24/7 Home Care Agency of NY, INC

Employment Application (HHA/PCA)

Name First:
Last:
Middle:
Address:

City:
State:.
Zip Code:
Home Phone Number:
Cell Number:
Emergency Contact Name:
Emergency Contact Phone Number:
Date of Birth:
01-01-1970
Place of Birth:
Gender:
Social Security Number:
United States Citizen:
Education: Do you have a High School Diploma?:
Training: Do You have a PCA Certificate?:

                 Do you have a HHA Certificate?:
Please Provide Certificate Registry Number:
Name of Training Program:
Address:
City:
State:
Zip Code:
Phone Number of Training Program:
Date of Completion:

Work History

1) Company Name:
Supervisor:
Address:
Phone Numer:
Reason for Leaving:
2) Company Name:
Supervisor:
Address:
Phone Numer:
Reason for Leaving:

24/7 Home Care Agency of Ny,inc does not discriminate because of age,sex,physical handicap,race,creed or national origin.
The agency is an equal opportunity employer.

I affirm that information inthis application is complete and true.I understand that if employed,false statements will be a case
for dismissal

Signature:
Date:
01-01-1970

24/7 Home Care Agency of NY, INC Employment

Interview Form

Personal Information

Name:
Phone Number:
Address:
What languages do you speak?(Check all that apply):
,

Work Preferance:

Indicate Location where you are willing to work:
How many hours a day can you work?:
Can you work on Live In cases?:
Can you work weekends?:
What days are you available to work?:
Do you drive?:
If Yes, do you have a car?:
Employee Signature:
Date:
01-01-1970

24/7 Home Care Agency of NY, INC Employment

2414 Ralph Avenue,
Brooklyn, NY 11234,
718-887-0782

HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT

I acknowledge that during the course of performing my assigned duties at 24/7 HomeCare Agency of NY, Inc. I may have access to, use or disclose confidential health information. I hereby agree to handle such information in a confidential manner at all times during and after my employment and commit to the following obligations:

A:   I will use and disclose confidential health information only in connection with and for the purpose of performing my assigned duties

B:    I Will request, obtain or communicate confidential health information only as necessary to perform my assigned duties and shall refrain from requesting , obtainig or communicating more confidential health information than is necessary to accomplish my assigned duties.

C:    I understand that as an employee of 24/7 HomeCare Agency of NY, Inc.that is a health care provider, the use and disclosure of information is governed by the rules and regulations established under HIPAA, the Health insurance portability and Accountability Act of 1996,and related policies and procedures of 24/7 Home Care Agency of NY, Inc.

D:    I will use and disclose confidential health information solely in accordance with the federal and 24/7 HomeCare Agency of NY, Inc policies and set forth above or elsewhere. I also agree to familiarize myself with any periodic updates or changes to such policies in a timely manner.

E:    I will immediately report any unauthorized use or disclosure of confidential health information that i become aware of the appropriate supervisor

F:    I also understand and agree that my failure to fulfill any of the obligations set forth in this agreement and/or my violation of any terms of this Agreement shall result in my being subject to appropriate disciplinary action, up to and including ,termination of employment.

Employee Signature:
Date:
01-01-1970

24/7 Home Care Agency of NY

ACKNOWLEDGMENT OF RECEIPT

The Employee Handbook/Code of Conduct/Compliance Program contain important information about the company, and I understand that I should consult the Administrator/Office Manager/General Manager regarding any questions not answered in thes documents. I have entered into my employment relationship with the Company voluntarily, and understand that there is no specified lengh of employment. Accordingly, either the Company or I can terminate the relationship at will, at any time, with or without cause, and with or without advance notice.

Since the information, policies and benefits described herein are subject to change at any time, I acknowledge that revisions to the handbook/Code of conduct may occur. All such changes will generally be communicated through official notices,and I understand that revised information may supersede modify, or elimiate existing policies.

