285 lines
24 KiB
PHP
Executable File
285 lines
24 KiB
PHP
Executable File
<html>
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<head><meta http-equiv=Content-Type content="text/html; charset=UTF-8">
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<style type="text/css">
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<!--
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span{display: inline-block;}
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/*pg2*/
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.pg9 span.cls_003{font-family:Times,serif;font-size:13px;color:rgb(0,0,0);font-weight:500;font-style:normal;text-decoration: none;line-height: 16px;}
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.pg9 span.cls_0033{font-family:Times,serif;font-size:13px;color:rgb(0,0,0);font-weight:500;font-style:normal;text-decoration: none;line-height: 16px;}
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.pg9 span.cls_007{font-family:Times,serif;font-size:13px;color:rgb(0,0,0);font-weight:600;font-style:normal;text-decoration: none;line-height: 16px;}
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.pg9 span.cls_002{font-family:Times,serif;font-size:8.1px;color:rgb(0,0,0);font-weight:bold;font-style:normal;text-decoration: none;line-height: 16px;}
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.pg9 span.cls_005{font-family:Times,serif;font-size:18.0px;color:rgb(0,0,0);font-weight:bold;font-style:normal;text-decoration: none;line-height: 16px;}
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.pg9 span.cls_004{font-family:Times,serif;font-size:12.0px;color:rgb(0,0,0);font-weight:bold;font-style:normal;text-decoration: none;line-height: 16px;}
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.pg9 span.cls_006{font-family:Times,serif;font-size:16.0px;color:rgb(0,0,0);font-weight:bold;font-style:normal;text-decoration: none;line-height: 19px;}
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.pg9 span.cls_007{font-family:Times,serif;font-size:16.0px;color:rgb(0,0,0);font-weight:500;font-style:normal;text-decoration: none;line-height: 19px;}
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.pg9 span.cls_0066{font-family:Times,serif;font-size:14.0px;color:rgb(0,0,0);font-weight:bold;font-style:normal;text-decoration: none;line-height: 19px;}
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p{padding: 0;margin: 0;}
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-->
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</style>
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<script type="text/javascript" src="112caf9c-411b-11eb-8b25-0cc47a792c0a_id_112caf9c-411b-11eb-8b25-0cc47a792c0a_files/wz_jsgraphics.js"></script>
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</head>
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<body>
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<div style="position:relative;margin:0 auto;top:0px;width:720px;height:1000px;overflow:hidden;" >
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<div class="pg9" style="">
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<div class="lefttop" style="float: left;width: 100%;padding-bottom: 15px;">
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<div style="" class="cls_003"><span class="cls_003" style="text-align: right; display: block;">New York State License Number xxxxxxxx</span></div>
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<div style="" class="cls_003"><span class="cls_003" style="text-align: right; display: block;">123 Pond Ave, Brooklyn, NY 1123 6 Phone:</span></div>
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<div style="" class="cls_003"><span class="cls_003" style="text-align: right; display: block;"> (xxx) xxx-xxxx</span></div>
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<div style="" class="cls_003"><span class="cls_003" style="text-align: right; display: block;">Fax: (xxx) xxx-xxxx</span></div>
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<div style="" class="cls_003"><span class="cls_003" > </span ><A HREF="http://www.wecuro.com/" style="text-align: right; display: block;text-decoration: none;font-weight: 600; color: #000;">www.wecuro.com</A>
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</div>
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</div>
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<div style=""><span class="cls_002" style="font-size: 11px;line-height: 16px;padding-bottom: 0px;">WECURO, INC.</span>
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</div>
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<div style="padding: 2px 0;border-top: 5px solid #000;border-bottom: 5px solid #000;width: 99%;">
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<span style="border-bottom: 2px solid #000;border-top: 2px solid #000;display: block;padding-bottom: 2px;font-size: 25px;line-height: 26px;" class="cls_005">Employee <!-- Reference, HHA --></span>
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</div>
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<p>
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<span class="cls_007" style="padding: 0px 0 0px 0;display: block;">PLEASE PRINT NAME AND ADDRESS <br>OF YOUR PREVIOUS EMPLOYER BELOW
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</span>
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</p>
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<p>
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<span class="cls_003" style="padding: 10px 0 0px 0;">Facility:</span>
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<u style="font-family: Times,serif;width: 260px;padding: 0 2px;display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<?php echo $emp->name_of_employeer; ?>
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</u>
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</p>
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<p>
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<span class="cls_003" style="padding: 4px 0 0px 0;">Address: </span>
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<u style="font-family: Times,serif;width: 256px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<?php echo $emp->address_of_employer; ?>
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</u>
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</p>
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<p>
