Position Applying For
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Address
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Zip Code
Phone Number
Home Phone
Email
Social Security #
Driver's License #
License Expiration Date
How long?
If answered NO, how long have you lived in your current state and county?
Give Dates & Position:
If YES, please explain why:
Number of moving violations in the past
Number of traffic accidents over the past 3 years for which you were responsible:
If YES, please list name and relationship:
Name
Relationship
What would you consider to be your main qualifications for being successful in the job for which you are applying?
Briefly describe any additional skills, knowledge or experience you have which may be of value toa | career at Person-Centered Home Care Services
EMPLOYMENT AND CONTRACT
HISTORY
Company Name
Company Address
From
To
Pay Rate
Name Of Supervisor
Telephone
Job field and responsibilities
Reason for leaving
Company Name
Company Address
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To
Pay Rate
Name Of Supervisor
Telephone
Job field and responsibilities
Reason for leaving
Name
Relationship
Address
City
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AK
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AR
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CO
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DE
DC
FL
GA
HI
ID
IL
IN
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KY
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MD
MA
MI
MN
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MO
MT
NE
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NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
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Zip Code
Cell Phone
Work Phone
Home Phone
Name
Relationship
Address
City
State
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Cell Phone
Work Phone
Home Phone
STATEMENT ON CRIMINAL
MATTERS
Employee Name
Employee Social Security Number:
This is a sworn statement affirming that there are no criminal matters pending
against me and I strongly deny the existence of any relevant
convictions.
Employee Signature
Date:
Please provide the following information for two (2) business and two (2) personal references
of persons not related to you:
HEPATITIS B VACCINATION
DISCLOSURE FORM
(Choose the most applicable)
Name
Date of birth
CONSENT FOR HEPATITIS B VACCINE
As a result of the nature of my occupational duties at PCHCS, there is a substantial risk of direct contact with blood or other potentially infectious materials which have been determined as likely to transmit the Hepatitis B virus. I am aware of the precautions that must be taken when dealing with blood and body fluid exposure. As part of Person-Centered Home Care Services Bloodborne Pathogen Exposure Control Plan and as a covered employee under PCHCS Occupational Health Program, I can receive vaccination against Hepatitis B at no cost.
In accordance with UTSA’s Bloodborne Pathogen Exposure Control Plan, I am being offered, free of charge, the Hepatitis B vaccination.
I have never received the Hepatitis B vaccine and would like to be vaccinated.
I have been informed that I am at risk of acquiring Hepatitis B because of the nature of my professional responsibilities.
I have read the information sheet that lists the indications, benefits, and presently known side effects of the Hepatitis B vaccine, have had an opportunity to ask questions, and have had them answered to my satisfaction.
I must receive three (3) doses of the vaccine over a period of six (6) months to confer optimal immunity.
I understand, however, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse reaction to the vaccine.
If I should terminate employment at PCHCS prior to receiving all three (3) doses of the Hepatitis B vaccine, I understand that it will be my responsibility to complete the vaccination series on my own initiative and at my own expense.
Employee Signature
Date
PREVIOUS IMMUNIZATION WITH HEPATITIS B VACCINE
I have previously completed a three-dose series the Hepatitis B Vaccine. I understand that it is
currently believed to be effective for life. I further understand that I will be contacted by PCHCS.
Occupational Health Coordinator if new information becomes available contradicting this belief.
Employee Signature
Date
DECLINATION STATEMENT
I understand that due to my occupational exposure to blood or other potentially infectious materials T
may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with Hepatitis B vaccine, at no charge to me; however, I decline Hepatitis B vaccination at
this time. T understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B,
a serious disease. IF, in the future I continue to have occupational exposure to blood or other
potentially infections materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the
vaccination at no charge to me.
Employee Signature
Date
CONFIDENTIALITY AGREEMENT
Confidential Information Policy
Confidential information is defined as any information of records, operational business information found in a person’s medical/program record, personal information, and work-related information (including salary information). All information relating to a person’s case, treatment, support services, or condition constitutes confidential information.
Employees, interns, or contractors of Person-Centered Home Care Services (PCHCS) who are allowed access or who encounter a person’s records, operational business information including, but not limited to, paper records, oral communication, audio recording, electronic display, and research data files must keep information confidential. Access to confidential information is permitted only on a need-to-know basis and limited to the minimum amount of confidential information necessary to accomplish the intended purpose of the use, disclosure, or request.
It is the policy of (PCHCS) that all employees, interns, volunteers, and contractors respect and preserve privacy and confidentiality of this information. Violations of this policy include, but are not limited to:
Accessing confidential information that is not within the scope of your assignment.
Misusing, disclosing without proper authorization, or altering confidential information.
Disclosing to another person your login and password for accessing electronic confidential information or for physical access to restricted areas (without authorization).
Using another person’s login and password for accessing electronic confidential information or for physical access to restricted areas (without authorization).
Intentional or negligent mishandling or destruction of confidential information.
Leaving private information unattended while signed on.
Attempting to access confidential information or restricted areas without proper authorization or for purposes other than official business.
Failing to take proper precautions for preventing unintentional disclosure of confidential information.
