Yes ☑ No ☐
Yes ☐ No ☑
Yes ☐ No ☑
24/7 Home Care Agency of NY, Inc does not discriminate because of age, sex, physical handicap, race, creed, sexual orientation and any other protected classification, or national origin.
This agency is an equal employment opportunity employer.
I affirm that the information in this application is complete and true. I understand that if employed,
false statements will be a cause for dismissal.
I do not wish to be given the HBV vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. I am aware that I may request to be provided with the vaccination at a later date during my employment with the agency.
ACKNOWLEDGMENT OF RECEIPT
I have received the Personal Assistant’s guide and I have chosen to participate in the CDPAS as a Personal Assistant. I understand that 24/7 Home Care Agency of NY, Inc is the fiscal intermediary and I am hired, supervised, scheduled and trained by the consumer and/or designated representative. I have received, read and understand my role and responsibilities as Personal Assistant working for a Consumer or his/herDesignated Representative participating in the 24/7 HOMECARE AGENCY OF NY, INC. CDPAS Program.
I have had an opportunity to ask questions concerning my wage and benefit package.
I have received the copy of the CDPAS Handbook, Code of Conduct, Compliance Program, Paid Family Leave and Notice of Employee Rights (regarding sick leave). Equal Employment Opportunity Act, Wage Parity, Antisexual harassment notice and Fair Labor Standards Act (FLSA) on the date listed below 1 understand that this form will be retained in my personnel file.
I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, you agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in your or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.
My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions. I further agree that, in accordance with 24/7 HomeCare’s Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 HomeCare to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 Homecare Agency of NY. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.
I acknowledge that I have been provided with a copy of an 24/7 Home Care Agency of NY, Inc Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.
I will provide 24/7 Home Care Agency of NY, Inc with my driver’s license and insurance card in order to transport my patient in my car and/or the patient’s car.
I will not be transporting my patient in my car and/or my patient’s car.
► START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee Is authorized to work In the United States.
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document's I have examined appear to be genuine and to relate to the individual.
Complete Steps 2-4 ONLY If they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.
Complete the worksheet on page 4 before making any entries
I certify that I am entitled to the number of withholding allowances claimed on this certificate
Please complete the following:
For the plan year effective(04-29-2021) I am waiving coverage for:
☐ Spouse/Domestic Partner
☐ Dependent (s) Please list names:
I am waiving coverage due to:
☑ My preference not to have coverage
☐ Coverage under my spouse's/domestic partner's plan name of carrier:
☐ Other coverage name of carrier:
Special Enrollment Notice and Certification - Please review and sign below if you wish to waive coverage
By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage.
I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period.
In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.
24/7 HomeCare Agency of NY, Inc
Doing Business As(DBA) name(s) :
2414 Ralph Avenue
Brooklyn, NY 11234
2414 Ralph Avenue
Brooklyn. NY 11234
☐Before a change in pay rates (s), allowances claimed
3.Employee's rate(s) of pay for each type of work or shift:
☐ Tips _________ per hour
☐ Meals _________ per meal
☐ Lodging _________
☐ Other _________
5.Regular payday: Friday/p>
7.Overtime Pay Rates(s) for each type of
work or shift: 1.5xReg Pay Rate
This must be at least 1 1/2 times the worker's weighted average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week. The overtime rate may vary from week to week depending on how many hours you worked at each rate of pay. The overtime rate may vary from week to week.
On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given below. I told my employer what my primary language is.
Check one:☐I have been given this pay notice in English because it is my primary language.
The employee must receive a signed copy of this form. The employer must keep the original for 6 years.
This is to certify that I am in receipt of Corporate Compliance Training and Educational Materials from my Consumer enrolled in 24/7 HOMECARE AGENCY OF NY, INC. CDPAP pertaining to the Federal False Claims Act, New York False Claim Act, Whistleblower Protection and Identifying Fraud and Abuse Law, as well as where to report these issue should they be suspected or uncovered.
I have been informed regarding HIPAA Privacy Rules by as provided to me by 24/7 HOMECARE AGENCY OF NY, INC and I acknowledge compliance with these rules as per NYS mandate.
