PTA Forms - ESSENTIAL HEALTHCARE SERVICES INC

Physical Therapist Assistant (PTA) Forms

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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

First Name(Required)

Middle Name

Last Name(Required)

Street Address(Required)

City, State, Zip Code(Required)

Home Phone(Required)

Business Phone(Required)

Emergency contact (person not living with you)

Desired Zip Codes(Required)

Have you ever applied for employment with this Agency?(Required)

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?(Required)

Yes

How did you learn of our organization?

Online Ad

Agency employee

Other

Are you willing to work(Required)

Evenings?

Weekends?

Position applying for(Required)

Education

College

School Name(Required)

Location of School(Required)

Course of Study(Required)

Degree/Dip(Required)

Vo-Tech or Trade

School Name

Location of School

Course of Study

Degree/Dip

High School

School Name(Required)

Location of School(Required)

Course of Study

Degree/Dip(Required)

Other

School Name

Location of School

Course of Study

Degree/Dip

Employment

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

1. Company Name(Required)

Telephone(Required)

Address(Required)

City, State, Zip Code

Dates of Employment

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Starting Pay(Required)

Job Title and describe your work(Required)

Reason for leaving(Required)

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?(Required)

Yes

If yes, what was your name?(Required)

Are you currently employed?(Required)

Yes

Do you have reliable transportation?(Required)

Yes

Professional References

Persons who can furnish information about job performance

1. Name(Required)

Telephone(Required)

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?(Required)

Yes

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

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

Yes

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

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(Required)

MM slash DD slash YYYY

Signature(Required)

(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(Required)

Date of Application:(Required)

MM slash DD slash YYYY

Previous Employer(Required)

Contact Person(Required)

Address

Phone(Required)

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(Required)

Date(Required)

MM slash DD slash YYYY

To be completed by previous employer:

Date of employment:

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Position Held(Required)

Would you rehire this individual?(Required)

Yes

Responsibilities

Reason for Leaving(Required)

Rate of Pay: (weekly/biweekly/salary)(Required)

Additional comments (training/skills)

Reference check performed by(Required)

Employee Emergency Contact Information

Employee Name(Required)

Current Address(Required)

Home Phone(Required)

Cell Phone(Required)

*In case of emergency, please contact:

Name(Required)

Phone(Required)

Relationship(Required)

Address(Required)

*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(Required)

was examined by me on(Required)

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(Required)

Date(Required)

MM slash DD slash YYYY

Address(Required)

Phone number(Required)

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(Required)

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

Yes

Other

If the answer is YES, please answer the following:

2. Have you ever had the BCG vaccine?(Required)

Yes

3. Do you have prolonged or recurrent fever?(Required)

Yes

4. Have you recently lost weight?(Required)

Yes

5. Do you have a chronic cough?(Required)

Yes

6. Do you cough up blood?(Required)

Yes

7. Do you have sweating at night?(Required)

Yes

8. Do you have any of the following risk factors(Required)

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)(Required)

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

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

Employee Signature(Required)

Date(Required)

MM slash DD slash YYYY

Reviewed by Signature(Required)

Date(Required)

MM slash DD slash YYYY

Hepatitis Vaccine Requirement

I,(Required)

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:(Required)

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(Required)

Date(Required)

MM slash DD slash YYYY

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(Required)

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(Required)

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(Required)

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(Required)

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(Required)

Employee/ Contractor Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Acknowledgement Form

Staff Name(Required)

Position(Required)

Employee Acknowledgment of Probation(Required)

Notice to Applicants(Required)

Transportation Responsibility Contract(Required)

Confidentiality Statement(Required)

Personal Health Information Pledge of Confidentiality(Required)

Signature of Individual Making Pledge(Required)

Signature of Individual Administering Pledge(Required)

Policy on Job(Required)

Non-Discrimination Policy(Required)

Anti-Harassment Policy(Required)

Universal Precautions(Required)

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

Infection Control(Required)

Use of Personal Protective Equipment(Required)

Waiver of Rights(Required)

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

Employee Statement of Commitment(Required)

Voluntary Substance Testing(Required)

Policy on Patient’s Progress Notes(Required)

Employee/ Contractor Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

AHCA Background Screening Compliance Form

Untitled(Required)

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

Date of Decision(Required)

MM slash DD slash YYYY

Untitled(Required)

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

Date of Decision(Required)

MM slash DD slash YYYY

Attestation(Required)

Employee/ Contractor Signature(Required)

Title(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Employee Name(Required)

Signature(Required)

Title(Required)

AHCA BGS Privacy Acknowledgement Form

Employee/ Contractor Signature(Required)

Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Auth to Release Information Form

Print Name(Required)

Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Background Check Consent Form

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

Yes

List former names under which you have been employed:(Required)

Print Name(Required)

Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Confidentiality- Non Compete Agreement

Print Name(Required)

Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Conflict of interest

I also work for another home care agency(Required)

Yes

I am disclosing the name of the agency/agencies(Required)

Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Consent For Drug Screening

Print Name(Required)

Signature(Required)

Today's Date (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Direct Deposit Information Form

Untitled(Required)

New Agreement

Change Account

Cancel Agreement

Employee Information

Employee Name(Required)

Social Society(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Account Information

Bank Name(Required)

Routing Number(Required)

This is Required Field(Required)

Checking

Savings

Account Number(Required)

