CNA Form

Step 1 of 28

Employment Application

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.

Personal Information

Last Name

First Name

Middle Name

Date

MM slash DD slash YYYY

Street Address

Home Phone

City, State, Zip Code

Business Phone

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Online Ad

Agency employee

Other

Are you willing to work

List the last five years employment history, starting with the most recent employer.

1. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

2. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

3. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

4. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

5. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

Was your last name different from your present name during the above listed jobs?

Yes

If yes, what was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Professional References

Persons who can furnish information about job performance

1. Name

Telephone

Address

2. Name

Telephone

Address

3. Name

Telephone

Address

General

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full

Are you capable of performing the job set forth in the job description?

Yes

If you answered No, which job requirement can you not meet?

Credentials/specialized skills & qualifications/equipment operated

List all states in which licensed giving registration and expiration date. Summarize special jobrelated skills and qualification acquired from employment or other experience.

Please read all statements below before signing this application

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Date

MM slash DD slash YYYY

Signature

(1) Applicant Reference Check

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

Applicant Name

Date of Application:

MM slash DD slash YYYY

Previous Employer

Contact Person

Address

Phone

I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

Applicant’s Signature

Date

MM slash DD slash YYYY

To be completed by previous employer:

Date of employment:

From

MM slash DD slash YYYY

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay: (weekly/biweekly/salary)

Additional comments (training/skills)

Reference check performed by

(2) Applicant Reference Check

Applicant Name

Date of Application:

MM slash DD slash YYYY

Previous Employer

Contact Person

Address

Phone

Applicant’s Signature

Date

MM slash DD slash YYYY

To be completed by previous employer:

Date of employment:

From

MM slash DD slash YYYY

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay: (weekly/biweekly/salary)

Additional comments (training/skills)

Reference check performed by

Employee Emergency Contact Information

Employee Name

Current Address

Home Phone

Cell Phone

*In case of emergency, please contact:

Name

Phone

Relationship

Address

*Please notify this Agency immediately if any of the emergency contact information changes.

Statement Of Good Health/free Of Communicable Disease

Explanation and Instruction:

Our company policy requires all employees who have direct contact with patients in the home setting to submit a statement from an appropriately licensed health care professional, based on an exam performed within the last twelve months. The employee must show no apparen signs or symptoms of communicable disease.

Statement to be signed by a Physician or appropriately licensed Healthcare professional.

Name

was examined by me on

MM slash DD slash YYYY

He/She is in adequate health to perform home health duties and show no apparent signs or symptoms of communicable disease.

Professional Signature

Date

MM slash DD slash YYYY

Address

Phone number

A PPD test was done in this office on

MM slash DD slash YYYY

and read on

MM slash DD slash YYYY

Rt. Forearm

Lt. forearm

Result

If redness present, size/description

Manufacturer name

Lot number

Tb Targeted Medical Questionnaire And Risk Form

Employee Printed Name

1. Have you ever had a positive TB skin test or history of TB infection?

Yes

If the answer is YES, please answer the following:

2. Have you ever had the BCG vaccine?

Yes

3. Do you have prolonged or recurrent fever?

Yes

4. Have you recently lost weight?

Yes

5. Do you have a chronic cough?

Yes

6. Do you cough up blood?

Yes

7. Do you have sweating at night?

Yes

8. Do you have any of the following risk factors

a. Silicosis (lung disease)

b. Gastrectomy

c. Intestinal Bypass

d. Weight 10% or more below ideal body weight

e. Chronic Renal Disease

f. Diabetes Mellitus

g. Prolonged high-dose corticosteroid therapy or other Immunosuppressive therapy

h. Hematologic Disorder i.e. leukemia or lymphoma

i. Exposure to HIV or AIDS

j. Other malignancies

Baseline Individual TB Risk Assessment

Answer “Yes” or “No”. Employee should be considered at risk for TB if any of the following statements are marked “Yes”.

Temporary or permanent residence of > 1 month in a country with a high TB rate (any country other than the U.S., Canada, Australia, New Zealand, and those in Northern or Western Europe)

Current or planned immunosuppression, including HIV infection, organ transplant recipient, treatment with a TNF alpha antagonist, chronic steroids, or other immunosuppressive medication.

Close contact with someone who has had infectious TB disease since the last TB test

Employee Signature

Date

MM slash DD slash YYYY

Reviewed by Signature

Date

MM slash DD slash YYYY

Hepatitis Vaccine Requirement

acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself.

It is my decision to:

Request that I receive the Hepatitis vaccine

Refuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to me.

Provide written proof of immunity (attach)

Provide written proof of previous vaccination (attach)

Provide written proof of medical contraindication (attach)

Attach Files

Drop files here or

Max. file size: 512 MB.

