New Hire Application | Unlimitedcare4

EMPLOYMENT APPLICATION

First Name

Middle Name

Last Name

Today's Date

Street Address

Unit Number

City

State

Zip Code

Phone

Date Available

Preferred Work Schedule

Day

Evening

Night

Are you permitted to work in the United States?

Yes

EDUCATION

PROFESSION

Please list any Licenses, Registrations and/or certifications that you have earned.

State

Number

Year Received

Exp. Date

Please list any Licenses, Registrations and/or certifications that you have earned.

State

Number

Year Received

Exp. Date

Please list any Licenses, Registrations and/or certifications that you have earned.

State

Number

Year Received

Exp. Date

EMPLOYMENT HISTORY

Employer's Name

Start Date

Employer's Address

Supervisor's Name & Title

End Date

Job Title

Position Responsibilities

Phone

Reason for Leaving

Employer's Name

Start Date

Employer's Address

Supervisor's Name & Title

End Date

Job Title

Position Responsibilities

Phone

Reason for Leaving

Employer's Name

Start Date

Employer's Address

Supervisor's Name & Title

End Date

Job Title

Position Responsibilities

Phone

Reason for Leaving

I certify that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation, willful omission, false or misleading information is grounds for rejection of this application form, refusal to hire, withdrawal of an offer of Employment, or immediate discharge whenever discovered. You are authorized to conduct investigations, including verification of prior employment history and education. I also understand that employment is dependent upon receipt of acceptable employment references and satisfactory completion of pre-employment health screening which will include illicit drug and alcohol testing and provision of documents required by the Immigration reform and Control Act of 1986. UNLIMITED CARE 4 CORPORATION does not discriminate against any qualified person because of age, race, color, religion, sex, national origin, disability or sexual orientation. By signing this application, I acknowledge that an offer of employment at UNLIMITED CARE 4 CORPORATION should not be interpreted as an offer of continued or permanent employment.

Your Signature

Curret Date

REQUEST FOR REFERENCES

Reference 1 First and Last Name

Reference 2 First and Last Name

Reference 3 First and Last Name

Referance 1 Phone

Referance 2 Phone

Referance 3 Phone

Reference 1 Address

Reference 2 Address

Reference 3 Address

I authorize and request my former/current employer, person given as a reference to answer all questions asked and give all information requested concerning my work performance, character, and job-related skills.

EMPLOYEE EMERGENCY INFORMATION

Person 1 to contact in case of Emergency

Relationship

Phone Number

Address

Person 1 to contact in case of Emergency

Relationship

Phone Number

Address

HOME HEALTH AIDE SELF COMPETENCY CHECKLIST

Instructions: Use the following answer key to indicate the extent of your previous experience and personal rating of experience.

BACKGROUND CONSENT FORM

I hereby authorize: UNLIMITED CARE 4 CORPORATION and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment, which may include Urine, Substance Abuse Testing. I release UNLIMITED CARE 4 CORPORATION and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regard to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name and all information is true and correct to the best of my knowledge.

Full Name Printed

Maiden or Other Names Used

Present Address (Street, City, State, Zip Code):

How long have you been at this address?

Former Address (Street, City, State, Zip Code):

How long have you been at this Former address?

Date of Birth

Social Security Number

Driver's License Number

State of License

Signature of Employee

Today's Date

SWORN DISCLOSURE STATEMENT

INSTRUCTIONS:

Effective July 1992, section 63.1-19413, Code of Virginia and UNLIMITED CARE 4 CORPORATION require that persons desiring registering with our agency provide a sworn statement of affiliation disclosing any criminal convictions or pending or pending criminal charges, whether within or outside the Commonwealth of Virginia.

Individuals convicted of the following cannot be hired: murder, abduction for immoral purposes, assaults and bodily wounding, robbery, sexual assault, arson, pandering crimes against nature involving children, taking indecent liberties with children, abuse and neglect of children, failure to secure medical attention for an injured child, obscenity offenses or abuse or neglect of an incapacitated adult. However, applications of convicted of one misdemeanor crime not involving abuse of neglect or moral turpitude may be hired provided five years has elapsed since the conviction.

Any person taking a false statement on this form regarding any criminal offense shall be guilty upon convictions of Class I misdemeanor.

Further dissemination of the information provided on this form is prohibited other than to a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.

Please print the information required in section one.

This statement must be provided to and maintained by the property in the employee's personal file.

First Name

Middle Name

Last Name

Social Security No.

EMPLOYEE AGREEMENT

I, employed as a, RN/CNA/HHA or LPN, have agreed to carry out the duties and responsibilities listed on my job description. I have been given a copy of my job description.

I have read and agree to the terms specified in this job description for the position I presently hold. I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.

Both the employer (UNLIMITED CARE 4 CORPORATION) and I, will treat each other with

mutual respect.

I understand that this job position may require a lot of flexibility and transportation on my part based on the needs of the clients that I may be assigned to work with.