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<span class="cls_003" style="padding: 4px 0 0px 0;">City:</span>
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<u style="font-family: Times,serif;width: 90px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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<span class="cls_003" style="padding: 4px 0 0px 0;">State: </span>
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<u style="font-family: Times,serif;width: 45px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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<span class="cls_003" style="padding: 4px 0 0px 0;">Zip: </span>
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<u style="font-family: Times,serif;width: 60px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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<p>
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<span class="cls_003" style="padding: 4px 0 0px 0;">To: </span>
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<u style="font-family: Times,serif;width: 284px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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<p>
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<span class="cls_003" style="padding: 4px 0 0px 0;">Tel: </span>
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<span class="cls_003" style="padding: 4px 0 0px 0;">(</span>
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<u style="font-family: Times,serif;width: 44px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<?php echo $emp->tel_of_employer[1].$emp->tel_of_employer[2].$emp->tel_of_employer[3]; ?>
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</u>
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<span class="cls_003" style="padding: 4px 0 0px 0;">)</span>
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<u style="font-family: Times,serif;width: 80px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<?php echo $emp->tel_of_employer[6].$emp->tel_of_employer[7].$emp->tel_of_employer[8]; ?>
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</u>
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<span class="cls_003" style="padding: 4px 0 0px 0;">-</span>
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<u style="font-family: Times,serif;width: 112px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<?php echo $emp->tel_of_employer[10].$emp->tel_of_employer[11].$emp->tel_of_employer[12].$emp->tel_of_employer[13]; ?>
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</u>
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</p>
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<p>
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<span class="cls_003" style="padding: 4px 0 0px 0;">Fax: </span>
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<span class="cls_003" style="padding: 4px 0 0px 0;">(</span>
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<u style="font-family: Times,serif;width: 44px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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<span class="cls_003" style="padding: 4px 0 0px 0;">)</span>
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<u style="font-family: Times,serif;width: 80px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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<span class="cls_003" style="padding: 4px 0 0px 0;">-</span>
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<u style="font-family: Times,serif;width: 112px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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<p>
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<span class="cls_003" style="padding: 8px 0 0px 50px;">Dear Employer: <br>The following applicant has applied for employment with <i style="font-weight: 700;">WECURO, Inc.</i> Kindly provide the requested <br>information to the best of your ability. The furnished reference information will be held in <br>strict confidence.<i style="padding-left: 340px;"> Thank you for your cooperation.</i></span>
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<span class="cls_003" style="padding: 0px 0 0px 50px;"></span>
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</p>
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<p>
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<span class="cls_006" style="padding: 8px 0 0px 0;">Print Name </span>
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<u style="font-family: Times,serif;width: 290px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;"><?=_na($cg->fname,'')?> <?=_na($cg->mid_name,'')?> <?=_na($cg->lname,'')?>
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</u>
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<span class="cls_006" style="padding: 4px 0 0px 0;">Social Security #: </span>
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<u style="font-family: Times,serif;width: 40px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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XXX
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</u>
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<span class="cls_003" style="padding: 8px 0 0px 0;">-</span>
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<u style="font-family: Times,serif;width: 35px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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XXX
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</u>
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<span class="cls_003" style="padding: 4px 0 0px 0;">-</span>
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<u style="font-family: Times,serif;width: 70px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<?=_na($cg->soc_sec[7],'')?>
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<?=_na($cg->soc_sec[8],'')?>
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<?=_na($cg->soc_sec[9],'')?>
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<?=_na($cg->soc_sec[10],'')?>
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</u>
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</p>
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<p>
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<span class="cls_006" style="padding: 8px 0 0px 0;">Signature</span>