Signature

Date

MM slash DD slash YYYY

I-9 Employment Eligibility Verification

Section 1. Employee Information and Attestation

(Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number

City or Town

State

ZIP Code

Date of Birth

MM slash DD slash YYYY

U.S. Social Security Number

Employee's E-mail Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Untitled

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work

(Alien Registration Number/USCIS Number):

until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions.)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

Signature of Employee

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Preparer and/or Translator Certification (check one):

Translator

I did not use a preparer or translator.

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Last Name (Family Name)

First Name (Given Name)

Address (Street Number and Name)

City or Town

State

ZIP Code

Acknowledgement Form

ALL EMPLOYEE/CONTRACTORS SIGN OFFS

Employee Sign-Off Regarding HIPAA Privacy

I have read and understand this policy on Protected Health Information (PHI) and security. I understand that should any situation arise where I breach patient privacy I will be disciplined up to and including termination.

Employee Sign Off Regarding HIPAA Privacy

Corporate Compliance Employee Sign Off

Our Agency is committed to providing the highest ethical health care and upholding conduct standards and corporate legal compliance. Our policies support a zero tolerance to any form of fraud or misconduct.

Corporate Compliance Employee Sign Off

Incident/Accidents Reporting Acknowledgement

I have been informed that I MUST report ALL incidents or accidents immediately to the supervisor or office.

Incident/Accidents Reporting Acknowledgement

Acknowledgement / Understanding of Zero Tolerance Sexual Abuse Policy

I acknowledge that I have read the sexual abuse policy and understand the organization will not tolerate abuse.

Acknowledgement / Understanding of Zero Tolerance Sexual Abuse Policy

Fraud/False Claims Laws/Whistleblower Protection Policy

I have received and reviewed the Agency policy on Fraud as part of my hire packet.

Fraud/False Claims Laws / Whistleblower Protection Policy

Employee/ Contractor Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Acknowledgement Form

Staff Name

Position

Employee Acknowledgment of Probation

Notice to Applicants

Transportation Responsibility Contract

Confidentiality Statement

Personal Health Information Pledge of Confidentiality

Signature of Individual Making Pledge

Signature of Individual Administering Pledge

Policy on Job

Non-Discrimination Policy

Anti-Harassment Policy

Universal Precautions

Consent Form to Release Physical/Medical Examination & Criminal Background Screening Data Form

Infection Control

Use of Personal Protective Equipment

Waiver of Rights

Personnel Policies – Safe and Adequate Care of the Patient (Safety of the Patient’s Immediate Environment)

Employee Statement of Commitment

Voluntary Substance Testing

Policy on Patient’s Progress Notes

Employee/ Contractor Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

AHCA Background Screening Compliance Form

Untitled

I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA).

Date of Decision

MM slash DD slash YYYY

Untitled

I have been granted an Exemption from Disqualification through the Florida Department of Health.

Date of Decision

MM slash DD slash YYYY

Attestation

Employee/ Contractor Signature

Title

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

AHCA BGS Privacy Acknowledgement Form

Employee/ Contractor Signature

Title

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Auth to Release Information Form

Print Name

Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Background Check Consent Form

Please provide me with a copy of my background investigation report.

Yes

List former names under which you have been employed:

Print Name

Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Confidentiality- Non Compete Agreement

Print Name

Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Conflict of interest

I also work for another home care agency

Yes

I am disclosing the name of the agency/agencies

Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Consent For Drug Screening

Print Name

Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Direct Deposit Information Form

Untitled

New Agreement

Change Account

Cancel Agreement

Employee Information

Employee Name

Social Society

Signature

Date

MM slash DD slash YYYY

Account Information

Bank Name

Routing Number

Account Number

Untitled

Checking

Savings

HHA Competency

Date

MM slash DD slash YYYY

Timeframe

On Hire

Annual

Review

Staff Name

Supervisor Name

*S = SATISFACTORY U = UNSATISFACTORY NA = NON-APPLICABLE

*** Proficiency must be demonstrated satisfactorily to perform the task independently.

1.1 Reading & Recording

Temperature

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Pulse(Radia)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Respirations

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.2 Bathing

Bed Bath

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Tub Bath

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Shower Bath

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Sponge Bath

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.3 Nail Care (No Cutting)

Fingernails

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Toenails

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.4 Skin Care

Backrub

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Incontinent Patient

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Foot Soaks

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Peri care

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

TED Hose

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Shave

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.6 Hair Shampoo in Sink

Hair Shampoo in Sink

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Hair Shampoo in Bed

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Hair Shampoo in Tub

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.7 Oral Hygiene

Brush Teeth

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Denture Care

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Toothettes

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.8 Toileting/Elimination

Urinal Placement

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Bedpan Placement

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.9 Safe Transfer Techniques

Bed to Chair

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Chair to Standing

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Assist w/ambulating

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Transfer Belt

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.10 Normal Range of Motion

Passive ROM Exercises

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Active ROM Exercises

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.11 Ambulation: Assistive Devices

Walker

Date

MM slash DD slash YYYY

Methodology Observation

Cane

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.12 Positioning

Turn Side to Side

Date

MM slash DD slash YYYY

Observer Initials

Assist

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

1.13 Communication Skills

Ability to Read

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Ability to Write

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Ability to Verbally Report Clinical info to Patients/rep/Caregivers/agency Staff

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Section 2: Tasks assessed through written or oral examination, or after observation of a HHA with a patient

Observation, reporting, and documentation of patient status and the care/service furnished

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor.

