Companion Forms - ESSENTIAL HEALTHCARE SERVICES INC

Homemaker /Companion Forms

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Caregiver 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(Required)

Last Name(Required)

Street Address(Required)

City, State, Zip Code(Required)

Home Phone(Required)

Emergency contact (person not living with you)

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

Yes

How many hours a week are you available for work?(Required)

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

Yes

How did you learn of our organization?(Required)

Online Ad

Agency employee

Other

Position applying for(Required)

Are you willing to work(Required)

Evenings?

Weekends?

References

Education

College(Required)

Location of School(Required)

Course of Study(Required)

Degree/Dip(Required)

Vo-Tech or Trade(Required)

Location of School(Required)

Course of Study(Required)

Degree/Dip(Required)

High School(Required)

Location of School(Required)

Course of Study(Required)

Degree/Dip(Required)

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

1. Company Name :(Required)

Telephone :(Required)

Supervisor’s Name:(Required)

Address(Required)

Dates of Employment:(Required)

Starting Pay:(Required)

Job Title and Describe your work:(Required)

Reason for leaving:(Required)

2. Company Name :(Required)

Telephone :(Required)

Supervisor’s Name:(Required)

Address(Required)

City, State, Zip Code

Dates of Employment:(Required)

Starting Pay(Required)

Job Title and Describe your work:(Required)

Reason for leaving:(Required)

3. Company Name

Telephone

Supervisor’s Name:

Address

Dates of Employment:

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

1. Name(Required)

Telephone(Required)

Address(Required)

2. Name(Required)

Telephone(Required)

Address(Required)

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.

License Type:(Required)

Issuing Authority(Required)

License Number:(Required)

Expiration Date:(Required)

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)

Caregiver Job Description

As a caregiver, you provide a variety of non-medical services that allow seniors to remain in their homes. These services generally fall under two categories:

1) Companionship/Homemaking

2) Personal Care

Companionship/Homemaking

This job does not require “hands on” services but does include the following “help” services:

1) Provide socialization, conversation and emotional reassurance to the client.

2) Encourage and participate in reading, appropriate games, and other activities to promote well-being and stimulate the mind and the spirit.

3) Encourage, monitor and assist with meal preparation and fluids.

4) Encourage mild exercise program that is safe and within client’s ability.

5) Provide timely medication reminders and observe the client for compliance in taking medications. Medications must be pre-dosed by the client or client’s representative or a licensed professional. Any irregularities noted in the pre-dosed medications should be reported immediately by the caregiver to the supervisor and recorded in the client binder.

6) Supervise the safety of client while he/she is toileting, bathing and dressing.

7) Remind and encourage daily exercise and/or exercises prescribed by a licensed physical therapist that the client can perform without the therapist being present. Passive range of motion may not be performed at this care level.

8) Assist with ambulation when the client is able to assist with the process. Caregivers may assist clients with the use of adaptive equipment for ambulation such as walkers, canes or wheelchairs once the client has been trained on the use of the equipment and released from the care of the prescribing health care professional.

9) Assist with nail care, limited to soaking and cleaning nails. Caregivers may not trim or clip nails. Nail care should not be provided to clients with a medical condition that might involve circulatory problems or loss of sensation.

10) Assist with home management as authorized by the client or their legal representative or company supervisor; as example, monitor food expirations, ordering/shopping for groceries/home supplies, and monitor home repair as needed.

11) Perform light housekeeping duties.

12) Pet care, limited to feeding and enabling pet to exit the house safely under the supervision of client. Water plants as needed.

13) Provide incidental shopping and errands.

14) Assist with mail and supervise deliveries to the client.

15) Report any concerns to supervisor (Quality Assurance Coordinator or Management).

PERSONAL CARE DUTIES

All duties listed above for Companion/Homemaker can also be performed under this category.

1) Hands-on assistance with Activities of Daily Living (ADL) such as: grooming, bathing, dressing and toileting.

2) Assist with shaving, only with the use of an electric shaver.

3) Assist with feeding client providing the client can still independently swallow and be positioned upright.

4) Assist with general skin care when skin is unbroken and when any chronic skin problems are not active. Skin care should be preventive rather than therapeutic in nature. Caregivers may apply non-medicated lotions and solutions that do not require a physician’s prescription.

5) Assist with pivot transfers (bed to chair, chair to bed, chair to commode, and wheelchair to car) only when the client has sufficient balance and strength to reliably stand, pivot and assist with the transfer. Adaptive and safety equipment may be used in transfers, provided the client and caregiver are fully trained in the use of equipment and can direct the transfer. Caregivers can assist with the use of gait belts and transfer devices with the proper training and demonstrated competency.

6) Empty or change external urinary and ostomy bags.

7) Assist with client directed non-invasive (non-inserted) care only when there is no need for skilled skin care or for observation or reporting to a nurse.

8) Assist client with blood sugar checks; that is limited to opening containers and handling equipment. Caregiver cannot perform procedures.

This Position may require the staff to lift greater than 50 lbs, stand, sit, kneel, or bend for prolonged periods of time.

IF ANY OF THE ABOVE SHOULD PROVE DIFFICULT TO ACCOMPLISH, IMMEDIATELY NOTIFY QUALITY ASSURANCE REPRESENTATIVE FOR FURTHER INSERVICE AND TRAINING

Signature(Required)

Date(Required)

MM slash DD slash YYYY

JOB ACCEPTANCE STATEMENT

I have read, understand and agree to the terms specified in this job description for the position I presently hold. A copy of this job description has been given to me.