Discussing confidential information with individuals, family members, classmates, or
employees for purposes other than official business.
Violation of this policy by may constitute grounds for disciplinary action up to and including termination
of employment in accordance with (PCHCS) Policies. Unauthorized release of confidential information
may else subject the violator to Personal, civil, and/or criminal liability and legal penalties.
I have read and understand the terms of the above statement and will read and comply with all PCHCS
policies and standards relative to confidentiality and information security.
Name
Employee Signature
Date
AVAILABILITY SCHEDULE
(Please fill your availability)
Writing Sample
Tell me why you think you will be a good fit for the position you are applying to.
DISCLOSURE FORM
(THIS FORM IS FOR EMPLOYER USE ONLY)
Information contained in this form shall be used for criminal background checking purposes only.
Date
Gov't ID
State Issued
Last Name
First Name
Social Security Number
Date of birth
Race
Sex
Home Phone
Cell Phone
Eye Color
Hair Color
Height
Weight
Place of birth
Email
Current Address
List all cities and states where you have lived with the past 7 years and provide the approximate daies
List all cities and states where you ave worked with the past 7 years and provide the approximate dates
List all names and aliases you have used formally and informally. Aliases are maiden names, married names, nicknames, and any other name used or known as.
During the past seven (7) years:
If you answered "YES" to questions 1 or 2 above, please provide an explanation in the box below for each conviction or pending case or trial. Please provide the following:
SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION
YOU MUST SIGN THIS FORM.
Read the following acknowledgment carefully before you sign.
Name of Facility Applying for
Applicant's Name
Applicant's Signature
Date
Memo to Employees on Policy and Procedure Changes to Documentation Update To: All Person-Centered Home Care Services (PCHCS) Employees
From: PCHCS Management Team
Date: Tuesday, February 8, 2022
Subject: Mandatory Requirement to Employees Regarding Documentation Record
Beginning November 8, 2021, Person-Centered Home Care Services will introduce the following modification in our company policy with regards to employees updating their personal documentation.
Employees must submit the original form of documentation to the agency no later than sixty (60) days before the expiration of their document on file. Employees are responsible for submitting valid documentation or any changes to information contained on an employee record timely and accurately.
Failure to submit valid documentation to the agency may result in but is not limited to the following:
Payroll Withholding
Employment Termination
There will be no exemptions. For questions, contact the office at 202-621-8304 .
Sincerely,
Employee Signature
Date
Employee Name
NON-DISCLOSURE AGREEMENT (NDA)
I. The Parties. This Unilateral Non-Disclosure Agreement, hereinafter referred to as the “Agreement”, effective as of January 8, 2021, hereinafter referred to as the “Effective Date”, is by and between:
Releasor described as a business entity known as PERSON-CENTERED HOME CARE SERVICES, LLC ("Releasor")
AND
Recipient described as 1 individual(s) known as __________________________ ("Recipient").
II. Confidential Information. In this Agreement, the term "Confidential Information" shall be proprietary information owned by the Releasor that is defined as: PERSON-CENTERED HOME CARE SERVICES’ employees hired on or after 2019 shall be paid by PERSON CENTERED HOMECARE SERVICES. All employees' information related to their duties and benefits (such as paid time off and vacation hours) shall be controlled and governed by PERSON-CENTERED HOME CARE SERVICES. All other benefits such as compensation, bonus, wage, 401K, and health benefits shall be paid and controlled by PERSON-CENTERED HOME CARE SERVICES.
III. Non-Disclosure. The Recipient agrees that it shall have the obligation to:
(a) Hold the Confidential Information in the strictest of confidence.(b) Not use the Confidential Information for any personal gain or detrimentally to the Releasor.(c) Take all steps necessary to protect the Confidential Information from disclosure and to implement internal procedures to guard against such disclosure.(d) Not disclose the fact that the Confidential Information has been made available or that discussions and negotiations are taking place or have taken place or any of its terms, conditions, or other facts with respect to the transaction.(e) Not disclose or make available all or any part of the Confidential Information to any person, firm, corporation, association, or any other entity for any reason or purpose whatsoever, directly, or indirectly, unless and until such Confidential Information becomes publicly available other than because of the breach by the Recipient of their confidentiality obligations hereunder.
This Section shall survive and continue after any expiration or termination of this Agreement and shall bind Recipient, its employees, agents, representatives, successors, heirs, and assigns.
IV. Exceptions to Confidential Information. The Recipient shall not be restricted from disclosing or using Confidential Information that:
(a) was freely available in the public domain at the time it was communicated to the Recipient by the Releasor.
(b) subsequently came to the public domain through no fault of the Recipient.
(c) is in the Recipient's possession free of any obligation of confidence at the time it was communicated to the Recipient by the Releasor.
(d) is independently developed by the Recipient or its representatives without reference to any information communicated to the Recipient by the Releasor.
(e) is provided by Recipient in response to a valid order by a court or other governmental body, as otherwise required by law; or
(f) is approved for release by written authorization of an officer or representative of the Releasor.