I understand that the major goal of the privacy rules is to assure that all of our consumers health information is properly protected, while allowing the flow of vital healthcare/clinical information to all employees participating in providing patient care/services. As such, we can provide and promote high quality, safe and effective homehealth care.
24/7 HOMECARE AGENCY OF NY, INC also protects the public's health and their well-being by implementing disciplinary action upon notifications on any HIPAA violations by our employees.
I,Personal Assistant certify that I have been trained regarding mandatory compliance responsibilities of the agency with the Department of Health. I have been trained and understand the following:
I acknowledge that I am solely responsible for these requirements in order to continue working with my CDPAP consumer. Violations of these requirements are grounds for immediate termination. I acknowledge that for the safety of the patients whom I will service, I will abide by 24/7 HomeCare policy.
I have received the Personal Assistant's guide and I have chosen to participate in the CDPAP as a Personal Assistant. I understand that 24/7 Home Care Agency of NY, Inc. is the fiscal intermediary and I am hired, supervised, scheduled and trained by the consumer and/or designated representative.
I understand that failure to accurately complete the time slip or the automated time and leave call in system may be construed as fraudulent and may result In disciplinary action.
I understand that my timesllps and automated time and leave call in must reflect the exact hours worked and that the work I do is for the consumer only. I understand that I must report my patient's hospitalization to the agency Immediately and that I can not be paid if the consumer is In the hospital.
I understand it is my responsibility to report any act of fraud or abuse.
If you are aware of any fraudulent activity and do not report It, you could be punished. Whistleblower laws protect employees against retaliation for reporting. All reports will remain confidential and can be filed in person or writing or verbally over the phone with: Sharon Halfon RN, Corporate Compliance Officer @ 718-887-0782.
I have received the Notice of Employee Rights for the Paid Safe and Sick Leave Law. My questions regarding Paid Safe and Sick Leave have been answered.
I know I can contact 24/7 Home Care Agency of NY, Inc, at the above address or telephone number if I have any other questions regarding this notice.
I understand the following about the Paid Safe and Sick Leave:
I acknowledge that I have received the necessary information and instructions regarding Paid Family Leave benefits.
I acknowledge that I will not be able to start working as a Personal Assistant for the CDPAS program until I am specifically informed by 24/7 Home Care Agency of NY,Inc that I am able to begin working on the case. Any allowance to work, that does not come directly from 24/7 Home Care Agency of NY, Inc, will be considered invalid. If I work under an invalid authorization I realize that I will not be able to be paid by 24/7 Home Care Agency of NY, Inc for the time that I worked. I understand that, generally, instructions to begin working as a Personal Assistant will be provided to me along with a caregiver code and an explanation of the process for clocking in and out.
My employer, 24/7 HomeCare Agency of NY, Inc, has recommended that I receive the influenza vaccination to protect the patients I serve.
I acknowledge that I am aware of the following facts:
Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:
I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available.
I also understand that I will need to wear a face mask during flu season while I am on a case with a patient.
I have read and fully understand the information on this declination form. I have also received a flu mask for this flu season.
☑I will NOT be getting the flu vaccine for the 2021-2022 Flu season. I will wear a surgical mask during any time spent with any patients.
☐I Received the Flu Vaccine for the 2021-2022 Flu Season.
I understand that failure to comply with these requirements will put me and the patient I care for at risk, and my employment with 24/7 HomeCare Agency of NY, Inc is conditional on meeting these requirements.
2414 Ralph Avenue Brooklyn, NY 11234 • T: 718-887-0782 • F: 718-874-2778 • Email: info(g)247nyhomecare.com
I, certify that I have been trained on the NYS Sexual Harassment Policy. I understand that Sexual harassment is a form of workplace discrimination. 24/7 HomeCare Agency of NY, Inc has a zero-tolerance policy for any form of sexual harassment, and all employees are required to work in a manner that prevents sexual harassment in the workplace. I also understand that Sexual harassment is against the law and that I have the legal right to a workplace free from sexual harassment, and I can file a complaint internally with, 24/7 HomeCare Agency of NY, Inc or with a government agency or in court under federal, state or local anti-discrimination laws. This policy applies to all employees, paid or unpaid interns, and non-employees and all must follow and uphold this policy.