I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST

I have read and am fully familiar with the Agency's policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other matter in which I would profit or gain directly or indirectly because of my membership on the Agency's Board of Directors or its committees, (if applicable), and/or my employment with the Agency. I will disclose all known relationships that may present a conflict of interest. Furthermore, I agree to immediately disclose any such interest or outside employment which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the Agency's business that might result in any profit or gain, directly or indirectly for myself.

Employee/Contractor Name(Required)

Date of Application:(Required)

MM slash DD slash YYYY

Employee Signature:(Required)

INDEPENDENT CONTRACTOR AGEEMENT

Contract Agreement

The undersigned individual is a, please select one:

□ Registered Contractor

□ License Practical Contractor

□ Certified Nurse’s Assistant

□ Home Health Aide/Companion

□ Other

Wishes to enter a non-exclusive placement contract with the Essential Healthcare Services dba Essential Staffing Services referred to in the document as “The Agency” to have it find limited contractual engagements for work for which the Undersigned holds the applicable license and required credentials.

2. The undersigned individual, referred to as Contractor throughout the rest of this agreement, understands that this engagement is as independent contractor, and not as an employee of The Agency or a contracting (client) or Healthcare Client. As such, the Contractor understands that he or she will be solely responsible for all payment of income and self-employment taxes. No taxes will be held from Contractor Income. Essential Healthcare Services will report all income over $600.00 per year to the Internal Revenue Service and the State of Florida and will provide the Contractor with a 1099 form for their records, to assist them in filing their taxes as required by law.

3. The Agency shall act solely as a contracting agent to sub-contract contractors to the facilities and homes.

4. Contractor appoints The Agency as his/her agent to find assignments for him/her and to receive compensation on his/her behalf. The agency appointment by the Contractor is irrevocable as to that particular contract. Essential Healthcare Services agrees to pay the contractor for his/her time at the agreed rate. Payment shall be made 1 time per week via direct deposit. Pay rates are confidential and disclosure may result in termination of contract.

5. The contractor agrees not to perform duties at the client or home outside the scope of his/her license or training

6. Each contractor/contractor represents to The Agency that:

A The contractor is licensed (if required) in the State of Florida to perform the type of nursing for which they are placed to, and their license is not suspended or revoked, and has never been suspended or revoked.

B The Contractor carries a current CPR card and requires number of CEU’s as required by the state of Florida.

C The Contractor is not covered by worker’s compensation or unemployment insurance through Essential Healthcare Services while being an independent contractor.

D. The contractor has a minimum of one year’s experience in one of the following four types of nursing healthcare fields listed above.

E. The contractor agrees that unless they are told otherwise, they are to wear standard nursing attire, including ID nametag and closed toe shoes while on duty.

7. The contractor agrees to supply any information necessary to ensure that Essential Healthcare Services meets its contractual obligation to the client, such as any disciplinary proceedings initiated against the contractor, employment history, etc.

8. The contractor understands that he/she does not provide services in a private home under any contract for which she is sent by the Agency, Inc. agency, unless prior authorization is obtained.

9. The contractor agrees to supply the time sheets signed by the authorized Client Representative no later than Friday of each week.

10. The contractor agrees that Essential Healthcare Services is not responsible for any employment or lack of employment.

11. The Contractor will be compensated for two (2) hours’ time & travel if their verified scheduled shift is not canceled prior to their arrival to the client only if the client does not utilize their right to use and compensate contractor for (4) four hours. Contractor has the option to refuse the four hours and not be compensated for time and travel.

12. The contractor has an absolute right to accept or reject any contract for any reason whatsoever, but once a contract is accepted, the contractor agrees that he/she or another contractor will show up at the appointed time. The contractor is free to subcontract with any contractor which is registered with The Agency in advance, and who is acceptable to the Client. The Contractor agrees not to seek or accept employment with any client facilities or individuals to whom The Agency has secured business relationships with for a period of 90 days after the last day worked at that client.

13. I hereby certify that I have not knowingly withheld any information that might adversely affect my chances of contracting with this agency. The answer(s) given by me are true and correct to the best of my knowledge.

14. I hereby certify that I, the undersigned applicant, have personally completed this application, or have noted the name of the individual assisting me in the completion of this application.

15. I understand that any omission or misstatement of material fact on this application, or any document used to secure contract(s) with this agency shall be grounds for rejection of this application, or for immediate discharge if I am contracted through this agency regardless of the time elapsed before discovery

16. I acknowledge and agree that this application will be considered by Essential Healthcare Services for no longer than six (6) months from the date it was made.

17. I understand and agree that if I am contracted through this agency, my contract(s) is/are at will and is/are for no definite period. These contracts may be terminated: at any time, with or without prior notice, for any reason, for no reason, in the opinion of either myself or Essential Healthcare Services.

18. If contracted through this agency, I will comply with all rules, regulations, instructions, policies, and procedures. I understand such rules, regulations, policies and procedures do not constitute a contract for placement and are subject to change at any time and without advance notice.

19. I understand it is the policy of The Agency’s Independent Contractors to comply with the Drug-Free Workplace Act of 1988.

20. I understand that some states in which Essential Healthcare Services does business require healthcare professionals to undergo a job related to physical. I agree to undergo a post-contract physically if contracted in any state with such a requirement.