I have had an opportunity to read the handbook,code of Conduct,and Compliance Program and I understand that i may ask my supervisor are any employee of the human Resources Department any questions I might have concerning the handbook.I accept the terms of the documents described above.i also understand that it is my responsibility to comply with all the policies of 24/7 Home Care Agency of NY,Inc and any revisions made. I further agree that if I remain with the Company following any modifications to the handbook, I there by accept and agree to such changes.

I have recived a copy of the Company's Employee Handbook (policies and procedures), code of Conduct, compliance Program,paid Family leve and Notice of Employee Rights (regarding sick leave)on the date listed below. I understand that I am expected to read the entire handbooks.additionally, I copy to the Company's representative listed below on the specified. i understand that this form will be retained in my personnel file.

I understand that I may be subject to discipline or other corrective action, up to and including termination of employment or termination of contract, if I violate the standards and requirements set fort in the Code of conduct, any specific compliance policies or procedures, or any aspect of the 24/7 Home Care Agency of NY, Inc Compliance Program.

E:    I will immediately report any unauthorized use or disclosure of confidential health information that i become aware of the appropriate supervisor

F:    I also understand and agree that my failure to fulfill any of the obligations set forth in this agreement and/or my violation of any terms of this Agreement shall result in my being subject to appropriate disciplinary action, up to and including ,termination of employment.

Signature of Employee:
Date:
01-01-1970
Employee's Name - Printed:

Confidentiality/Conflict of Interest Statement

As an employee of 24/7 Home Care Agency of NY, Inc, and as a condition of my employment I agree to the following:

1. I understand that I am responsible for complying with the HIPAA polices, which were presented to me upon employment.

2. I will not access or utilize patient information, unless needed to perform my job duties.

3. All information recived during the course of employment with the agency, will be treated as privileged and condidential information.

4. I will not log onto any of the agency's computer system, existing now or the future, using a password other than my own.

5. I will not email, fax or phone to transmit any patient information unless I am instructed to do so by the Administrator or Director of Nursing.

6. I will not take patient information from the premises in paper or electronic form without approval from the Administrator or Director of Nursing.

7. Upon termination of my employment, I agree to maintain confidentiality regarding any information learnt or gained while an employee of the agency and will return all keys, ID cards or any device that would provide continued access to agency or information within the agency.

8. Iunderstand that all reports,accounting records,research reports,expense accounts,time sheets and other documents must accurately and clearly represent the relevant facts or the true nature of a tra nsaction.

9. I understand I shall never offer any financial inducement, gift, payoff, kickback,or bribe intended to induce, influence or reward favorable decisions of any government personnel or representative, any customer, contractor or vendor in a commercial transaction or any person in a position to benefit the agency or the employee in any way.

To ensure no conflict of interest The Agency defines "conflict of interest" as those activities or actions which:

. Conflict with the mission, philosophy of objection of the Agency.

. Violate local, state or federal regulations.

. Violate local, state or federal regulations.

. Place the Agency, personnel, clients or their families at risk ethically, financially or legally.

. To protect the Agency's assets, both material, concepts and publications,as well as to include:

. Confidentiality of patient diagnosis.

. Financial matters.

. Staff salaries.

. Nursing or executive plans that can go to unauthorized agencies.

. Anything given to staff (e.g.forms, systems, and equipment) that goes to unauthorized people.

By signing this document I understand that violation ofthis agreement will result in discip linary action, up to and including, termination.

Employee Name:
Signature :
Date:
01-01-1970

Paid Family Leave NEW YORK Need-To Know PFL Information for covered Employees

What is paid Family Leave?

Starting in January 2018, Paid Family Leave (PFL) becomes a mandatory benefit in New York, providing you with job protection and paid time off for these qualifying events:

  • To Provide care for a family member with a severe health condition
  • To bond whith a child after Birth, Adoption, or to welcom child into foster care
  • To cope with a military exigency leave event.

Am I eligible for Paid Family Leave ?

Here's what it takes to be eligible to go out on paid leave: You must make it throught what's called a "qualification period," i.e:

  • lf you work 20 or more hours per week, you must have been employed at least 26 consecutive weeks at your curre nt employer
  • If you work less than 20 hours a week, you must have completed at least 175 work days at your current employer
  • If you change jobs, your time worked at the previous employer does not count.In other words you start over with a new qualification period
  • Time out on DBL (statutory disability insurance) does not count towards your qualification period

How much can I get?