Job Description/Handbook Acknowledgment

Print Name(Required)

Employee Signature(Required)

Date(Required)

MM slash DD slash YYYY

Orientation For Direct Care Employees

Employee Printed Name(Required)

Signature(Required)

Date of Completion(Required)

MM slash DD slash YYYY

Orientation Program

Agency Mission, Philosophy, Vision and Plan and Organizational Chart(Required)

Advance Directives(Required)

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

Policies and Procedures HIPAA TB(Required)

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

Training Specific to Job Descriptions ie equipment(Required)

Cultural diversity(Required)

Patient Rights/Responsibilities and Grievance Policy(Required)

Ethics, Conflict of Interest and Confidentiality of Patient Information(Required)

Supervision and Evaluation(Required)

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

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

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

Actions to Take in Unsafe Situations(Required)

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

Patient Care Responsibilities Including Charges for Service/Care(Required)

Incidences, variance and Occurrences reporting(Required)

Understanding and coping with Alzheimer’s Disease and Dementia(Required)

Identifying and Reporting Abuse, Neglect and Exploitation(Required)

Fraud/Abuse/Corporate Compliance, False Claims, False Statements, Whistle Blowing(Required)

Community Resources(Required)

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

Documentation - Record keeping(Required)

Accreditation/ Regulatory Bodies and requirements(Required)

Medical Device/Hazards reporting(Required)

Exposure Control Plan(Required)

Communication Barriers(Required)

Photo ID Badge Issued(Required)

Employee/ Contractor Signature(Required)

PTA-Job Description

Employee Signature(Required)

Date(Required)

MM slash DD slash YYYY

PTA Skills Checklists

Date(Required)

MM slash DD slash YYYY

Timeframe(Required)

On Hire

Annual

Review

Staff Name(Required)

Supervisor Name(Required)

Completion of visit paperwork per policy(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Home safety check and assessment of the patient’s home environment ev visit(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Documentation of visit notes: complete and timely (i.e. PTA Note etc.).(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Follows the PTA written Plan of Care (POC)(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Demonstrates proper body mechanics(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

ADL instruction(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Infection Control: PPE, exposure plan, disposal of infectious waste.(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Implements POC and/or home exercise program safely & effectively(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Communication skills with patient/family(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Communication with care team/supervisor(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

ROM exercises per POC(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Ongoing attention to PT’s functional findings such as gait and equipment management, and bed mobility and transfer activities and reports changes(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Instruction in use/ safety of orthotic devices and other assistive devices as per POC(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Teaching of energy conservation techniques as per the POC under the direction of the PT(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Standard precautions(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

Hand Hygiene(Required)

Date

MM slash DD slash YYYY

Observer Initials

Methodology Observation

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

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

Evaluator Signature/Title(Required)

Agency Name(Required)

Employee Signature(Required)

Date of Completion(Required)

MM slash DD slash YYYY

Post-Hire Medical Questionnaire

Name(Required)

Height(Required)

Weight(Required)

1. Have you ever had a back injury?(Required)

Yes

26. Do you have or have you ever had hyperinsulinism?(Required)

Yes

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

Yes

27. Do you have or have you ever had chronic osteomyelitis?(Required)

Yes

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

Yes

28. Do you have or have you ever had thrombophlebitis?(Required)

Yes

4. Have you ever had a neck injury?(Required)

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

7. Have you ever had a knee injury?(Required)

Yes

32. Do you have or have you ever had tuberculosis?(Required)

Yes

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

Yes

33. Do you have or have you ever had allergies or asthma?(Required)

Yes

9. Have you ever had a shoulder injury?(Required)

Yes

34. Do you have or have you ever had skin trouble?(Required)

Yes

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

Yes

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

Yes

11. Have you ever had an elbow injury?(Required)

Yes

36. Do you have or have you ever had kidney trouble?(Required)

Yes

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

Yes

37. Do you have or have you ever had muscular dystrophy?(Required)

Yes

13. Do you have or have you ever had epilepsy?(Required)

Yes

38. Do you have or have you ever had ulcers?(Required)

Yes

14. Do you have or have you ever had diabetes?(Required)

Yes

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

Yes

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

Yes

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

Yes

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

Yes

41. Do you have or have you ever had cancer?(Required)

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?(Required)

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?(Required)

Yes

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

Yes

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

Yes

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

Yes

44. Do you have or have you ever had arthritis or rheumatism?(Required)

Yes

20. Do you have or have you ever had multiple sclerosis?(Required)

Yes

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

Yes

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

Yes

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

Yes

22. Do you have or have you ever had vascular disorder?(Required)

Yes

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

Yes

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

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).(Required)

Yes

24. Do you have or have you ever had hemophilia?(Required)

Yes

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

Yes

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

Yes

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

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Front and back of ID and social security card(Required)

Drop files here or

Max. file size: 512 MB.

Physical Therapist Assistant (PTA) Forms

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

Employee Emergency Contact Information

Statement Of Good Health/free Of Communicable Disease

Tb Targeted Medical Questionnaire And Risk Form

Hepatitis Vaccine Requirement

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

Job Description/Handbook Acknowledgment

Orientation For Direct Care Employees

Orientation Program

PTA-Job Description

PTA Skills Checklists

Post-Hire Medical Questionnaire

Quick Inquiry

Schedule Consultation