I have been given the Complaint Form and contact information if I ever must file a complaint for sexual harassment.
Under a new New York state law, working New Yorkers will be able to take time off to care for a loved one while still receiving a portion of their salary. The eligible employees will now be able to take up to 8 weeks of benefits and job-protected leave in any 52-week period at up to 50 percent of their salary.
Full-Time employees (Individuals working 30 or more hours a week): must work 20 or more hours per week for 26 or more consecutive weeks of employment.
Part Time employees (individuals working less than 30 hours a week): must work fewer than 20 hours per week for 175 days in a 52-consecutive week period.
The employee must provide advance notice of 30 days. If providing notice of less than 30 days an explanation must be given.
Types of Leave
Payroll Deductions to Fund Paid Family Leave Benefits
The maximum employee contribution is 0.126 percent of their weekly wage, not to exceed $1,305.92 as per NY DOL.
New York State has more information about the Paid Family Leave program at www.ny.gov/paidfamilyleave
All requests for Paid Family Leave must be made through the Human Resources Department. Please call Sharon at 718-887-0782
I have received 24/7 Home Care Agency of NY, Inc, Personnel Policy and Privacy Notice. My questions regarding the Personnel Policy and Privacy Notice have been answered.
I know I can contact 24/7 Home Care Agency of NY, Inc at the above address or telephone number if I have any other questions regarding this form.
I further understand that my employment is at will, and neither 24/7 Home Care Agency of NY, Inc nor I have entered a contract regarding the duration of my employment. Except as otherwise provided in a valid and enforceable collective bargaining agreement, I am free to terminate my employment with the 24/7 Home Care Agency of NY, Inc at any time, with or without reason and 24/7 Home Care Agency of NY, Inc has the right to terminate my employment, or otherwise discipline, transfer, or demote me at any time, with or without reason at the discretion of the Facility. No employee of24/7 Home Care Agency of NY, Inc can enter into an employment contract for a specified period of time or make any agreement contrary to this policy without the written approval of the Administrator.
Dear Staff Member:
24/7 HomeCare Agency of NY, Inc is dedicated to conducting its business honestly and ethically wherever 24/7 HomeCare Agency of NY, Inc operates. In order to meet this commitment, 24/7 HomeCare Agency of NY, Inc as set forth in this Code of Conduct the principles and rules to be followed by all personnel who work with 24/7 HomeCare Agency of NY, Inc.
The purpose of this Code of Conduct is to inform all personnel and interested third parties that 24/7 HomeCare Agency of NY, Inc is fully dedicated to approaching all of its activities, including compliance with laws and regulations, in an ethical manner. This Code of Conduct will familiarize new personnel with the ethical standards that guide our business and patient relationships in our highly regulated environment. For existing personnel, it will reaffirm our commitment to ethical behavior in all circumstances. Since everyone at 24/7 HomeCare Agency of NY, Inc has a personal stake in this important program, we strongly urge each of you to review this information thoroughly and refer to it whenever situations arise requiring you to exercise your judgment.
Compliance with laws, regulations and out policies require the full commitment of all 24/7 HomeCare Agency of NY, Inc personnel. Each of us is personally and professionally responsible for understanding and adhering to this Code of Conduct and the supporting policies and procedures, including those areas covering your specific job responsibilities. The purpose of this Code of Conduct is to provide you with guidance on ethical and compliance issues. However, this Code of Conduct cannot cover every issue you may encounter. If you have a question or encounter a situation which concerns you, you should ask for 24/7 HomeCare Agency of NY, Inc through your department supervisor, the Administrator and/or the Compliance Officer.
Compliance Hotline is 718-887-2922 or the email is firstname.lastname@example.org
Purpose of the FAIR Program.
