Application Date 3/31/2020 3:55 AM
 
t: (716) 268-8705
 
   
     
Employment Application

Please fill out all sections of the application below.  The 'Submit' button will appear at the bottom of the eForm when you have finished all relevant sections.

  Please enter all required information below. Click 'Next' button when you are done to move to next screen.
Applicant Personal Information
       
Email Address *    
Social Security Number *    
       
First Name *    
Middle Initial    
Last Name *    
Maiden Name (if applicable)    
       
Current Street Address *  
Apt/Suite/House*  
City *    
State *    
Zipcode *    
Phone Number *    
Cell Phone Number    
       
Date of Birth *  
 
Country of Birth *    
       
Gender *    
Race/Ethnicity *    
Height *    ft  inches  
Weight *    lbs  
Hair *    
       
Picture of Certificate if applicable  

No picture of applicant attached.

 
       
Password – For office use only :
Applicant or Authorized Representative Review and Verification

(All applicants looking for employment must complete and sign this Section. 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". It should be noted that if we do not receive the acceptable ids the application will be rejected)
                  List A                                                                             OR                                      List B                                   AND                                  List C
     Identity and Employment Authorization                                                                                                                                     Identity                                                               
             Employment Authorization

Document Title
 
Document Title
                Acceptable IDs

Document Title
Expiration Date (if any)(mm/dd/yyyy)
  Expiration Date (if any)(mm/dd/yyyy)
Expiration Date (if any)(mm/dd/yyyy)
Attach Front of ID
  Attach Front of ID
Attach Front of ID
Attach Back of ID
  Attach Back of ID
Attach Back of ID
 
 
 
       
Emergency Contact      
       
First Name *      
Last Name *      
Phone Number *      
Relationship *        
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  Please enter all required information below. Click 'Next' button when you are done to move to next screen.
Position Related Information
       
Office where you are applying *    
Have you applied to this company before? *        
Are you currently certified (PCA and/or HHA)? *          
Why do you want to work as a caregiver?*  

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Type of Employment desired:
  (Check all that apply)
  Please check all that apply:  

 

 

 

   

 

 

 

 

 

  

 
Did you have appointment or are you a Walk In? *          
How did you hear of us? *    
       
How can we send you important updates? *    
       
Languages known      
       
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  Please enter your previous employment history below. Click 'Next' button when you are done to move to next screen.
Employment Information
     Never employed before or no employment history  
       
Add Employer      
       
 
Company Name *   Remove    
Best Contact Person        
Phone Number *        
Fax Number        
           
           
       
     By signing below, you are providing your consent for us to contact the above named employers.  All information is kept confidential.  
   
Applicant Signature *

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Date Signed *
 
 
       
       
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  Please enter the name and phone number of a friend, coworker, or neighbor that you have known for more than a year. Click 'Next' button when you are done to move to next screen.
Reference Information
       
Add Reference      
       
 
First Name *  
     
Last Name *        
Street Address        
City        
State        
Zipcode        
Phone Number *        
Email Address        
           
Number of Years Known *        
   
     
First Name *  
     
Last Name *        
ReferenceStreetAddresset Address        
City        
State        
Zipcode        
Phone Number *        
Email Address        
           
Number of Years Known *        
   
           
       
     By signing below, you are providing your consent for us to contact the above named personal references.  All information is kept confidential.  
   
Applicant Signature *

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Date Signed *
 
 
       
          
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  Please read and agree to the consent agreement below. Click 'Next' button when you are done to move to next screen.
Conditions of Employment
   
Reporting to work with impaired abilities; or the possession, consumption, or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph, and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal. (With the exception of a drug authorized by a physician/primary health care provider for the employee's use while on the job, and whose performance is not noticeably impaired will not be considered in violation of this policy. Employees are responsible for asking the prescriber about any side effects that may influence performance.)  
     
I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without prior notice.  
     
The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.  
     