Benefit Stage Effective Date Maximum Length of Paid Leave
01/01/20188 weeks
01/01/201910 weeks
01/01/202010 weeks
01/01/202112 weeks
Maximum Benefit Amount***
Payable % of Employee's Average Weekly WageTo the Maximum % of NY Average Weekly Wage$ Max based on 2016 NYSAWW of $1,305.92**
50%50%$653
55%55%$718
60%60%$784
67%67%$875

Permittent Leave

  • The benefit for employees who take paid leave in daily increments is based on their average number of days worked per week during the last 8 weeks before taking paid leave
  • Numberof hours worked during those days has no influence onthe maximum benefit
  • The total number of intermittent days is capped at 60 days, even if you work more than 5 days/week on average.

How much does it cost?
Paid Family Leave is typically referred to as an employee-funded benefit, but it is up to your employer to decide if and how much to deduct from you. If your employer takes contributions from you, hereare a few key things to know:
Based on the law and regulations that govern Paid Family Leave, employers .. .

  • Can start taking payroll deductions from you as early as July 1,2017, although the benefit doesn't go into effect until January 1,2018.
  • Don't have to refund any early deductions to you if you leave the company before January 1,2018.
  • Can start taking deductions from you as soon as you start a new job, even during your qualification period. Here's how the maximum contribution is calculated:
Your maximum contribution is 0.126%* of your weekly wage capped at New York's average weekly wage (NYSAWW), which is currently $1,305.92=67,907.84 per year**
The PFL rate is set by NY State and can be adjusted on an annual basis effective every January 1. The 2018 rate had to be set by June 1,2017. Thereafter, updated rates are set and announced by the New York State by September 1 of each year for the following calendar year. For any further questions please contact your Supervisor at 718-887-2922 or go on www.PaidLeaveNY.Com
I have received and reviewed the above information regarding Paid Family Leave on the date below.

Name of Employee:
Signature :
Date:
01-01-1970

Declination of Influenza Vaccination

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:

  • Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
  • Influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications, and death
  • If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
  • If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.
  • I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t change, my immunity declines over time. This is why vaccination against influenza is recommended each year.
  • I understand that I cannot get influenza from the influenza vaccine.
  • The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including
    • all patients in this healthcare facility
    • my coworkers
    • my family
    • my community

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons

  I have received the Flu Vaccine and do not need to decline


  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.

Signature: :
Name (print):
Date:
01-01-1970
.

24/7 Home Care Agency of NY, INC

Hepatitis B Vaccination Form

I, understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV Infection). I have been given the opportunity by 24/7 Home Care Agency of NY, Inc. to be vaccinated with HBV vaccine at no charge. If you would like to request the Hepatitis B Vaccination please do not sign below and fill out a request form.


PLEASE SIGN ONLY IF DECLINING HEPATITIS B

Declination of Hepatitis B Vaccination

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.

Signature:
Date:
01-01-1970

Agreement between 24/7 Home Care and
HHA/PCA Live-in

  • All PCA/HA assigned to live-in cases are to be present in the consumer home for 24 hours each working day.
  • During each live in day, based on a 13 hour day, HHA's/PCA's are to perform tasks in accordance with the verbal or written care plan. , HHA 's/PCA 's may not work in excess of 13 hours in any day and no more than 5 Live in days per week
  • During each 24 hour day, , HHA's/PCA's are to take eleven hours for personal time which will include hours of sleep, meal breaks and other personal time, remaining on premises at all such times.
    • 8 hours of sleep time
    • 2 hours meal breaks
    • 1 hours of personal time- reading, watching television, etc.
  • If any , HHA's/PCA's finds it impossible to e the specified breaks from work duties because such times are constantly interrupted by the needs of the patient, she/he must call the administrator and 24/7 Home Care Agency of, Inc
  • I understand and will abide by the agency's rules stated in this agreement regarding time worked on live- in cases.
Signature:

