referring employee:
date: / / / gentiva id: (First & last initial, last 4 SSN digits, 2-digit birth month, 2-digit birth date)last name: / first name: / Middle Initial:
cost center /dept #: / location / department name: / job title:
report to manager: / work telephone: ()- / e-mail:
employee referred to gentiva:
gentiva id: (First & last initial, last 4 SSN digits, 2-digit birth month, 2-digit birth date) / hire date:/ /last name: / first name: / job title:
reports to: / cost center/dept #: / location / department name:
job class: ads (administrative) giv (ft clinical) ppv (pay per visit) *pdm(per diem)
*Referral bonuses are not awarded for referral of Per Diem Employees. Exceptions to this policy must be made in accordance with market specific recruiting initiatives and require “Non-standard Bonus Approvals” below. Review guidelines and confirm eligibility by reviewing the Employee Referral Bonus Policy prior to submitting the form for approval / processing: Employee Referral Policy.
I acknowledge that the Employee listed above was hired by Gentiva Health Services as a direct result of my referral and that I meet the referral bonus guidelines as outlined in Gentiva’s Policy and Procedure.
Referring Employee: ______
Print Name Signature
I verify that this referral was documented on the initial employment application during the interview process. Both Employees are actively employed, have completed a minimum of 90 days of employment and are in good standing with the company. I have reviewed the Employee Referral Policy and verify that the referring Employee meets all bonus eligibility requirements. In addition, as hiring manager, I understand that the referral bonus amount will be charged to the cost center to which the new Employee was hired.Cost center/Department # to be charged:
Hiring Manager: ______
Print Name Signature
I verify that I have reviewed the Gentiva application and/or interview notes in the Applicant Tracking System (ATS) to verify this new hire was an employee referral. Please attach the application and/or ATS screen shot. Amount to be paid:
Recruitment Manager: ______
Print Name Signature
Additional Approvals Required for Non-Standard Bonus Payment (See Policy 7-4).
I verify that my Region/Department was running an Enhanced Employee Referral Program to fill this position. I have attached the Enhanced Program Flyer/Email. This Employee should be paid the following amount:
HR Director/HR AVP: ______Print Name Signature
RECRUITERS: Please E-mail or fax completed Request Form toor913-814-1275 with approvals.
______
Amount Paid Date Processed ESC Signature
© Gentiva® Health Services, 2013