V. Use or Disclosure of Confidential Information. Recipient shall only use the Confidential Information as directed by the Releasor and not for its own purposes or the purposes of any other party. Recipient shall disclose the Confidential Information received under this Agreement to any person within its organization only if such persons are on a "need to know" basis. Recipient shall advise each person to whom disclosure is permitted that such information is the confidential and proprietary property of the Releasor and may not be disclosed to others or used for their own purpose. This Section shall survive and continue after any expiration or termination of this Agreement and shall bind Recipient, its employees, agents, representatives, successors, heirs, and assigns.
VI. Notice of Disclosure. In the event that the Recipient receives a request or is required (by deposition, interrogatory, request for documents, subpoena, civil investigative demand or similar process) to disclose all or any part of the Confidential Information, the Recipient agrees, if legally permissible, to (a) promptly notify the Releasor of the existence, terms and circumstances surrounding such request or requirement, (b) consult with the Releasor on the advisability of taking legally available steps to resist or narrow such request or requirement and (c) assist the Releasor in seeking a protective order or other appropriate remedy; provided, however, that the Recipient shall not be required to take any action in violation of applicable laws. If such protective order or other remedy is not obtained or that the Releasor waives compliance with the provisions hereof, the Recipient shall not be liable for such disclosure unless disclosure to any such tribunal was caused by or resulted from a previous disclosure by the Recipient not permitted by this Agreement.
VII. Term. This Agreement, with respect to Confidential Information, will remain in effect for perpetuity.
VIII. Return of Confidential Information. Upon request from the Releasor or upon the termination of negotiations and evaluations between the Parties, Recipient will promptly deliver to Releasor all originals and copies of all documents, records, software programs, media and other materials containing any Confidential Information. Recipient shall also retum to Releasor all equipment, files,
and other personal property belonging to Releasor. Recipient shall not be permitted to make, retain,
or distribute copies of any Confidential Information and shall not create any other documents,
records, or materials in any form whatsoever that includes the Confidential Information.
IX. Indemnification. The Parties agree to indemnify and keep each other, always, fully, and effectively
indemnified in respect of al claims, demands, losses, damages, liabilities, costs and or expenses of
any kind whatsoever incurred by the Releasor which arise out of or in connection with any breach of
this Agreement by the Recipient.
X. Notice. Any notice provided in this Agreement must be in writing and must be either personally
delivered, mailed by first class mail (postage prepaid and return receipt requested) or sent by
reputable overnight courier service (charges prepaid) to the Parties at the addresses below indicated:
Releasor’s Address: 7600 Georgia Ave NW Washington DC, 20012 Suite 316
Recipient's Address:
If the above-stated addresses should change, the Parties shall specify by certified mail, with return receipt, to one another.
XI. Covenants. The parties hereto agree that the covenants, agreements, and restrictions (hereinafter "this covenant") contained herein are necessary to protect the business goodwill, business interests, and proprietary rights of the Releasor and that the parties hereto have independently discussed, reviewed, and had the opportunity of legal counsel to consider this Agreement.
XII. Authority. This Agreement sets forth the entire Agreement and understanding between the Parties and supersedes all prior oral or written agreements and understandings relating to the subject matter of this Agreement. This Agreement may not be modified or discharged, in whole or part, except by consent in writing signed by the Parties.
XIII. Assignment. This Agreement may not be assigned or otherwise transferred by either party without the prior written consent of the non-transferring party.
XIV. Binding Arrangement. This Agreement will be binding upon and inure to the benefit of the parties hereto and each Party’s respective successors and assigns.
XV. Severability. If any provision of this Agreement is held by a court of competent jurisdiction to be unenforceable because it is invalid or in conflict with any law of any relevant jurisdiction, the validity of the remaining provisions shall not be affected, and the rights and obligations of the parties hereto shall continue to be in effect.
XVI. Governing Law. This Agreement shall be governed by and construed in accordance with the laws in the State of Washington DC.
XVII. Authority. Each party hereto represents and warrants that it has the full power and authority to enter and perform this Agreement, and each party knows of no law, rule, regulations, order, agreement, promise, or undertaking or other fact or circumstance which would prevent its full execution and performance of this Agreement.
XVIII. Counterparts. This Agreement may be executed in any number of counterparts, each of which shall be an original, but all of which together shall constitute one and the same agreement.
XIX. Execution. IN WITNESS WHEREOF, the Parties hereto have executed this Agreement.
Agreement as of
20
Releasor’s Signature
Recipient's Signature
Below is a list of three healtheare agencies. If hired or applied by them, select which that applies to you.
Date Started:
Date Ended:
Date Started:
Date Ended:
Date Started:
Date Ended:
Date Started:
Date Ended:
Duties performed:
Is this applicant eligible for rehire?
Suitable for work with elderly and sick individuals?
Would you hire this person to work with your family member?
Comments:
Completed By
Signature
Position
Date
Driver's License
State ID
Social Security Card
Work Permit
HHA/CNA License
High School Diploma
CPR
First Aid Certification
Physical, PPD and Chest X-ray
Covid (2 doses)
Medicaid Welcome Letter
Background Check
checklist form if endorsement please upload MD CNA Certification.
ONBOARDING FURTHER DOCUMENTS
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