Print Name:

Date:
01-01-1970

24/7 HomeCare Agency of NY                              Tel:718-887-0782

Waiver of Group Health Benefits & Notice of Special Enrollment Rights

Employer Name:
24/7 Home Care Agency of NY, INC

Please complete the following:

Employee Name(First):
Employee Name(Last):
Employee Name(Ml):
Employee Social Security Number:

For the plan year effective (01-01-1970) I am waiving coverage for:

Myself

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 coveragename of carrier:

This other coverage is:
Individual COBRA Medicare TRICARE (formerly CHAMPUS)
Medicaid Employer-Sponsored Group Plan

Special Enrollment Notice and Certification - Please review and sign below if you wish to waive coverage

By signing below, Icertify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. Iam declining enrollment as indicated above. Iunderstand that Iam 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 Ilose, 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 Ido not do so, Iwill not be able to enroll until my employer's next annual open enrollment period.

In addition, Iunderstand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, Imay be able to enroll myself and my eligible dependent(s). However, Imust 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, Ishould contact my group administrator.


Signature of Employee :
  Date of Signature:
01-01-1970

J O B   D E S C R I P T I O N
Home Health Aide(HHA),Personal
Care Assistant (PCA)
REPORTS TO REGISTERED NURSE l DIRECTOR OF NURSING/REGISTERED NURSE DESIGNEE

SUMMARY

The Home Health Aide is a member of the home care team trained to provide personal care, other unskilled services, and companionship in the home setting, under the direction, instruction, and supervision of a Director of Nursing/Registered Nurse designee and the patient

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

  • Assists the patient in the Activities of Daily Living (ADL) including personal care, hygiene, baths, back rubs, shampoo, skin and nail care, eating, dressing, elimination, exercises, ambulation, and changing/making patient’s bed. Plans and prepares meals.
  • Encourages the patient’s family to participate in patient’s care.
  • Provides companionship to the patient
  • Assists in the maintenance of a safe and healthy environment Uses equipment and supplies safely and properly.
  • Reminds the client to take, and assists client and/or family, with self-administered oral medications as ordered by the physician, in compliance with the laws in the state of operation.
  • Takes and records accurate patient vital signs when advised.
  • Follows the Home Health Plan as written, approved, and supervised by the Registered Nurse or Physical Therapist
  • Gives emotional support to the patient and/or family.
  • Informs Registered Nurse (RN)/Director of Nursing/Registered Nurse Designee of changes in patient’s condition.
  • Documents activities and findings and submits documentation as required by company procedures.

This job description is not intended to be all-inclusive. The employee will be expected to perform other reasonable related duties as assigned by management

JOB LIMITATIONS
The Home Health Aide will not function in any manner viewed as the practice of nursing according to the State’s Nurse Practice Act Specifically, the home health aide will not administer medications, take physician’s orders or perform procedures requiring the mining, knowledge, and skill of a nurse, specifically sterile techniques

QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION ANDJOR EXPERIENCE
High school diploma or general education degree (GED) or equivalent, and meets the training requirement in accordance with state and federal laws. (Effective 8J14/90, a person who has successfully completed a state established or other training program that meets the requirements of CFR 484.36(b), or a competency evaluation program or state licensure program that meets the requirements of S 484.36(b).) At least one year of experience in home care, nursing, or hospital experience preferred.

LANGUAGE SKILLS
Ability to communicate effectively with patient/client, family members, clinical management, and staff. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.

REASONING ABILITY
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with simple problems in the home setting.

OTHER SKILLS AND ABILITIES
Nurse’s Aide skills, observation skills, communication skills, knowledge of home health care. Good physical and mental health. Caring attitude, tact, patience, and good personal hygiene.