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Maintenance of a clean, safe, and healthy environment

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Recognizing emergencies and the knowledge of institute emergency procedures and their application

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Adequate nutrition and fluid intake

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Recognizing and reporting changes in skin condition

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

2.6 Meal Preparation

Feeding

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Special diets

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

2.7 Infection Control

Hand Washing

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Proper Bag Technique

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Use of PPE

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Standard Precautions

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

I attest that I am a licensed RN and have determined that the above-named employee has successfully completed these skills.

Evaluator Signature/Title

Agency Name

Employee Signature

Date of Completion

MM slash DD slash YYYY

Job Description/Handbook Acknowledgement

Print Name

Signature

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Orientation For Direct Care

Employee Printed Name

Signature

Date of Completion

MM slash DD slash YYYY

Trainer Printed Name/ Title

Signature

Date of Completion

MM slash DD slash YYYY

Orientation For Direct Care

Agency Mission, Philosophy, Vision and Plan and Organizational Chart

Advance Directives

Types of Care Provided by the Agency including Information Provided to Patients Regarding Charges

Policies and Procedures HIPAA TB

Personnel Policies, Job Descriptions Employee Handbook/Benefits and Professional Boundaries of All Disciplines

Training Specific to Job Descriptions ie equipment

Cultural diversity

Patient Rights/Responsibilities and Grievance Policy

Ethics, Conflict of Interest and Confidentiality of Patient Information

Supervision and Evaluation

Home Safety (including Bathroom, Electrical, Environment, Fire and Hazards)

Safety Issues in the Home (Including Security, fire prevention and Guns in the Home)

Emergency Preparedness Plan/Actions to Take in the Event of a Disaster

Actions to Take in Unsafe Situations

OSHA Requirements, Safety and Infection Control in the Home/Standard Precautions

Patient Care Responsibilities Including Charges for Service/Care

Incidences, variance and Occurrences reporting

Understanding and coping with Alzheimer’s Disease and Dementia

Identifying and Reporting Abuse, Neglect and Exploitation

Fraud/Abuse/Corporate Compliance, False Claims, False Statements, Whistle Blowing

Community Resources

Quality Assurance/Outcome and assessment Information Set (OASIS) and other required documents

Documentation - Record keeping

Accreditation/ Regulatory Bodies and requirements

Medical Device/Hazards reporting

Exposure Control Plan

Communication Barriers

Photo ID Badge Issued

Print Name

Title

Employee/ Contractor Signature

Date

MM slash DD slash YYYY

PACE Orientation Acknowledgement

Name

Signature

Date

MM slash DD slash YYYY

Post-Hire Medical Questionnaire

Name

Height

Weight

1. Have you ever had a back injury?

Yes

26. Do you have or have you ever had hyperinsulinism?

Yes

2. Have you ever had a hematite intervertebral disc in your back?

Yes

27. Do you have or have you ever had chronic osteomyelitis?

Yes

3. Have you ever had a back surgery for a removal of a disc?

Yes

28. Do you have or have you ever had thrombophlebitis?

Yes

4. Have you ever had a neck injury?

Yes

29. Do you have or have you ever had a total dizziness?

Yes

5. Have you ever had a hematite disc in your neck?

Yes

30. Do you have or have you ever had a magmatic fever?

Yes

6. Have you ever had a neck surgery for removal of a disc?

Yes

31. Do you have or have you ever had a varicose veins or your leg ulcer?

Yes

7. Have you ever had a knee injury?

Yes

32. Do you have or have you ever had tuberculosis?

Yes

8. Have you ever had a surgery on either of your knees?

Yes

33. Do you have or have you ever had allergies or asthma?

Yes

9. Have you ever had a shoulder injury?

Yes

34. Do you have or have you ever had skin trouble?

Yes

10. Have you ever had a surgery on either of your shoulders?

Yes

35. Do you have or have you ever had reactions to serum or drugs?

Yes

11. Have you ever had an elbow injury?

Yes

36. Do you have or have you ever had kidney trouble?

Yes

12. Do you have or have you ever had an amputation of your foot, leg, arm or hand?

Yes

37. Do you have or have you ever had muscular dystrophy?

Yes

13. Do you have or have you ever had epilepsy?

Yes

38. Do you have or have you ever had ulcers?

Yes

14. Do you have or have you ever had diabetes?

Yes

39. Do you have or have you ever had a head injury?

Yes

15. Do you have or have you ever had cardiac disease (heart trouble)?

Yes

40. Do you have or have you ever had a mental retardation?

Yes

16. Do you have or have you ever had Marie-Strumpell disease?

Yes

41. Do you have or have you ever had cancer?

Yes

17. Do you have or have you ever had total loss of sight of one or both eyes or a partial loss of corrected vision of more than 75% bilaterally?