21. The Contractor shall supply all of the required labor and necessary equipment needed for each work assignment in the Contractor’s capacity as independent contractor. Contractor agrees to provide services for the CLIENTS, which have contracted with The Agency. The contractor is free to decline any work assignments made available by the company.

22. It is the Contractor’ obligation to pay income and self-employment taxes on amounts earned, and the Company will provide a 1099 reflecting amounts earned.

23. The Company will compensate the Contractor by engagement worked at a rate to be agreed upon between the company and the contractor. Contractor is responsible for Contractor’s expenses related to Contractor’s assignments.

24. The Contractor is personally responsible for any continuing education or training required for maintaining his/her professional license/certificates, and the Contractor shall maintain at Contractor’s sole expense the necessary professional licenses/certificates.

25. The Contractor is not limited to working exclusively for the company and may secure other and additional work.

26. The Contractor is responsible for maintaining any worker’s compensation, health, or disability insurance required or which may be required by the Company or the healthcare providers contracting with the Company. The Contractor agrees to indemnify and hold harmless the company from any claims or liability arising out of the work performed by the Contractor under this agreement.

27. The laws of Florida shall govern this Agreement. If any part of this agreement is judged invalid, illegal, or unenforceable, the remaining parts shall not be affected and shall remain in full force and effect. The party stipulated that the venue for any legal actions between the parties shall occur in Hillsborough County, Florida.

28. This Agreement shall be binding on the Company and the Contractor, their successors and assigns.

29. The Company may terminate this agreement at any time based on the Contractor’s failure to provide services hereunder or for the Contractor’s failure to obtain and maintain the required and necessary professional licenses/certificated. Further, either party may terminate this Agreement with or without cause, effective upon fifteen (15) days prior notice given to the other party

30. The contractor acknowledges and agrees that the names and addresses of the Company’s clients and procedures are and will remain the exclusive property of the Company, and that such names and procedures are of a confidential nature and of great economic value to the Company and shall not be disclosed in any manner

31. The Contractor agrees to notify the Company of their availability on a regular basis, but not less than once per week. The Contractor also acknowledges that they are responsible for beginning and completing all shifts they accept

32. The Contractor agrees to complete and turn into the Company any signed time slips to the branch office in a timely manner. The Contractor also understands they will not be paid unless all time slips are signed by the Client, filled out completely and correctly.

33. It is the intent of the contractor and company that the term “contractor” wherever used herein means Independent Contractor and not agent, servant, or employee.

34. This agreement is to be constructed under the laws of the State of Florida.

I agree to this contract and understand its terms

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Signature(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.

TB Questionnaire

Employee Printed Name(Required)

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

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

None of the Above

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

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)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

ACKNOWLEDGEMENT OF CONFIDENTIALITY

The Health Insurance Portability and Accountability Act ensure the patient’s right to privacy of Protected Health Information to be always maintained. Any information related to the care of patients through Essential Healthcare Services, Inc. will be held as confidential. All information, written or verbal will be disclosed only to appropriate health care personnel, appropriate staff, those with a “need to know basis,” or to individuals the patient requests. The following are conflicts of interest or potential conflicts of interest relating to my affiliation with the Agency.

CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION

It is both the Agency's and the employee's responsibility to ensure that every patient's health information is always protected. By signing below, you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency's policy regarding patient's Protected Health Information will be provided to you upon hire. I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated for use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with HIPAA Rule and Regulations. I will protect all Electronic Records including passwords as outlined in the HIPAA manual.

PROTECTION OF HEALTH INFORMATION

There are specific guidelines to ensure patients’ Protected Health Information is kept private. I understand that my employment with the agency involves handling Protected Health Information. I will ensure patients’ records are protected by enforcing the following measures: • Patient Protected Health Information will be transported in a protected travel chart when traveling. • When transmitting and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area. • Patient Protected Health Information will be returned to the agency upon acknowledgement of the patient being discharged. I pledge to make every effort to keep patients’ Protected Health Information always protected.

HIPAA CONFIDENTIALITY AGREEMENT

EMPLOYEE CONFIDENTIALITY AGREEMENT of PATIENT HEALTH INFORMATION AND PERSONAL INFORMATION in accordance with HIPAA REGULATIONS For good consideration and as an inducement for Essential Healthcare Services, Inc. the undersigned Employee hereby agrees not to directly or indirectly use, manipulate or copy compete any patient health information (PHI), to include personal health information or personal contact information (address, phone, email address, etc.) with the business of the Agency and its successors and assigns during the period of employment. Misuse of PHI or personal contact information will result in termination and report with action to HIPAA federal agencies. Fines related to civil and criminal offences for gross misconduct with the above information are the direct responsibility of said employee. The Employee acknowledges that the Agency shall or may in reliance of this agreement provide Employee with access to trade secrets, customers and other confidential data and goodwill. Employees agree to retain said information as confidential and not to use said information on his or her own behalf or disclose same to any third party or for their own personal or monetary gain. The Employee agrees to not copy and to return all such Agency supplied Information immediately upon termination of employment. Further employees agree not to solicit any of the customers or employees of employer Essential Healthcare Services, Inc. for any purpose for a period of two years after termination. This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.

Employee/Contractor Name(Required)

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

MM slash DD slash YYYY

Employee/ Contractor Signature(Required)

PRIVACY POLICY ACKNOWLEDGEMENT FORM

I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and Federal Bureau of Investigation, which describes the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse. I understand and agree that I will read and comply with the guidelines contained in the privacy policies.