The Agency values each employee and looks forward to good relations with and among all of its employees. Occasionally, however, disagreements may arise between you and our agency or between employees in a context that involves the Agency We believe that the resolution of such disagreements will be best accomplished by internal dispute resolution and, where that fails, by external binding arbitration that is conducted by a neutral arbitrator. For these reasons, the Agency has adopted this Fact-Finding and Issue ResolutionProgram (the "FAIR Program"). The FAIR Program is effective immediately upon your execution of this document (the "Effective Date").
The FAIR Program is an essential element of Your employment and/or continued employment with the Agency.Although the FAIR Program Is a binding agreement between you and the Agency, It does not create a contract of employment for a specific term or otherwise affect the at-will nature of Your employment. You Indicate your agreement to be bound by the FAIR Program's terms and conditions by beginning or continuing your employment with the Agency.
What does the FAIR Program cover?
The FAIR Program applies to any and all Claims, regardless of when those claims arose or accrued or were first asserted, between You and the Agency (as these terms are defined below). For the avoidance of doubt, the FAIR Program applies to claims that accrued, arose, or were asserted before execution of this agreement and to claims that accrued, arose, or were asserted after execution of this agreement. The FAIR Program also applies to Claims that arise or are asserted after your employment with the Agency ends.
For purposes of the FAIR Program and this document, the following terms have the following meanings:
"The Agency" means 24/7 Homecare Agency of NY, Inc., each of its subsidiaries, affiliates, and successor entities, as well each of their partners, principals, owners, directors, agents, and employees against whom a Claim is asserted by You.
"You" and "your" refers to you and any other person who may assert your rights.
"Claim" includes any claim, dispute, allegation, controversy or action between you and The Agency that in any way arises from or relates to your employment with The Agency or the termination of your employment with The Agency, and that is based on a legally protected right (i.e., statutory, regulatory, contractual, or common-law rights). The term Claim includes, for example, any employment, labor, wage and hour, overtime, or compensation related claims. As further examples, the term Claim includes, without limitation, claims, disputes, demands or actions that may arise under the following laws (all as amended):
The above list is not exclusive, and is only provided to illustrate examples of Claims. All Claims, whether listed above or not, must be resolved through the FAIR Program.
Are any Claims excluded from the FAIR Program?
Yes. The term "Claim" does not include the following, which are for a court or an agency and not an arbitrator to decide:
The FAIR Program also does not prevent You from pursuing a claim based on alleged violations of any applicable collective bargaining agreement grievance procedure. Claims that are independent of rights under the CBA and/or that can be resolved without interpreting the collective bargaining agreement are not excluded from the FAIR Program. For instance, a claim alleging a violation of New York Labor Law, the Fair Labor Standards Act, or any other federal or state law is subject to the FAIR Program.
The FAIR Program also does not prevent You from filing a charge, testifying, assisting, or otherwise participating in any investigation or proceeding conducted by the equal employment opportunity commission, or another government agency to the extent You have a protected right to do so. But if You take such action in relation to a claim, controversy, or other dispute that would constitute a Claim and you have not fully pursued such dispute through the FAIR Program, The Agency may request the agency in question to defer its processing or investigation of such charge until the FAIR Program has been completed. Notwithstanding Your rights under this subsection. You agree that, to the maximum extent permitted by law. You may recover monetary relief with respect to a Claim only through the FAIR Program.
The FAIR Program does not require the Agency to begin arbitration proceedings or initiate any other procedure whatsoever before taking any action regarding your employment with which you might disagree, such as coaching, counseling, warning, reprimand, suspension, investigation, discipline, demotion, changing your days or hours of work, or termination.
Can a Claim be resolved in court? No. Under the FAIR Program, You and the Agency each waive your respective rights to have a Claim decided by a court, judge, jury and, where permitted by law, an administrative agency. Instead, You and the Agency agree that the internal dispute resolution (if any) and arbitration under the FAIR Program are the sole and exclusive methods for resolving Claims. If either You or the Agency files an action in court or another forum not contemplated by the FAIR Program asserting one or more Claims and the other party successfully stays such action andMr compels arbitration of such Claim, the arbitrator may assess reasonable costs and expenses, including an award of reasonable attorneys' fees, incurred in seeking such stay and/or order compelling arbitration against the party that filed the action in court or such other forum.