Yes

42. Do you have or have you ever had any permanent physical condition which constitutes a 20% impairment of a member of the body as a whole?

Yes

18. Do you have or have you ever had a cerebral disability from poliomyelitis?

Yes

43. Are you new or have you ever been obese (30% over normal body weight)?

Yes

19. Do you have or have you ever had a cerebral palsy?

Yes

44. Do you have or have you ever had arthritis or rheumatism?

Yes

20. Do you have or have you ever had multiple sclerosis?

Yes

45. Have you ever been treated/advised to seek treatment for alcoholism?

Yes

21. Do you have or have you ever had Parkinson's disease?

Yes

46. Have you ever had a hernia? If the answer is yes, where is the location of the body?

Yes

22. Do you have or have you ever had vascular disorder?

Yes

47. Have you ever been treated for substance abuse or addiction?

Yes

23. Have you ever had psychoneurotic disability following treatment in a recognized Medical or mental institution, in excess of 6 months?

Yes

48. Have you ever had any injury, surgery, or disability which has not been described in the questions above? (If so, state in detail the nature of the injury, surgery or disability).

Yes

24. Do you have or have you ever had hemophilia?

Yes

49. Do you have or have you ever had a high blood pressure?

Yes

25. Do you have or have you ever had ankylosis of a major weight-bearing joint?

Yes

All statements and information given in this application are true, to the best of my knowledge and belief.

Signature

Date

MM slash DD slash YYYY

W4 Form

Step 1: Enter Personal Information

(a) First name and middle initial

Last name

(b) Social security number

Address

City or town, state, and ZIP code

Single or Married filing separately

Married filing jointly or Qualifying surviving spouse

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
Do only one of the following. (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4). If you or your spouse have self-employment income, use this option; or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependent and Other Credits

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 $

Multiply the number of other dependents by $500 $

Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here

Step 4 (optional): Other Adjustments

4(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income $

4(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here

4(c) Extra withholding. Enter any additional tax you want withheld each pay period

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.)

Date

MM slash DD slash YYYY

CAPTCHA

CNA Form

Employment Application

Personal Information

Education

College

Vo-Tech or Trade

High School

Other

Employment

Professional References

General

Credentials/specialized skills & qualifications/equipment operated

Please read all statements below before signing this application

(1) Applicant Reference Check

(2) Applicant Reference Check

Employee Emergency Contact Information

Statement Of Good Health/free Of Communicable Disease

Tb Targeted Medical Questionnaire And Risk Form

Hepatitis Vaccine Requirement

I-9 Employment Eligibility Verification

Acknowledgement Form

Employee Sign-Off Regarding HIPAA Privacy

Corporate Compliance Employee Sign Off

Incident/Accidents Reporting Acknowledgement

Acknowledgement / Understanding of Zero Tolerance Sexual Abuse Policy

Fraud/False Claims Laws/Whistleblower Protection Policy

Acknowledgement Form

AHCA Background Screening Compliance Form

AHCA BGS Privacy Acknowledgement Form

Auth to Release Information Form

Background Check Consent Form

Confidentiality- Non Compete Agreement

Conflict of interest

Consent For Drug Screening

Direct Deposit Information Form

Employee Information

Account Information

HHA Competency

1.1 Reading & Recording

1.2 Bathing

1.3 Nail Care (No Cutting)

1.4 Skin Care

1.6 Hair Shampoo in Sink

1.7 Oral Hygiene

1.8 Toileting/Elimination

1.9 Safe Transfer Techniques

1.10 Normal Range of Motion

1.11 Ambulation: Assistive Devices

1.12 Positioning

1.13 Communication Skills

Section 2: Tasks assessed through written or oral examination, or after observation of a HHA with a patient

2.6 Meal Preparation

2.7 Infection Control

I attest that I am a licensed RN and have determined that the above-named employee has successfully completed these skills.

Job Description/Handbook Acknowledgement

Orientation For Direct Care

Orientation For Direct Care

PACE Orientation Acknowledgement

Post-Hire Medical Questionnaire

W4 Form

Step 1: Enter Personal Information

Step 2: Multiple Jobs or Spouse Works

Step 3: Claim Dependent and Other Credits

Step 4 (optional): Other Adjustments

Step 5: Sign Here

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