Employee/Contractor Name(Required)

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

MM slash DD slash YYYY

Employee/ Contractor Signature(Required)

Attestation of Compliance with Background Screening Requirements

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

Under penalty of perjury, I hereby swear or affirm that I meet the requirements for qualifying for employment in regard to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.

Employee/Contractor Name(Required)

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

MM slash DD slash YYYY

Employee/ Contractor Signature(Required)

ELECTRONIC DOCUMENTATION AND SIGNATURE AUTHENTICITY AGREEMENT

I understand that Agency staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as authentication on patient record documents and other agency documents generated in the electronic system. For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge my use of the Signature Passcode, and my Login authentication password will serve as my legal signature. I further understand that the Administrator issues employee passwords and the Signature Passcode’s are issued by the software application. Signature Passcodes and passwords will be changed on an as needed basis if system security is breached. I understand that prior to exporting documentation to the agency server, I am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. (OASIS Comprehensive Assessments will not require electronic signature until required information is obtained, which may be up to five days after the corresponding MO date i.e.: MOO30, MOO32 etc.) I understand that: I cannot divulge my login password, Signature Passcode, I must exit the computerized application at the end of each working day or whenever the computer is not in my immediate possession, I must type in (rather than save) the login password that allows me access to the agency computer network, and my Signature Passcode. I must review all of my documentation online prior to submitting it to the agency server.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

FIELD EMPLOYEE STANDARDS AND PROCEDURES

Standards and Procedures

This Agency requires adherence to the following Standards and Procedures:

1. All employees are expected to dress in a manner appropriate to the healthcare environment, or as directed by the patient/client/family. This includes personal hygiene, jewelry, hair and makeup.

2. Please do not smoke in the presence of a patient/client.

3. Always wear your ID Badge.

4. You are expected to arrive on time to all assignment that you have accepted. However, if an emergency or any situation should cause you to be five minutes late, or more or to be totally absent from the assignment you must notify the Agency immediately. PLEASE DO NOT CALL YOUR PATIENT DIRECTLY. You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment. A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION!

5. If you have any problem, incident or accident on the job, do not discuss it with the patient/client, but call the Agency immediately.

6. If the patient/client asks you to stay longer than your assignment or to leave earlier, you must call the Agency first, for approval.

7. Paraprofessional personnel (i.e. Aides) hereby acknowledge that they WILL NOT UNDER ANY CONDITIONS, DISPENSE OR ADMINISTER ANY MEDICATION.

8. UNDER NO CIRCUMSTANCES are you to ask for or accept any money from your patient/client or take home property that belongs to the patient/client.

9. There shall not be any involvement with the patient/client’s financial affairs (i.e. check writing).

10. You are expected to honor the confidentiality of any patient/client information which is obtained in the regular course of your employment.

11. No personal telephone calls should be made or received by you while on assignment.

12. Please do not discuss your pay or any other personal affairs with the patient/client/family.

13. As an employee of this Agency, you are not authorized to accept any direct employment that may be offered to you by your patient/client/family. If you are requested to do so, please have the patient/client contact us.

14. It is imperative that all signed notes and documentation, including Daily Log, be filled out properly and returned to the office as per our schedule. If the patient/client is unable to sign your note, a family member or responsible party may sign.

15. During the course of employment, this Agency’s proprietary materials (i.e. forms, medical records) will be used only in connection with employment and will not be disclosed to anyone without authorization from the Agency.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Employee/Contractor Signature(Required)

Confidentiality-Non-Compete Agreement

Agreement

The Agency requires that the Employee avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition.

The Employee agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding employees, clients and the Agency business.

The Employee will have access to information not generally made available to the public, such as identity of clients, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purpose other than for the Agency's own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to Agency administration and/or projects, or outside investigations of the Agency. The employee is prohibited from disclosing any defaming information regarding Agency personnel and/or personnel incidents related to any violations of the personnel policies.

During the course of employment and for a twelve month period thereafter the Employee is prohibited from engaging in any of the following: induce any employee of the Agency to resign, encourage any client or entity to discontinue any relationship with the Agency, solicit any client of the Agency (current and within the past twelve month period), enter into competitive employment or seek to provide competitive services while employed within twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source.

Upon termination of employment or at the request of the Agency, the Employee is required to return all of the Agency's property including keys, client records, ID badge, forms, manual, beeper, etc. to the Agency and will not retain copies.

Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, cost of replacing and training employees improperly solicited for competitive employment, etc. suffered by the Agency. Employees will be required to reimburse the Agency for all legal fees, costs and other expenses.

This agreement is in effect during the Employee's employment and for twelve months thereafter. It does not modify the right of the Employee to resign at any time or of the Agency to terminate employment without prior cause, notice or liability and does not modify any other Agency policy.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Employee/Contractor Signature(Required)

EMPLOYEE POLICIES AND PROCEDURES

Policy Acknowledgment

 I understand that copies of policy and procedure manuals are available and that it is my responsibility to read, understand and confirm all applicable Agency policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions.

 I have read the Agency’s Policy and Procedure on Abuse, Neglect and Exploitation and agree to comply with and am bound by the Policy.

 I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its employees, nor is it an expression of my term of employment.

 I affirm that I have auto insurance coverage as required by this state and the Agency and I agree to keep it fully in force on any vehicle I use for the conduction of Agency business during the term of my employment. The Agency has the right to request proof of insurance at any time during the term of employment and that I am required to follow all Agency requirements and state and local laws.