J O B   D E S C R I P T I O N
Home Health Aide(HHA),

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The work requires moderately heavy physical exertion on a regular and recurring basis such as: extensive driving, assisting patient in transfer activities (wheelchair, to bed, to tub, to commode) and providing substantial support to individuals in ambulation. While performing the duties of this job, the employee is regularly required to use hands to finger, to handle or feel, and talk or hear. The employee frequently is required to stand; walk; reach with hands and arms’ and stoop, kneel, crouch, or crawl. The employee is occasionally required to sit. The employee must occasionally lift and/or move over 100 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job

  • Patient home setting, exposure to infectious diseases, automobile.

QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION ANDJOR EXPERIENCE
High school diploma or general education degree (GED) or equivalent, and meets the training requirement in accordance with state and federal laws. (Effective 8J14/90, a person who has successfully completed a state established or other training program that meets the requirements of CFR 484.36(b), or a competency evaluation program or state licensure program that meets the requirements of S 484.36(b).) At least one year of experience in home care, nursing, or hospital experience preferred.

LANGUAGE SKILLS
Ability to communicate effectively with patient/client, family members, clinical management, and staff. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.

REASONING ABILITY
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with simple problems in the home setting.

OTHER SKILLS AND ABILITIES
Nurse’s Aide skills, observation skills, communication skills, knowledge of home health care. Good physical and mental health. Caring attitude, tact, patience, and good personal hygiene.

Supervisor Signature : ................................Date
01-01-1970
  Employee Signature:
Title:

(Signing this document acknowledges that the job description and responsibilities have been reviewed with me, the employee.)

Aide Skills Inventory

Date:
01-01-1970
Caregiver Name:
PCA:
HHA:
Please mark an X in the appropriate box next to each entry based on your experiences in patient care.

Skill Experienced Needs Review Not Capable Skill Experienced Not Capable Not Capable
SPECIALTY CARE PERSONAL CARE
Infant 0-2 yr Infant 0-2 yr
Pediatric 2-13 yr Bed Bath/Sponge Bath
Adolescent 13-18 yr Hair Care
Adult Oral/Mouth Care
Geriatric Denture Care
Alzheimer’s/Dementia Hearing Aids
Parkinson’s Disease Skin Care/Grooming
Hospice Care Shaving
Spinal Cord Injury Nail Care
Brain/Head Injury Foot Care
Stroke Pressure Sore Precautions
Amputee NUTRITION
Diabetes Prepare/Serve Meals
Cardiac/Heart Fluid Restrictions
Pulmonary/Respiratory Assist with Feeding
HOME MAKING Intake/Output Readings
Laundry/Washer/Dryer PEG Site Care
Dishes/Dishwasher Swallow Precautions
Linens/Making Beds UNIVERSAL PRECAUTIONS
Vacuum/Mop Use of Protective Equipment
Garbage Disposal Masks
Blender Gloves
TRANSFERRING Gowns/Aprons
Wheelchair CPR Shields
Pivot VITAL SIGNS
Repositioning Temperature
Hoyer Pulse
Slide Board Respirations
DRESSING Blood Pressure
Upper Body TOILETING
Lower Body Toilet Transfers
Sock Aids Use of Bedside Commode
Shoe Horn Use of Bedpan/Urinal
Immobilizers Foley Cath Care
TEDHose/Elastic Stockings Empty Ostomy
Orthopedic Devices Use of Diapers/Depends
Prosthesis AMBULATION
OTHER Use of Gait Belt
Use of Gait Belt Range of Motion
Weight/Scale Weight-bearing Restrictions
Languages Spoken Ambulation with Devices
Languages Read/Write (Cane, Walker, Crutches)
Aide Signature:
Date:
01-01-1970
HR Supervisor: .................................................................
Date:
01-01-1970

Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Multiple Hourly Rate Employees

1.Employer Information

Name :
24/7 HomeCare Agency of NY, Inc

Doing Business As(DBA) name(s) :

FEIN (optional):

Physical Address:
2414 Ralph Avenue
Brooklyn, NY 11234

Mailing Address:
2414 Ralph Avenue
Brooklyn, NY 11234

Phone:
718-887-0782


2.Notice Given:

At hiring

Before a chance in pay rates (s), allowances claimed or payday

3.Employee,s rate(s) of pay foe each type of work or shift:

  • $ per hour for hourly cases
  • $ per hour for 13 hrs on Live-in Cases
  • $ per hour for

4.Allowaces taken:
None
Tips per hour
Meals.per hour
Lodging
Other

5.Regular payday:

6.Pay is:
Weekly
Bi-weekly
Other:....................