I affirm and hereby certify that all the information submitted in this application is true and accurate to the best of my knowledge.
Applicant Signature *

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Date Signed *
 
   
     
     
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  Please enter all required information below. Click 'Next' button when you are done to move to next screen.
Department of Health - Criminal Health Records Check
DOH CHRC 102 (1/07)     
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 to obtain consent from the subject individual for fingerprinting and criminal history record information pursuant to Article 28-E of the Public Heath Law and Section 845-b of the Executive Law.
Section 1 - Subject Individual Information
 LAST Name FIRST Name Middle Initial Maiden Name
 - - - -
 Date of Birth (mm/dd/yyyy) Mother's Maiden Name * Alias: AKA
 -
 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 Department of Health (DOH) 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 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. If I believe an error has been made by DCJS for any New York State conviction/charge or the FBI for a non-New York State conviction/charge, I understand that I should notify DCJS and/or the FBI to report and request correction of this error to the addresses below.
NYS Division of Criminal Justice Services Criminal History Bureau
Record Review Unit-5th Floor
4 Tower Place, Albany, NY 12203
(518) 485-7675
Federal Bureau of Investigation
Criminal Justice Information Services (CJIS) Division
1000 Custer Hollow Road, Clarksburg, WV 26306
(304) 625-5590
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 (indicate as appropriate):
   been convicted of a crime in New York State or any other jurisdiction
         have a final finding of patient or resident abuse
8   My current mailing or home address is indicated in Section 1 of this form.  
9   I have read this form and hereby consent to the request by agency to use fingerprints to obtain my criminal 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 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).
Applicant Signature:

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Date: 
Signature of Parent or Legal Guardian 
(if subject individual is under 18 years of age)
 
             Date: 
Section 3 - Agency Authorized Person Information
Agency Name:   PFI/Operating License Number:     
Print Name of Authorized Person:   Title:     
Signature of Authorized Person:
 
Date:

 
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Annual Tuberculosis Questionnaire
       
    Applicant Name  
    Please indicate by checking the boxes below if you have noticed any of the following symptoms:  
      Unexplained fevers for now                         
      Night sweats                                                
      Unintentional weight loss                             
      Cough for more than 3 weeksbsp;              
      Loss of Appetite                                           
      Hoarseness                                                 
      Bloody Sputum                                            
      Chest Pain                                                   
      Fatigue                                                        
      Completed INH Therapy                             
       
    By signing below, you are confirming your answers above.   
   
Applicant Signature *

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Agency Representative 
 
 
Date Signed *  
 
 
       
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  Please enter all required information below.  Consent or decline where shown. Click 'Next' button when you are done to move to next screen.
Hepatitis Information Acknowledgement
    Applicant Name   

 

Hepatitis B infection is a viral infection of the liver which may be transmitted from person to person by direct contact with blood/body fluids, secretions, or excretions of the infected person. This can be transmitted from individuals who are carriers of the disease to facility personnel. A carrier of Hepatitis B is defined as a person who may or may not have symptoms of the infection, and in whom the virus remains alive in the blood or other body fluids. Hepatitis B infections may result in chronic infection of the liver, cirrhosis, and less frequently, liver cancer

Declination
If I decline the vaccination, I either have received the vaccination prior, OR understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I 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 infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
 

 

 

 
       
       
    I have read and understand the information regarding Hepatitis B. My signature below indicates acknowledgment of this information and my decision to either accept or decline the Hepatitis B vaccination.  
    By signing below, you are DECLINING to participate in the HEP-B program. If at any time you decide you would like to be vaccinated against HEP-B please notify your processor and we will schedule an appointment for you to be vaccinated free of charge.  
   
Applicant Signature *

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Agency Representative 
 
 
Date Signed *  
 
 
       
          
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Seasonal Influenza Declination Form
       

I DECLINE to be vaccinated against the influenza virus.  I have had the opportunity to be vaccinated, but refused.  I accept responsibility for my declination and risk of exposure.  I agree to always wear a face mask provided to me by Community Home Health Care while caring for my patient throughout the Flu season.

 
     
     
       
    By signing below, you are DECLINING to participate in the flu vaccine program.  
   
Applicant Signature *

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Date Signed *  
 
 
       

New York State has instated a mandate that all licensed caregivers must be vaccinated against Covid-19 unless otherwise exempt.

 
Please select the option that applies to you.*    
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Employee Acknowledgement for Providing Care During The COVID-19 Pandemic

The safety and health of our employees and clients is always the top priority at the Agency. We are committed to keeping you healthy, while continuing to provide essential health care services to our patients.