 I understand that only the Agency has the authority to admit clients and will supervise with appropriate personnel all services provided.

 As a caregiver, I will carry out the plan of treatment, submit time sheets, clinical and progress notes as appropriate and, at a minimum, on a weekly basis, I will participate in developing and reviewing plans of care, periodic client evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend required staff meeting and in-service training. Home health aides are required to have 12 hours of in-service training annually.

 I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided. I understand that all information, both written and verbal, regarding client and employee health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease; testing, results or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, drug or alcohol abuse is protected under specific law. All information in connection with the examination, care or provision of services to any client will not be disclosed without the individual's written consent except as may be necessary to provide services as required by law. Information may be used in statistical or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of client/ employee confidentiality is subject to civil and criminal penalties.

 If I mistakenly exceed my accrued or earned sick or vacation leave balance, I authorize the Agency to deduct any amount from my paycheck(s) to correct my accrued or earned sick or vacation leave balance. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Employee/Contractor Signature(Required)

RECEIPT OF JOB DESCRIPTION & EMPLOYEE HANDBOOK

Employee Handbook Acknowledgment

This is to acknowledge that I have received a copy of the Agency Employee Handbook and understand that it sets forth the terms and conditions of my employment as well as the duties, responsibilities, and obligations of employment with the company. I understand and agree that it is my responsibility to read the Employee Handbook and abide by the rules, policies, and standards set forth in the Employee Handbook.

My signature below indicates that I have received a copy of the Company's Personnel Policies and Procedures Manual.
I understand that this manual contains information regarding the Company's rules, regulations and benefits which affect me as an employee/contractor.
I acknowledge that I have read and understood Company policies.
I also understand that the Company may revise, supplement or rescind policies, procedures or benefits described in the manual, with or without notice.
I understand and agree to comply with the present and future guidelines and procedures set forth in the Handbook and any future revisions thereof.
I further understand that this Handbook is intended to be informational only, that The Practice may discontinue it or change it from time to time, and that, since The Practice is an "at will" employer, my employment or contract may be terminated by me or The Agency for any reason, with or without cause, and with or without notice, and nothing in this Handbook may be interpreted as a contract between me and The Practice or a promise of continued employment or provision of services.
I understand that no individual manager or supervisor at The Agency, other than the Administrator (or similarly situated officer), and only in a signed and written document, has the authority to alter this at-will arrangement.
I acknowledge that my employment with the Agency is not for a specified period and I can be terminated at any time for any reason, with or without cause or notice, by me or by the company. I acknowledge that no oral or written statements or representations regarding my employment can alter the foregoing. I also acknowledge that no employee has the authority to enter into an employment agreement—express or implied—providing for employment other than at will.
I acknowledge that except for the policy of at-will employment, the company reserves the right to revise, delete, and add to the provisions of this Employee Handbook. All such revisions, deletions, or additions must be in writing and must be signed by the President of the company. No oral statements or representations can change the provisions of this Employee Handbook. I also acknowledge that, except for the policy of at-will employment, terms and conditions of employment with the company may be modified at the sole discretion of the company with or without cause or notice at any time. No implied contract concerning any employment-related decision, term of employment, or condition of employment can be established by any other statement, conduct, policy, or practice.
I understand that the foregoing agreement concerning my at-will employment status and the company's right to determine and modify the terms and conditions of employment is the sole and entire agreement between me and our Agency concerning the duration of my employment, the circumstances under which my employment may be terminated, and the circumstances under which the terms and conditions of my employment may change. I further understand that this agreement supersedes all prior agreements, understandings, and representations concerning my employment with the company.
If I have questions regarding the content or interpretation of this handbook, I will bring them to the attention of my supervisor.
I have read and completely understand my job description issued to me by Essential Healthcare Services dba The Agency Staffing. I agree to follow the complete description of what my job will consist of to the best of my ability.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Employee/Contractor Signature(Required)

PERSONAL PROTECTIVE EQUIPMENT FOR SAFETY AND INFECTION CONTROL ACKNOWLEDGMENT

I understand a Personal Protective Equipment (PPE Kit) is available in the office and contains the following:

Barrier Safety Goggles
CPR Shield Face Barrier
Fluid Resistant Gown
Gloves
Biohazard Bag
Sharps Container
TB Mask (N95 or similar purchased from Uline.com)

I have been instructed in the use of this equipment and understand that I must comply with Policies and Procedures regarding use of personal protective equipment.

CORPORATE COMPLIANCE POLICY

Acknowledgment of Receipt and Understanding

As you know, our Home Care Agency and our Staff members have always been committed to providing exceptional health care and upholding ethical conduct standards and legal compliance.

Our policy formally and clearly states that there is zero tolerance to any form of fraud or misconduct.

This Agency believes that every employee or agent plays a key and active role in maintaining its image and reputation.

I hereby acknowledge that I have appraised of and agree to comply with the Agency’s Corporate Compliance Policy. I understand that in no way does this create an obligation or contract of employment and that I, as well as the Agency, have the right to end the employment relationship at any time.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Employee/Contractor Signature(Required)

Background Check Consent Form

Authorization & Release Form

REQUEST, AUTHORIZATION, CONSENT & RELEASE FOR INVESTIGATIVE BACKGROUND INFORMATION

These abovementioned reports may include but are not limited to information as to my character, general reputation, and personal characteristics, motor vehicle records, criminal records, current and former employers, military records, and educations records, professional and personal references. I request, authorize and consent to the release and disclosure of all information including but not limited to the above to, The Agency and Investigative Company.