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<u style="font-family: Times,serif;width: 300px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 18px;height: 20px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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<p>
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<span class="cls_006" style="padding: 2px 0 0px 0;margin-top:8px; width: 98%;text-align: center;border-top: 1px dashed #000;">FOR AGENCY USE ONLY </span>
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</p>
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<p>
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<span class="cls_0066" style="padding: 8px 0 0px 0;">Employed From </span>
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<u style="font-family: Times,serif;width: 35px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 15px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;"><!-- 4455 -->
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</u>
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<span class="cls_0066" style="padding: 4px 0 0px 0;">/</span>
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<u style="font-family: Times,serif;width: 35px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 15px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<!-- 4444 -->
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</u>
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<span class="cls_0066" style="padding: 8px 0 0px 0;">/</span>
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<u style="font-family: Times,serif;width: 35px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 15px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<!-- 4656 -->
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</u>
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<span class="cls_0066" style="padding: 4px 0 0px 0;">To</span>
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<u style="font-family: Times,serif;width: 35px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 15px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;"><!-- 4455 -->
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</u>
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<span class="cls_0066" style="padding: 4px 0 0px 0;">/</span>
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<u style="font-family: Times,serif;width: 35px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 15px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<!-- 4444 -->
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</u>
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<span class="cls_0066" style="padding: 8px 0 0px 0;">/</span>
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<u style="font-family: Times,serif;width: 35px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 15px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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<!-- 4656 -->
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</u>
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<span class="cls_0066" style="padding: 4px 0 0px 0;"> Clinical Area</span>
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<u style="font-family: Times,serif;width: 180px;padding: 0 2px; display: inline-block;font-size: 13px;line-height: 15px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;"><!-- 4455 -->
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</u>
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</p>
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<p>
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<span class="cls_0066" style="padding: 8px 0 0px 0;">Kindly Check </span>
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<span class="cls_003" style="padding: 2px 0 0px 0;" >(if both check off both): </span>
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<span class="cls_0066" style="padding: 8px 0 0px 10px;"> HHA </span>
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<span class="cls_003" style="padding: 2px 0 0px 5px;" ><img src="<?php if($eha->skill_name == 'HHA') echo $tick ; ?>" style="width: 12px;" alt=""></span>
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<span class="cls_0066" style="padding: 10px 0 0px 30px;"> PCA </span>
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<span class="cls_003" style="padding: 2px 0 0px 5px;" ><img src="<?php if($eha->skill_name == 'PCA') echo $tick ; ?>" style="width: 12px;" alt=""></span>
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</p>
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<table style="margin: 0 auto;border-collapse: collapse;margin-top: 8px;">
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<tr>
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<td style="width: 110px;font-weight: 600; text-align: center;font-size: 12px;line-height: 16px;font-family: Times,serif;border: 1px solid #000;"><i>PLEASE EVALUATE:</i></td>
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<td style="width: 110px;font-weight: 600; text-align: center;font-size: 12px;line-height: 16px;font-family: Times,serif;border: 1px solid #000;">OUTSTANDING</td>
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<td style="width: 110px;font-weight: 600; text-align: center;font-size: 12px;line-height: 16px;font-family: Times,serif;border: 1px solid #000;">GOOD</td>
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<td style="width: 110px;font-weight: 600; text-align: center;font-size: 12px;line-height: 16px;font-family: Times,serif;border: 1px solid #000;">FAIR</td>
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<td style="width: 110px;font-weight: 600; text-align: center;font-size: 12px;line-height: 16px;font-family: Times,serif;border: 1px solid #000;">POOR</td>
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</tr>
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<tr>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;">HHA Clinical skill </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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</tr>
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<tr>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;">Ability To Work Independently </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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</tr>