7.Overtime Pay Rates(s) for each type of work or shift:

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.

8.Employee Acknowledgement:

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.
My primary language is
I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary lanuage.
Print Employee,s Name
Employee's Signatue
Date
Preparer's Name and Title

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

NYS Department of Health
ACKNOWLEDGEMENT AND CONSENT FORM FOR FINGERPRINTING AND DISCLOSURE OF CRIMINAL
HISTORY RECORD INFORMATION
THIS FORM IS TO BE RETAINED BY THE AGENCY- DO NOT FORWARD TO THE DOH CHRC UNIT. chrc@health.state.ny.us

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

SECTION 1 – SUBJECT INDIVIDUAL INFORMATION

LAST Name FIRST Name M.I.
Date of Birth (mm/dd/yyyy) Mother’s Maiden Name Alias: AKA
01-01-1970
Mailing Address (street) City State Zip
'

SECTION 2 - ATTESTATION

  1. I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI).
  2. I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI.
  3. I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary to be provided to the agency to which I applied for a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I have a criminal history, as maintained by DCJS or the FBI, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. I have been advised that by law, DOH is authorized and may be required to provide the results of the criminal history record check through a criminal history record summary to the agency. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be disclosed to persons authorized by law.
  4. I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place.
  5. I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI.
  6. I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information.
  7. I certify to the best of my knowledge and belief that I (check as appropriate):
    Have Have not been convicted of a crime in New York State or any other jurisdiction
    Do Do not have a final finding of patient or resident abuse
    If you have checked either “Have” and/or “Do”, please provide a brief explanation.(Optional)
  8. My current mailing or home address is indicated in Section 1 of this fo
  9. I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own (not applicable for Expedited Review submitted pursuant to CHRC Form 104).
Employee Signature:
  Date:01-01-1970
Signature of Parent or Legal Guardian
(if subject individual is under 18 years of age):
  Date:01-01-1970

SECTION 3 – AGENCY AUTHORIZED PERSON INFORMATION

Agency Name:24/7 HomeCare Agency of NY, Inc PFI/Operating License Number:...........
Print Name of Authorized Pers:.................... Title:.......................
Signature of Authorized Person:................ Date:........................

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

► 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.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
.
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
01-01-1970
U.S. Social Security Number
Employee's E-mail Address
Employee's Telephone Number

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):

1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident(Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): 01-01-1970
         Some aliens may write "N/A" in the expiration date field.(See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number

1. Alien Registration Number/USCIS Number:

         OR

2. Form I-94 Admission Number:

         OR

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1 Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
01-01-1970

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
01-01-1970
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page

Commuter Benefits Participation Form

Under NYC’s Commuter Benefits Law, certain employers must offer commuter benefits to existing full- time employees beginning January 1, 2016 or four weeks after an employee begins full-time work, whichever is later. For more information, please call 311 or visit nyc.gov/commuterbenefits to read Frequently Asked Questions about the Commuter Benefits Law.

Note to Employees:
Your employer is required by law to offer you a commuter benefits program; however, your participation is voluntary. You may decline to enroll in the program, or you may cancel your participation at any time. You may also choose to enroll in the program at a later date.

EMPLOYER INFORMATION
Employer Name24/7 HomeCare Agency of NY, Inc
Address2414 Ralph Avenue
City/State/ZIP CodeBrooklyn, NY 11234
Phone Number212-807-7887
EMPLOYEE INFORMATION
Name (First/Middle/Last)
Address
City/State/ZIP Code
Phone Number
Email Address
Date of Hire01-01-1970

I,, (Employee’s printed name) Accept Decline my employer’s offer to use pre-tax income to pay for qualified transportation benefits to the extent permitted under federal law.