I understand that my compensation for services with family healthcare services is based on hourly basis.

I acknowledged to have received a copy of my schedule and understand that this may change based on client’s needs.

It is my responsibility to notify UNLIMITED CARE 4 CORPORATION at least two weeks' in

advance if I chose to terminate this agreement. I also understand that UNLIMITED CARE 4

CORPORATION (employer) can terminate my services at any time with or without cause.

Signature of Employee

Today's Date

DRUG AND ALCOHOL POLICY AGREEMENT

It is the policy of UNLIMITED CARE 4 CORPORATION that all its employees be free of the influence of alcohol and drugs. All employees must be fit for the duty physically and mentally, as is necessary to perform work in a safe and competent manner.

Possession, trading, manufacture and sale of illegal drugs or alcohol on the job is therefore a violation of this policy.

Also, it is a violation of this policy to work under the influence of illegal drugs or alcohol. Violations of this policy are subject to disciplinary action up to and including termination.

I certify that I am not under the influence of drugs or alcohol, nor will I use or possess in anyway controlled substances (marijuana, heroin, cocaine, crack, hash etc.). I understand that these examples do not cover all controlled substances. Failure to comply ·with this agreement may result in termination of my employment with UNLIMITED CARE 4 CORPORATION I have been briefed and fully understand UNLIMITED CARE 4 CORPORATION drug and alcohol policy and I agree to fully comply with the provisions herein.

Signature of Employee

Today's Date

JOB DESCRIPTION

JOB TITLE: Home Health Aide

REPORTS TO: Registered Nurse/Administrator

JOB SUMMARY: The Home Health Aide carries out supportive duties for the Nursing Department of a health care provider by performing specified non-skilled medically related skills under the direction and supervision of a Registered Professional Nurse, other agency designated health care professional and administrator.

JOB RESPONSIBILITIES:

Follows personal care activities documented in a written assignment by a health professional (RN or Therapist). Activities include assistance with personal care hygiene, activities of daily living.

Encourages client participation in activities to the extent to which client is able.
Assists with ambulation, eating, dressing, shaving and physical transfer.
Assists client to bed, commode, and/or chair
Turns and position bed bound client
Maintain appropriate documentation of all services as per agency policy and procedure
Changes bed linen
Maintains a clean, safe and healthy environment
May grocery shop for list often items or less
Informs supervisor of any changes in client's condition or home situation.

ACTIVITIES THE HOME HEAL TH AIDE MAY NOT PERFORM INCLUDE:

Administration of Medication
Irrigation of urinary catheters, colostomies, or wounds
Noso- gastric tube feeding or gastric irrigation
Catheterization
Applying heat by any method
Changing of sterile dressing
Any other services not included in the client's care package.
Any services requiring the skills of a licensed nurse and/or therapist.
Irrigate body cavities such as giving an enema
Providing care to a tracheotomy tube.

QUALIFICATIONS:

Must provide evidence of formal training and/or certification as a home health aide as required by state law and federal law. Must also provide evidence of competency training and evaluation as well as evidence of at least quarter attendance of in-service education programs. Must have a sympathetic attitude towards the care of the sick as well as have the ability to read, write and carry out job directions and the maturity and ability to deal effectively with the demands of the job. A minimum of one (1) year current experience and high school diploma is preferred.

By my signature, I acknowledge and accept the responsibilities of this position. I am qualified by education and/or experience to carry out these duties.

Signature of Employee

Today's Date

SALARY AGREEMENT

I accept the agreed upon hourly rate/salary by Unlimited Care 4 HHC.

I understand that if I apply for a full-time position, I would be on an initial 90 days probationary

period after which an evaluation of my performance would made by my supervisor. Final offer for the position would then be made If I have met the satisfactory requirements for the job description.

An annual performance evaluation would be performed by the administrator/director as outlined in the agency's policies and procedures.

To maintain exclusive professional standards, UNLIMITED CARE 4 CORPORATION, prohibits any staff to solicit or transfer patients under their care to another agency/provider while employed as a staff or for 2 years after staffs employment is terminated. If I hired as an administrative staff, I would not establish/set-up or own a Home Health care Agency for two years from termination of my service with UNLIMITED CARE 4 CORPORATION.

Signature of Employee

Today's Date

EMPLOYMENT STATEMENT OF CONFIDENTIALITY

I, the undersigned, understand the importance of observing strict confidentiality policies. Therefore, I agree not to discuss / release any information obtained within the agency, any UNLIMITED CARE 4 CORPORATION client, their medical records, or any client's condition with any individual not directly associated with the client. I also agree that any information that is released regarding the client or the client's record will only be done with proper authorization and / or in accordance with established agency policy for the release of the information.

My signature on this document indicates that I understand and agree to abide by the aforementioned policies, and that any breach in the aforementioned policies will result in implementation of the Disciplinary procedure up to and including possible IMMEDIATE DISMISSAL from employment at UNLIMITED CARE 4 CORPORATION.