This authorization in original or copy form shall be valid for one year from the date indicated next to my signature. According to the Fair Credit Reporting Act, The Agency will notify me if employment is denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that upon written request to "SCS" within a reasonable amount of time after the date indicated below, I will be given a full and accurate disclosure as to the nature and substance of all information provided to Essential Healthcare Services further understand that when requesting a copy of the report, proper identification will be required and I should direct my request to management.

This consumer authorization serves as the required, stand alone, consumer notification that a report may be requested and used for the purpose of evaluating me for employment, promotion, reassignment, or retention as an employee.

I understand that any decision to hire me is contingent upon the results of an investigator report. I further understand that misrepresentation or omission of information will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered.

Please provide me with a copy of my background investigation report. Yes No

List former names under which you have been employed:

Employee/Contractor Name(Required)

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

MM slash DD slash YYYY

Signature(Required)

Auth to Release Information Form

Please PRINT clearly in black ink (Initial All & Sign Below) ***This form should be completed by the applicant.*** I AUTHORIZE MY EMPLOYERS, SCHOOL, LAW ENFORCEMENT AGENCIES AND/OR PERSONS WHO MAY AIDE Essential Healthcare Services IN DETERMINING MY SUITABILITY FOR PLACEMENT TO PROVIDE REFERENCE INFORMATION TO ESSENTIAL SERVICES. I RELEASE ALL SUCH EMPLOYEES, INDIVIDUALS AND/OR ORGANIZATIONS CONTACTED FROM ALL LIABILITIES FOR ISSUING THIS INFORMATION TO Senior Care Source, Inc.

I ALSO AUTHORIZE Essential Healthcare Services TO DISCLOSE INFORMATION TO A CLIENT ONLY AFTER RECEIVING MY CONSENT ON EACH JOB OPPORTUNITY.

Employee/Contractor Name(Required)

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

MM slash DD slash YYYY

Signature(Required)

Influenza Vaccination Accept/ Declination

Healthcare Form

Essential Healthcare Services has recommended that I receive the influenza vaccination to protect the patients I serve. I understand that because I work in a health care environment, I may place others at risk if work while infected with the influenza (flu) virus.

In declining an influenza vaccination for non-medical reasons, I am aware that:

Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year.
Influenza vaccination is recommended for me and all other healthcare workers to prevent influenza disease and its complications, including death.
If I contract influenza, I will shed the virus 24-48 hours before influenza symptoms appear. My shedding the virus can spread influenza infection to patients in this facility.
If I become infected with influenza, even when my symptoms are mild, I can spread severe illness to others. I understand that the strains of virus that cause influenza infection change almost every year, which is why a different influenza vaccine is recommended each year.
I cannot get the influenza disease from the influenza vaccine.
The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including patients in this healthcare setting, my coworkers, my family or my community.

Despite these facts, I am choosing to decline influenza vaccination right now. If I change my mind, I can receive a free influenza vaccination by notifying Essential Healthcare Services so long as the vaccine is still available.

I have read and fully understand the information presented above and choose to decline vaccination.

I further understand that it is the policy of this agency that all unvaccinated staff members will be required to wear a mask when providing services or when in contact with patients/clients/consumers.

Hepatitis B Accept/Declination

O.S.H.A. Regulation states that all health care professionals with occupational exposure to bloodborne pathogens must be offered hepatitis B vaccinations. You have been determined to be at risk to blood borne pathogens.

I have already received the hepatitis B vaccine.

I decline the hepatitis B vaccine

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine. However, I decline hepatitis B vaccination at this time. I understand that by declining this 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 vaccination series.

Employee/Contractor Name(Required)

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

MM slash DD slash YYYY

Signature(Required)

CONSENT FOR DRUG/ALCOHOL SCREEN TESTING

If you are offered and accept an assignment with Essential Healthcare Services in the interest of safety for all concerned, you will be required to take a urine test for drug and/or alcohol use. I, have been fully informed of the reason for this urine test for drug and/or alcohol (I understand what I am being tested for), the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my potential employer and become part of my record. If this test is positive, and for this reason I am not hired, I understand that I will be given the opportunity to explain the results of this test. I hereby authorize these test results to be released to Essential Services

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Abuse Statement

I Have never been shown by credible evidence (via a court or jury, a department investigation or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of or intentional or grossly negligent misconduct as evidence by an oral or written statement to this effect obtained at the time of application.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Conflict Of Interest

Conflict of Interest Policy

POLICY:

No employee or member of the Governing Body, Advisory Committee, or other individual, committee, or entity shall derive any profit or gain directly or indirectly by reason of their association with the agency, without the prior knowledge and approval of the Governing Body. All board members and/or employees, at the discretion and specific request of the board, will be required to submit a disclosure statement annually.

If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Administrator and Governing Body.

In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the agency and a board member shall not participate in discussions unless requested by the board nor vote on such transactions. The abstention and the reason for it shall be recorded in the minutes.

Field staff in any capacity understand that all patients are patients of the Agency not personal patients of the field staff. Patients may never be serviced privately by an employee of Our Agency for the financial gain of the employee. Should an employee terminate employment with Essential Healthcare Services, the field staff understand that the patient may not be encouraged or otherwise moved from our Agency to another agency.