I, * , acknowledge that the Agency has set forth four required classes that must be completed by a caregiver prior to caring for any client(s) during the novel coronavirus (COVID-19) pandemic. These four required classes include:

  1. Infection Control
  2. Disaster Planning/Emergency Preparedness
  3. COVID-19 Program
  4. Donning and Doffing PPE

I understand the purpose of the education provided by the Agency is to ensure that all caregivers are trained to minimize the chances of COVID-19 infection, as well as transmission of COVID-19 to themselves, clients and those a caregiver comes into contact with. This training also is to further ensure that all caregivers are aware of, and can identify, the symptoms of COVID-19, as well as best practices for patient safety and screening. I will be notified and understand it is my choice to take a case with confirmed or suspected Covid-19.

I further acknowledge and understand that a failure to complete all of this education will put myself, my clients and all those I come in contact with at risk. It may also jeopardize my employment with the Agency.

I further acknowledge and understand that in addition to training, the Agency is taking certain precautions outlined by the Centers for Disease Control (“CDC”), Centers for Medicare and Medicaid Services (“CMS”), and the New York State Department of Health (“DOH”) for client and caregiver safety. Specifically, I acknowledge that the Agency is taking the following precautions and procedures, and that I am required to comply with the following, during the COVID-19 pandemic:

  1. I will answer the required health screening questions timely and accurately, on a daily basis, prior to arriving for work.
  2. I will self-monitor for fever by taking my temperature at least two times daily and will remain alert for respiratory symptoms. I will record this information on a daily basis as directed and will be able to provide my log to the Agency, if requested.
  3. I will screen all clients, as well as any other person who resides in or is present in the homecare setting for signs and symptoms of COVID-19, prior to providing services. If symptoms are noted, I will immediately inform my coordinator at the Agency before providing any further services.
  4. In the event that I exhibit a fever, respiratory and/or other COVID-19 symptoms, regardless of whether I have received a confirmed diagnosis. I will immediately inform my coordinator at the Agency, follow any directives from my coordinator concerning providing further services and comply with the Agency’s referral to my medical doctor or another healthcare provider.
  5. I will communicate with my coordinator if I believe I need personal protective equipment (“PPE”). I understand that the following options are available to me for obtaining PPE during the COVID-19 crisis:
    1. I may pick PPE up from the Agency’s local office;
    2. I may have PPE delivered to my home; or
    3. I may have PPE delivered to a client’s home.
  6. I will report any COVID-19 symptoms exhibited by clients to the Agency immediately. I will also make the Agency aware of any instances where another individual in the household is exhibiting signs or symptoms of COVID-19, or if I have been exposed to possible or confirmed COVID-19, regardless of whether the individual has received a confirmed diagnosis.
  7. I understand that in the event that one of my clients is suspected or confirmed to have or been exposed to COVID-19, I will be required to take certain additional steps to reduce the risk of transmission while providing services in the patient’s home. I will follow directions to be provided by my coordinator.
  8. I further agree to report any COVID-19 symptoms exhibited by other caregivers and/or a caregiver’s failure to comply with the requirements set forth in this document to the Agency immediately following the existing reporting procedures of the Agency’s employee handbook.
  9. I understand that I have access and should call the Agency 24 hours a day 7 days a week for reporting and guidance as needed.
  10. I am aware that Agency office staff has received education, and that policies are being regularly updated due to the fluidity of the crisis. I understand that the Agency is working with the relevant local and state agencies to make sure our COVID-19 policies reflect the most current information to keep us all safe, and that the foregoing procedures may need to be revised or additional procedures added. I understand that I can ask my coordinator for additional guidance in the event I have questions about any precaution or procedure and any such changes will be communicated through official notices by the Agency.

By executing this document, I acknowledge that I understand the nature and risks of the COVID-19 pandemic, the steps the Agency is taking to address such risks, prevent transmission, and have had the opportunity to ask and have questions answered. I understand that it is my responsibility to diligently follow the guidance provided by the Agency, as well as relevant CDC, CMS, and DOH guidance to protect myself, the Agency’s clients, the Agency and those with whom I come in contact.

I * certify that I have read the foregoing document and have had the opportunity to ask and have questions answered. I fully understand the requirements set forth herein and agree to comply with the requirements.

I further understand that failing to follow the precautions and procedures set forth in this document will be subject to immediate action and may result in disciplinary actions, including the possibility of termination of employment with the Agency.

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  I confirm all information on this application is accurate and documents provided are genuine.
Signature *

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Date*  
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