[{"required":true,"id":1,"type":"text","question":"Address Line"},{"required":true,"id":4,"type":"text","question":"City"},{"required":true,"id":3,"options":[{"label":"AK","value":"AK"},{"label":"AL","value":"AL"},{"label":"AR","value":"AR"},{"label":"AZ","value":"AZ"},{"label":"CA","value":"CA"},{"label":"CO","value":"CO"},{"label":"CT","value":"CT"},{"label":"DC","value":"DC"},{"label":"DE","value":"DE"},{"label":"FL","value":"FL"},{"label":"GA","value":"GA"},{"label":"HI","value":"HI"},{"label":"IA","value":"IA"},{"label":"ID","value":"ID"},{"label":"IL","value":"IL"},{"label":"IN","value":"IN"},{"label":"KS","value":"KS"},{"label":"KY","value":"KY"},{"label":"LA","value":"LA"},{"label":"MA","value":"MA"},{"label":"MD","value":"MD"},{"label":"ME","value":"ME"},{"label":"MI","value":"MI"},{"label":"MN","value":"MN"},{"label":"MO","value":"MO"},{"label":"MS","value":"MS"},{"label":"MT","value":"MT"},{"label":"NC","value":"NC"},{"label":"ND","value":"ND"},{"label":"NE","value":"NE"},{"label":"NH","value":"NH"},{"label":"NJ","value":"NJ"},{"label":"NM","value":"NM"},{"label":"NV","value":"NV"},{"label":"NY","value":"NY"},{"label":"OH","value":"OH"},{"label":"OK","value":"OK"},{"label":"OR","value":"OR"},{"label":"PA","value":"PA"},{"label":"PR","value":"PR"},{"label":"RI","value":"RI"},{"label":"SC","value":"SC"},{"label":"SD","value":"SD"},{"label":"TN","value":"TN"},{"label":"TX","value":"TX"},{"label":"UT","value":"UT"},{"label":"VA","value":"VA"},{"label":"VI","value":"VI"},{"label":"VT","value":"VT"},{"label":"WA","value":"WA"},{"label":"WI","value":"WI"},{"label":"WV","value":"WV"},{"label":"WY","value":"WY"},{"label":"Others","value":"Others"}],"type":"select","question":"State"},{"required":false,"id":32443,"options":[{"label":"Female","value":"F"},{"label":"Male","value":"M"},{"label":"I Decline To Answer","value":"99"}],"type":"select","question":"EEO (Optional)\n\nIMPORTANT: APPLICANTS PLEASE READ.\n\nQualified applicants are considered for employment, and employees are treated during employment without regard to race, color, religion, national origin, citizenship, age, sex, marital status, ancestry, physical or mental disability, veteran status or sexual orientation. Solely to help us comply with federal and state Equal Opportunity record keeping, reporting, and other legal requirements, we request that you complete this data information questionnaire.\n\nPLEASE NOTE:\n\nRefusal to complete this information will not subject any applicant or employee to adverse treatment. The information that you provide will be recorded and maintained in a confidential file, separate from all other records. This information will not be used in consideration for your employment. \n\nGender:"},{"required":true,"id":6,"type":"text","question":"Zip Code"},{"required":false,"id":32444,"options":[{"label":"Hispanic or Latino \n(Persons of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race)","value":"5"},{"label":"White or Caucasian \n(Not Hispanic or Latino) Persons having origins in any of the original peoples of Europe, the Middle East or North Africa.","value":"1"},{"label":"Black or African American \n(Not Hispanic or Latino) Persons having origins in any of the black racial groups of Africa.","value":"2"},{"label":"American Indian or Alaskan Native \n(Not Hispanic or Latino) Persons having origins in any of the original people of North and South America (including Central America) and maintain cultural identification through tribal affiliation or community attachment.","value":"4"},{"label":"Asian \n(Not Hispanic or Latino) Persons having origins in the Far East, Southeast Asia or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.","value":"7"},{"label":"Native Hawaiian or Other Pacific Islander \n(Not Hispanic or Latino) Persons having origins in Hawaii, Guam, Samoa or other Pacific Islands.","value":"3"},{"label":"Two or More Races \n(Not Hispanic or Latino) All persons who identify with more than one of the above five race categories.","value":"6"},{"label":"I Decline To Answer","value":"99"}],"type":"select","question":"Ethnicity"},{"required":false,"id":32445,"options":[{"label":"I identify as one or more of the classifications of protected Veteran listed above","value":"21"},{"label":"I am not a protected Veteran","value":"91"},{"label":"I decline to disclose my Veteran status","value":"99"}],"type":"select","question":"This employer may be a Government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment:\n\nDisabled veterans;\nRecently separated veterans;\nActive duty wartime or campaign badge veterans;Armed Forces service medal veterans.\n\nThese classifications are defined as follows:\n\nA 'disabled veteran' is one of the following:\nA veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by theSecretary of Veterans Affairs\nA person who was discharged or released from active duty because of a service-connected disability.\nA 'recently separated veteran' means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.\nAn 'active duty wartime or campaign badge veteran' means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.\nAn 'Armed forces service medal veteran' means a veteran who, while serving on activee duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.\n\nProtected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll- free, at 1-866-4-USA-DOL.\n\n\nIf you believe you belong to any of the categories of protected Veterans listed above, please indicate by checking the appropriate box below. As a government contractor subject to VEVRAA, we request this information to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA."},{"required":false,"id":32446,"options":[{"label":"Yes, I have a disability (or previously had a disability)","value":"Y"},{"label":"No, I don't have a disability","value":"N"},{"label":"I don't wish to answer","value":"99"}],"type":"select","question":"Why are you being asked to complete this form? \nBecause we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. 1 To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.\nIf you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. \n\nHow do I know if I have a disability? \nYou are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. \n\nDisabilities include, but are not limited to:\n\nBlindness\nAutism\nBipolar disorder \nPost-traumatic stress disorder (PTSD)\nDeafness \nCerebral palsy\nMajor depression \nObsessive compulsive disorder\nCancer \nHIV/AIDS\nMultiple sclerosis (MS) \nImpairments requiring the use of a wheelchair\nDiabetes \nSchizophrenia\nMissing limbs or partially missing limbs \nIntellectual disability (previously called mental retardation)\nEpilepsy \nMuscular dystrophy\n\nReasonable Accommodation Notice \nFederal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.1. Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete. \n Disability:"},{"required":true,"id":11,"options":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}],"type":"select","question":"Only US Citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States?"},{"required":true,"id":12,"type":"text","question":"Minimum Salary Requirement"},{"required":true,"id":13,"options":[{"label":"Hour","value":"H"},{"label":"Week","value":"W"},{"label":"Month","value":"M"},{"label":"Year","value":"Y"}],"type":"select","question":"Salary Type"},{"required":false,"id":14,"type":"text","question":"Mobile Phone - By leaving your mobile number in the above field you are authorizing the company to text you. By not leaving your mobile number, you have opted out."},{"required":true,"id":15,"type":"text","question":"Date Available To Start "},{"required":true,"id":21494,"options":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}],"type":"select","question":"Are you able to work OT and weekends?"},{"required":true,"id":21500,"options":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}],"type":"select","question":"Do you have 2+ years working in collections? "},{"required":true,"id":22066,"options":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}],"type":"select","question":"Are you bilingual in Spanish and English?"},{"required":true,"id":23950,"options":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}],"type":"select","question":"Do you have experience in a call center environment?"},{"required":true,"id":61358,"options":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}],"type":"select","question":"Do you have at least one year of on-the-job experience in a hospital business office or medical accounts receivable environment?"}]