Employee’s Signature:
    Date:01-01-1970

If you have questions about your employer’s obligations under NYC’s Commuter Benefits Law or to report non-compliance, please contact the Department of Consumer Affairs (DCA) at nyc.gov/commuterbenefits, email commuterbenefits@dca.nyc.gov, or contact 311 (212-NEW- YORK outside NYC).

Home Health Aide/ PCA Acceptance Test

Please circle the correct answer for the following questions:

  • Clients sometimes express religious beliefs with which the home health aide does not agree. In dealing with these situations, which of these understandings should the aide use as a guide?
    • A. Clients have a right to their own beliefs, which should be respected.
    • B. Clients should be told not to discuss their beliefs with aides
    • C. Aides should explain their beliefs to the clients
    • D. Aides should pretend they have the same beliefs that the clients have.
  • Mrs. Wayne, a home health aide, leaves the home of Mr. David, a terminally ill client. A neighbor stops her and says, "Mr. Davis is sick isn't he? I hear he is dying." What is the best response for the aide to answer?
    • A. "Yes, Mr. Davis is very ill."
    • B. "How do you know Mr. Davis is so sick?"
    • C. "I'm sorry, I can't discuss Mr. Davis"
    • D. "Mr. Davis is doing as well as can be expected"
  • Miss Ferri, a home health aide, is assigned to care for Mr. Conway. Miss Ferri notices that she feels very angry when she is with the patient. What should Miss Ferris do because she feels this way?
    • A. Tell Mr. Conway how she is feeling.
    • B. Find out if other aides have felt this way.
    • C. Try to pretend Mr. Conway is someone she likes.
    • D. Talk with the agency supervisor about the situation.
  • A client accuses a home health aide of stealing five dollars. The aide has not taken the clients' money, but the client does not believe the aide. What should the aide do?
    • A. Ask the other aides who care for the client if they took the money.
    • B. Ask the client why the aide is being accused.
    • C. Offer to give the client five dollars.
    • D. Notify the agency supervisor.
  • Which of these actions is the home health aide permitted to take in relation to drug administration?
    • A. Recording and reporting the client's reaction to the medication.
    • B. Giving nonprescription medications whenever the client asks for them.
    • C. Adjusting the dosage of the medication given to the client.
    • D. Adjusting the times medications are given to fit into the client's scheduled.
  • The home health aide is helping Mrs. Elden with her bed bath. Mrs Elden requests to wash her genital and rectal areas herself. Which of these measures should the aide take?
    • A. Have Mrs. Elden use cold water only in washing her genitals.
    • B. Have Mrs. Elden use no soap when washing her rectal area.
    • C. Remind Mrs. Elden to wash from the vaginal area toward the rectal area.
    • D. Tell Mrs. Elden she cannot wash herself.
  • A patient who has been on bed rest is too weak to get up in a chair. The home health aide helps the client to sit on the edge of the bed. The client says "I am dizzy". What should the aide do?
    • A. Rub the client's feet.
    • B. Help the client to a standing position.
    • C. Put a cool compress on the clients head.
    • D. Support the client in sitting position and wait a minute or two to see if the dizziness goes away.






  • Pressure ulcers are most likely to be prevented if:
    • A. The patient is turned on each side every 2 hours
    • B. Clients sleep all day
    • C. Clients eat well.
    • D. Clients shower frequently.
  • An aide is taking care of a patient who becomes aggressive. The patient is cursing and yelling. What should the aide do?
    • A. Yell back at the patient.
    • B. Tell the patient to calm down.
    • C. Move away from the patient and give the patient a few minutes to calm down.
    • D. Leave the patient and go home.
  • A fall risk patient asks the aide to go to the supermarket to buy some groceries. What should the patient do?
    • A. Leave the patient alone and go to the supermarket.
    • B. Tell the patient she cannot leave him alone and ask if he wants to go with her or order in delivery.
    • C. Put the patient to sleep and then go to the supermarket.
    • D. Tell the patient she doesn't want to go.





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Id Card
SOCIAL SECURITY CARD
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