________________________________________ ____________________________ ________________ Signature of Director of Nursing, Clinical Manager Date or Authorized Designee Home Health Agency. - - Personnel/Operations Policies B-45