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST

I have read and am fully familiar with the agency’s policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other matters in which I would profit or gain directly or indirectly as a result of my membership of the agency’s Governing Body or its committees or my employment. Furthermore, I agree to disclose any such interest which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the agency’s business that might result in any profit or gain directly or indirectly, for myself.

I also work for another homecare agency:(Required)

Yes

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

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Orientation Handbook

Orientation Handbook for Independent Contractors, Student Interns, and Agency Staff:

Initial and Annual Trainings

Emergency Preparedness Acknowledgement of Understanding and Compliance Form for Contractors/Interns/Temporaries

I have received a copy of the InnovAge Emergency Preparedness/Hazard Communication Instructional Guide for Independent Contractors, Student Interns and Agency Staff. This information has been reviewed by me, and I was given the opportunity to have any questions answered before signing the acknowledgement. By my signature below, I attest that I have read and understand the contents of the Emergency Preparedness Instructional Guide. I also acknowledge that I am capable and will abide by these rules as an independent contractor, student intern, or agency staff.

Bloodborne Pathogens Acknowledgement of Understanding and Compliance Form for Contractors/Interns/Temporaries

I have received a copy of the InnovAge Bloodborne Pathogens Instructional Guide for Independent Contractors, Student Interns and Agency Staff. This information has been reviewed by me, and I was given the opportunity to have any questions answered before signing the acknowledgement. By my signature below, I attest that I have read and understand the contents of the Bloodborne Pathogens Instructional Guide. I also acknowledge that I am capable and will abide by these rules as an independent contractor, student intern, or agency staff.

Hazard Communication Acknowledgement of Understanding and Compliance Form for Contractors/Interns/Temporaries

I have received a copy of the InnovAge Hazard Communication Instructional Guide for Independent Contractors, Student Interns and Agency Staff. This information has been reviewed by me, and I was given the opportunity to have any questions answered before signing the acknowledgement. By my signature below, I attest that I have read and understand the contents of the Hazard Communication Instructional Guide. I also acknowledge that I am capable and will abide by these rules as an independent contractor, student intern, or agency staff.

HIPAA Privacy and Security Acknowledgement of Understanding and Compliance Form for Contractors/Interns/Temporaries

I have received a copy of the InnovAge HIPAA Privacy and Security Instructional Guide for Independent Contractors, Student Interns and Agency Staff. This information has been reviewed by me and I was given the opportunity to have any questions answered before signing the acknowledgement. By my signature below, I attest that I have read and understand the contents of the HIPAA Privacy and Security Instructional Guide. I also acknowledge that I am capable and will abide by these rules as an independent contractor, student intern, or agency staff.

Dementia and Alzheimer’s Acknowledgement of Understanding and Compliance Form for Contractors/Interns/Temporaries

I have received a copy of the Dementia and Alzheimer’s Curriculum for Independent Contractors, Student Interns and Agency Staff. This information has been reviewed by me, and I was given the opportunity to have any questions answered before signing the acknowledgement. By my signature below, I attest that I have read and understand the contents of the Dementia and Alzheimer’s curriculum. I also acknowledge that I am capable and will abide by these rules as an independent contractor, student intern, or agency staff.

Geriatric Care: Risk Factors and Chronic Conditions Acknowledgement of Understanding and Compliance Form for Contractors/Interns/Temporaries

I have received a copy of the Geriatric Care: Risk Factors and Chronic Conditions for Independent Contractors, Student Interns and Agency Staff. This information has been reviewed by me and I was given the opportunity to have any questions answered before signing the acknowledgement. By my signature below, I attest that I have read and understand the contents of the Geriatric Care: Risk Factors and Chronic Conditions curriculum. I also acknowledge that I am capable and will abide by these rules as an independent contractor, student intern, or agency staff.

Orientation Handbook Acknowledgement

I have received a copy of the InnovAge Orientation Handbook for Independent Contractors, Student Interns and Agency Staff. This information has been reviewed with me along with the essential functions of the assignment I have been given. By my signature below, I attest that I have read and generally understand the contents of the handbook and that I am capable of performing the functions to which I have been assigned as an independent contractor, student intern, or agency staff. I also understand that I am not an employee of InnovAge and am therefore not eligible for any employee benefits or programs.

Employee/Contractor Name(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Direct Deposit Information Form

I hereby authorize Essential Healthcare Services dba Essential Staffing Services to deposit the entire net amount owed to me directly to my account(s) indicated below electronically or by any other commercially accepted method. I agree to notify my employer immediately of any changes to the information indicated below so that my pay may be properly distributed. I understand that in the event my employer notifies my financial institution that I am not entitled to the funds deposited to my account, my bank is authorized to debit my account for the adjustment. I understand that in the event my financial institution is not able to deposit any electronic transfer into my account due to any action I take, my employer can NOT issue the funds to me until the funds are returned to my employer by my financial institution.

Untitled(Required)

New Agreement

Change Account

Cancel Agreement

Employee Information

Employee Name(Required)

Social Society #(Required)

Account Information

Bank Name(Required)

Routing Number(Required)

Untitled(Required)

Checking

Savings

Account Number(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Emergency Contact List

Must supply at least one emergency contact.

