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(2021-02-12) 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,Dana BoothePersonal 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 Dana Boothe 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 Dana Boothe 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.