Signature of Employee

Today's Date

HEPATITUS B VACCINE DECLINATION FORM

I understand that due to the occupational exposure of blood or other potential infectious materials, I may be at risk of acquiring hepatitis B (HBV) infection. I have been informed about the importance of being vaccinated against hepatitis B. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B. If in the future I want to be vaccinated against hepatitis B, arrangements will be made for me to acquire the vaccine.

Employee's name

Signature of Employee

Today's Date

UNIVERSAL PRECAUTIONS QUIZ

Below is a set of 8 multiple choice and true/false questions. For multiple choice questions choose the one best answer. None of the questions are meant to be a trick question. Read each question carefully before choosing the correct answer.

1. Needle stick injures and exposure of mucous membranes of unintact skin to blood may lead to which disease:

AIDS/hepatitis B

Common cold or flu

Tuberculosis

2. What personal protective equipment (barriers) need to be worn to protect the mucous membranes of the face against splash with blood/body fluids?

Mask

Goggles

All of the above

3. Disposable gloves -

Should not be washed or disinfected

Should be worn when there is the possibility that hands may become soiled with blood/body fluids

Should be discarded after the procedures for which they were applied is completed

Ahould be discarded after the procedures for which they were applied is completed

4. Which of the following is true about Hepatitis B vaccine?

It cannot transmit AIDS or Hepatitis B to the person who receives it

It is very effective in preventing the transmission of Hepatitis B to exposed staff

All health care workers at risk of being exposed to Hepatitis B should consider being vaccinated against Hepatitis B

All of the above

None of the above

5. Under Universal Precautions, hands must be washed after gloves are removed because the gloves may contain tiny defects in them that can lead to band contamination.

True

False

6. Universal Precautions treats all blood as if it contains diseases causing organisms (germs).

True

False

7. Infectious waste must be placed in a labeled color- coded bag.

True

False

8. Universal Precautions must be followed because it is the law

True

False

9. A client offers a nurse aide a twenty-dollar bill as a thank you for what the aide has done. The aide should:

Take the money so as to not offend the client

Politely refuse the money

Take the money and buy something for herself

Ask the nurse in charge what to do

10. All of the following are examples of abuse or neglect except:

Assist in picking up the phone for the client

Leaving a client alone in the bathtub

Threatening to withhold the client's meal

Leaving a client in wet and soiled clothes to watch TV

11. If a client is found lying on the floor, what should the aide do?

Check for responsiveness

If unresponsiveness call 911

Call the office and the client's family

All of the above

12. In giving care according to client's Bill of Rights, the HHA should:

Provide privacy during client's personal care

Open the client's mail without permission

Use client's personal possession's for yourself

Prevent the client from complaining about care

13. A client wakes up in the night and asks for something to eat, the aide should:

Check the client's diet before offering nourishment

Tell the client that they can't eat during the night

Explain that breakfast will be available in four hours

Tell him that you are too tired to get up and get their meal

14. If a client is confused the aide should:

Ignore the client because what he says doesn't make sense

Watch the client so that he doesn't hurt himself

Lock the client in a room so that he does not bother you

Call agency and tell them the client is bothering you

15. What is the process of restoring a disabled client to the highest level of function?

Responsibility

Retention

Rehabilitation

Reincarnation

16. When providing care the aide should wash hands:

Before doing a task

After doing a task

Not wash hands because they are already clean

Both A & B are correct

17. Clean bed linen placed in client's room but not used should be:

Returned to the linen closet

Used for another client in the one-on-one room

Not wash hands because they are already clean

Both A & B are correct

18. The HHA finds a conscious client lying on the floor. The first thing the aide should do is:

Help the client to sitting position

Call for assistance to get the client up

Offer the client a cup of water

Check for signs of injury

19. If you find your client sad and crying, you should:

Ask the client if something is wrong

Tell the client to cheer up

Tell the client to stop crying because it is driving you crazy

Call the client's family

20. Client's have the right to:

Have access to a telephone

Have a decent meal

Given privacy when asked

All of the above

21. When a client is going to the hospital/nursing home, the aide should:

Call and notify the agency

Wait until the client is picked up

Home is where the Health is

Keep your loved one safe at home. Contact us today.

EMPLOYMENT APPLICATION

EDUCATION

PROFESSION

EMPLOYMENT HISTORY

REQUEST FOR REFERENCES

EMPLOYEE EMERGENCY INFORMATION

HOME HEALTH AIDE SELF COMPETENCY CHECKLIST

Instructions: Use the following answer key to indicate the extent of your previous experience and personal rating of experience.

BACKGROUND CONSENT FORM

SWORN DISCLOSURE STATEMENT

EMPLOYEE AGREEMENT

DRUG AND ALCOHOL POLICY AGREEMENT

JOB DESCRIPTION

SALARY AGREEMENT

EMPLOYMENT STATEMENT OF CONFIDENTIALITY

HEPATITUS B VACCINE DECLINATION FORM

UNIVERSAL PRECAUTIONS QUIZ