Employee Name(Required)

Address(Required)

Phone(Required)

Employee Name

Address

Phone

Areas of Availability Checklist

Applicant Name:(Required)

Hillsborough County

Tampa 33602

Tampa 33605

Tampa 33609

Tampa 33612

Tampa 33615

Tampa 33618

Tampa 33625

Tampa 33634

Tampa 33647

Riverview 33569

Riverview 33568

Seffner 33584

Plant City 33566

Temple Terrace 33617

Ruskin 33570

Sun City Center 33573

Lutz 33558

Hillsborough County

Tampa 33603

Tampa 33606

Tampa 33610

Tampa 33613

Tampa 33616

Tampa 33619

Tampa 33626

Tampa 33635

Brandon 33510

Riverview 33578

Valrico 33594

Plant City 33563

Dover 33527

Temple Terrace 33637

Ruskin 33573

Lutz 33548

Odessa 33556

Hillsborough County

Tampa 33604

Tampa 33607

Tampa 33611

Tampa 33614

Tampa 33617

Tampa 33624

Tampa 33629

Tampa 33637

Brandon 33511

Riverview 33579

Valrico 33596

Plant City 33565

Thonotosassa 33592

Apollo Beach 33572

Wimauma 33598

Lutz 33549

Polk County

Lakeland 33801

Lakeland 33809

Lakeland 33812

Winter Haven 33880

Haines City 33844

Davenport 33897

Bartow 33830

Lake Wales 33859

Polk County

Lakeland 33803

Lakeland 33810

Lakeland 33813

33881

Davenport 33837

Auburndale 33823

Fort Meade 33841

Mulberry 33860

Polk County

Lakeland 33805

Lakeland 33811

Lakeland 33815

33884

Davenport 33896

Polk City 33868

Lake Wales 33853

Highland City 33846

Manatee County

Bradenton 34201

34205

34208

34211

Ellenton 34222

Holmes Beach 34217

Myakka City 34251

Manatee County

34202

34206

34209

34212

Palmetto 34220

Parrish 34219

Bradenton Beach 34217

Cortez 34215

Manatee County

34203

34207

34210

Lakewood Ranch 34202

34221

Anna Maria 34216

Longboat Key 34228

Availability

Days

8-hour

Availability

Nights

12-hour

Availability

Weekends

Overnight

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 Name(Required)

Date(Required)

MM slash DD slash YYYY

Employee/ Contractor Signature(Required)

Post-Hire Medical Questionnaire

This Home Health Agency is committed to encouraging the employment of physically disabled persons, but it also wants to protect its rights to seek reimbursement from the Special Disability Trust Fund if an employee's pre-existing condition contributes to a subsequent injury by that employee in the course of employment. Your answers to this Questionnaire will not be used as the bases for deciding whether to employ you and your response to this questionnaire will be considered and treated as a confidential medical record which will not be included in your personnel file. Warning! This Home Health Agency, and its insurance carrier intend to rely upon the information provided by you in this Questionnaire. It is your obligation to provide truthful and complete information in response to the questions presented below. If it is later determined that you gave an intentional false response, you may be disqualified from receiving workers' compensation benefits. In addition, you may be subject to termination of employment if it is later determined that you deliberately falsified your responses to this Questionnaire. INSTRUCTIONS- Answer YES or NO to the following questions. If your answer is YES listing the approximate date of injury or treatment.

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

Upload all documents listed :

Document List

State-issued ID
Social Security Card
Passport
Professional License
CPR Card (2yr)
Health Statement
ID Badge Photo

Note: All files should be in Photo or PDF.

Note: Please upload one document at a time to allow for complete submission

State-issued ID Front & Back(Required)

Drop files here or

Max. file size: 512 MB.

Social Security Card Front & Back

Drop files here or

Max. file size: 512 MB.

Passport

Drop files here or

Max. file size: 512 MB.

Professional License

Drop files here or

Max. file size: 512 MB.

CPR Card (2yr)

Drop files here or

Max. file size: 512 MB.

Health Statement

Drop files here or

Max. file size: 512 MB.

ID Badge Photo

Drop files here or

Max. file size: 512 MB.

Instruction: All sections must display a green checkmark before pressing the submit button.

Homemaker /Companion Forms

Caregiver Employment Application

Personal Information

References

Education

Caregiver Job Description

JOB ACCEPTANCE STATEMENT

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST

INDEPENDENT CONTRACTOR AGEEMENT

Employee Emergency Contact Information

TB Questionnaire

Hepatitis Vaccine Requirement

ACKNOWLEDGEMENT OF CONFIDENTIALITY

CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION

PROTECTION OF HEALTH INFORMATION

HIPAA CONFIDENTIALITY AGREEMENT

PRIVACY POLICY ACKNOWLEDGEMENT FORM

Attestation of Compliance with Background Screening Requirements

ELECTRONIC DOCUMENTATION AND SIGNATURE AUTHENTICITY AGREEMENT

FIELD EMPLOYEE STANDARDS AND PROCEDURES

Confidentiality-Non-Compete Agreement

EMPLOYEE POLICIES AND PROCEDURES

RECEIPT OF JOB DESCRIPTION & EMPLOYEE HANDBOOK

PERSONAL PROTECTIVE EQUIPMENT FOR SAFETY AND INFECTION CONTROL ACKNOWLEDGMENT

Background Check Consent Form

Auth to Release Information Form

Influenza Vaccination Accept/ Declination

Hepatitis B Accept/Declination

CONSENT FOR DRUG/ALCOHOL SCREEN TESTING

Abuse Statement

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