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<tr>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;">Cooperation </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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</tr>
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<tr>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;">Attendence and reliability </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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</tr>
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<tr>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;">Communication skills </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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</tr>
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<tr>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;">Appearance</td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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<td style="width: 110px;font-weight: 600;padding-left: 4px; font-size: 12px;line-height: 16px;height: 30px; font-family: Times,serif;border: 1px solid #000;"> </td>
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</tr>
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</table>
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<p>
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<span class="cls_007" style="padding: 8px 0 0px 0;"> Has employee completed in-service requirements </span>
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<span class="cls_007" style="padding: 2px 0 0px 30px;" >YES</span>
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<span class="cls_003" style="padding: 2px 0 0px 5px;" ><!-- <img src="check.png" alt="" style="width: 12px;"> --></span>
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<span class="cls_007" style="padding: 8px 0 0px 30px;">NO</span>
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<span class="cls_003" style="padding: 2px 0 0px 5px;" > </span>
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</p>
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<p>
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<span class="cls_003" style="padding: 10px 0 0px 0;">ADDITIONAL COMMENTS:</span>
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<u style="font-family: Times,serif;width: 480px;padding: 0 2px;display: inline-block;font-size: 13px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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<p>
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<span class="cls_002" style="padding: 5px 0 0px 0;">IF NO LONGER EMPLOYED</span><br>
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<span class="cls_003" style="padding: 0px 0 0px 0;">IF NO LONGER EMPLOYED</span>
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<u style="font-family: Times,serif;width: 480px;padding: 0 2px;display: inline-block;font-size: 13px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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<p>
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<span class="cls_003" style="padding: 10px 0 0px 0;"> WOULD YOU CONSIDER APPLICANT FOR REHIRE? </span>
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<span class="cls_003" style="padding: 2px 0 0px 30px;" >YES</span>
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<span class="cls_003" style="padding: 2px 0 0px 5px;" ><!-- <img src="check.png" alt="" style="width: 12px;"> --></span>
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<span class="cls_003" style="padding: 10px 0 0px 30px;">NO</span>
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<span class="cls_003" style="padding: 2px 0 0px 5px;" > </span><br>
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<span class="cls_003" style="padding: 0px 0 0px 0;">IF NOT, PLEASE EXPLAIN</span>
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<u style="font-family: Times,serif;width: 480px;padding: 0 2px;display: inline-block;font-size: 13px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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<p>
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<span class="cls_007" style="padding: 15px 0 0px 0;">SIGNATURE</span>
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<u style="font-family: Times,serif;width: 298px;padding: 0 2px;display: inline-block;font-size: 16px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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<span class="cls_007" style="padding: 15px 0 0px 0;"> DATE</span>
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<u style="font-family: Times,serif;width: 55px;padding: 0 2px;display: inline-block;font-size: 16px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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<span class="cls_007" style="padding: 15px 0 0px 0;"> /</span>
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<u style="font-family: Times,serif;width: 55px;padding: 0 2px;display: inline-block;font-size: 16px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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<span class="cls_007" style="padding: 15px 0 0px 0;"> /</span>
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|
<u style="font-family: Times,serif;width: 60px;padding: 0 2px;display: inline-block;font-size: 16px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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|
<p>
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|
<span class="cls_007" style="padding: 8px 0 0px 0;">TITLE</span>
|
|
<u style="font-family: Times,serif;width: 334px;padding: 0 2px;display: inline-block;font-size: 16px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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|
<span class="cls_007" style="padding: 8px 0 0px 0;">FACILITY</span>
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|
<u style="font-family: Times,serif;width: 180px;padding: 0 2px;display: inline-block;font-size: 16px;line-height: 16px;height: 16px; text-decoration: none;border-bottom: 1px solid #a0a0a0;">
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</u>
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</p>
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</div>
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</div>
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</body>
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</html>
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