How should You Raise a Claim under the FAIR Program? If You believe You have a Claim against the Agency, You should first give the Agency a chance to investigate and resolve the Claim before You file a demand for arbitration (the arbitration process is explained further below). You do not need to use any specific form to submit a Claim. Simply write a letter explaining your Claim and the relief sought, and submit the letter to the Compliance Officer listed in your Compliance Training Module. As part of this process, a Agency representative might meet with you to discuss your Claim. Or, depending on the nature of the Claim, the Agency will investigate the Claim on its own, such as by reviewing its records. If You do not receive a satisfactory response from the Agency within 30 days of the date that you submitted Your letter or if you disagree with the response from the Agency, You must follow the arbitration procedure set forth below if you wish to pursue the Claim.
The Arbitration Process
How much time do You have to file a Claim? An arbitration proceeding under the FAIR Program must be commenced within the time period prescribed by the statute of limitations applicable to the Claim being asserted. For purposes of statute of limitations, an arbitration proceeding is deemed commenced when a demand for arbitration is filed with ADR Systems. Filing an internal Claim under the FAIR Program will not extend the time period within which You must file a demand for arbitration.
Welcome to 24/7 HomeCare Agency
|A||Tax Forms from TAXOA||YES||NO||N/A|
|B||1-9 Form, Wage form, W-4||☐||☐||☐|
|1.Employment Requirements and Agency Policies||☐||☐||☐|
|4.HIV Confidentiality Policy||☐||☐||☐|
|5.Infection Control. Universal Precaution||☐||☐||☐|
|7.Emergency Disaster Preparedness||☐||☐||☐|
|9.Required E V V, (clock in/out)||☐||☐||☐|
|11.Absences and Lateness Policy||☐||☐||☐|
|12.Patient Abandonment Policy||☐||☐||☐|
|13.No Call No Show Policy||☐||☐||☐|
|15.Cellular/Wireless Device Policy||☐||☐||☐|
|18.Equal Employment Opportunity Policy||☐||☐||☐|
|19. Pregnancy Accommodations||☐||☐||☐|
|20. Anti-Harassment Policy||☐||☐||☐|
|21.Sexual Harassment Policy||☐||☐||☐|
|22.Protection Against Retaliation||☐||☐||☐|
|D||Code of Conduct||☐||☐||☐|
|E||a. Fraud and Abuse||☐||☐||☐|
|b. Professional Standard||☐||☐||☐|
|F||HHA/PCA Activity -- DUTY CODES/Timesheets||☐||☐||☐|
|G||HHA Exchange App||☐||☐||☐|
|I||Missing Documentation from Application Process||☐||☐||☐|
I have read my job description and understand that I will be evaluated based on the performance criteria in my job description. I acknowledge having completed all of the orientation in service curriculum.
As an employee of 24/7 Home Care Agency of NY, Inc I, ,understand that any attempt on my part to provide services to a patient without the knowledge of the agency would be harmful and damaging to the agency. I agree that during the term of my employment with the agency and for a period of ninety (90) days after the end of myemployment:
I recognize that a breach of this agreement can result in harm to the agency and agree that in the event of such a breach, I will be liable to pay the agency a minimum of the full payment the agency would have earned had I not circumvented the agency, plus further damages to the extent allowed by law and that the agency shall be entitled to and may seek any and all additional remedies to the extent available by law.
*If wage supplements are paid as a single payment awed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.
List any additional benefits and attach listing to this document.
Copies of the above listed agreements or summaries may be obtained by:
On this day I have been notified of my pay rate, overtime rate, allowances, supplements/benefits, and designated payday provided on this form (LS 62) attached and this addendum on the date given below.My primary language is I have been given this notice in my primary language ☐ Yes ☐ No
Note 1: Benefit eligibility and costs outlined on separate provided grid and can also be found at JN Savasta
Note 2: Amounts accrue weekly, but enrollment in benefits is based on total monthly accruals from a month prior.
For example, total accruals in January determine eligibility and enrollment for March benefits. Costs for benefits outlined in previously referenced grid