Department of Homeland Security

Section 2 - Attestation

Department of Homeland Security

Section 2 - Attestation

SECTION 3 – AGENCY AUTHORIZED PERSON INFORMATION

SECTION 3 – AGENCY AUTHORIZED PERSON INFORMATION

Reference Consent and Authorization Form

Reference Consent and Authorization Form

APPLICANT

COMPANY REPRESENTATIVE

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 Address

Street Number *

Street Name *

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

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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

Acceptable IDs Document Title	Acceptable IDs 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 *

Position Related Information

Office where you are applying *

Have you applied to this company before? *

Yes No

Are you currently certified (PCA and/or HHA)? *

Yes No

Why do you want to work as a caregiver? Please answer this question in English or Spanish only*

0 Characters

Training Agreement

This Agreement is entered into on the date set forth below and is between Accucare Home Health Services (the “Company”) and the prospective trainee whose name and signature appears below (the “Prospective Trainee”)

The Company provides free personal care aide (PCA) training approved by the New York State Department of Health for the express purpose of identifying suitable candidates for employment as personal care aides for the Company only.		I agree
Upon completion of the PCA training program, the Prospective Trainee will become a personal care aide and will be eligible for consideration for employment by the Company. The Company intends to hire the Prospective Employee as a home care aide upon completion of the Company’s training program if it determines that the Prospective Trainee is in all respects qualified and suitable for employment with the Company.		I agree
The Prospective Trainee desires to be enrolled in the training program provided by the Company because he/she intends to work for the Company as a personal care aide when he/she completes the training program. The Prospective Trainee hereby agrees that he/she intends to work for the Company as a home care aide if he/she is offered such employment by the Company. The Prospective Trainee further agrees that if the Company offers him/her employment at the conclusion of the training program, he/she will not work for another licensed home care agency located in New York State for a period of six (6) months (unless the Company does not offer him/her assignments with sufficient hours to meet his/her employment needs, in which case he/she may supplement his/her work for the Company with additional work for another agency).		I agree
This Agreement is not a contract guaranteeing employment for any specific duration. The Company reserves the right, in its sole and exclusive judgment, to determine whether any candidate for employment meets its criteria to work as a home care aide and to be offered employment with the Company. No management representative of the Company other than the President has the authority to enter into an agreement with any person for employment for any specified period of time or to make any promises or commitments guaranteeing employment for any specific duration. Any employment agreement entered into by the Company shall not be enforceable unless it is in writing and signed by the President.		I agree
The Company is committed to the principles of equal employment opportunity and to compliance with all federal, state and local laws concerning discrimination in employment. To this end, the Company ensures equal opportunity to all employees, applicants and other individuals regardless of race, color, religion, creed, ancestry, age, gender, national origin, veteran status, marital status, sexual orientation or other protected status. The Company also complies with applicable federal, state and local laws providing for non-discrimination in employment for qualified individuals with disabilities. The Company provides reasonable accommodations for such individuals in accordance with these laws.		I agree

The signatures of the Company and the Prospective Trainee below confirm that the Prospective Trainee is seeking to enroll in the Company’s training program in order to become qualified to seek employment with the Company as a personal care aide and to be employed by the Company if offered such employment.

Prospective Trainee:		Accucare Home Health Services Representative
Name * :		Name :
Signature * Reset Signature		Signature
Date * :		Date :

APPLICANT		COMPANY REPRESENTATIVE
Name * :		Name :
Signature Reset Signature		Signature Reset Signature
Date:		Date : Driver's License Verified (for non-certified applicants)

Type of Employment desired:
(Check all that apply)

Please check all that apply:

Full Time

Part Time

Weekends

Afternoon Hours

Morning Hours

Have a car

Can work with smoking patients

Can work in a home with pets

Knowledge of kosher kitchen

Did you have appointment or are you a Walk In? *

Walk In Appointment

How did you hear of us? *

Languages known

Add Language

1

Remove

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By signing below, you are providing your consent for us to contact the above named employers. All information is kept confidential.

Applicant Signature *	Reset Signature
Date Signed *

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*Reference Information*

Add Reference

First Name *

Last Name *

Street Address

City

State

Zipcode

Phone Number *

Email Address

Number of Years Known *

The above named reference is not a family member

First Name *

Last Name *

ReferenceStreetAddresset Address

City

State

Zipcode

Phone Number *

Email Address

Number of Years Known *

The above named reference is not a family member

By signing below, you are providing your consent for us to contact the above named personal references. All information is kept confidential.

Applicant Signature *	Reset Signature
Date Signed *

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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 agree

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.

I agree

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 agree

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 *	Reset Signature
Date Signed *

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NEW YORK STATE DEPARTMENT OF HEALTH

DOH CHRC form 102: Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information

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-

Middle Initial-

Maiden Name-

Date of Birth (mm/dd/yyyy) -

Alias: AKA

Mother's Maiden Name

Mailing Address (Street) -

City -

State-

ZIP Code -

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. In accordance with applicable laws, DOH will furnish appropriate summary information 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, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. 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. I have been informed that upon receiving notification from DCJS that there is a subsequent pending criminal action or proceeding or conviction, the DOH shall promptly notify an authorized person(s) of a provider of the additional allegation or new conviction.

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 (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 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 form.

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 re-disclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency in accordance with applicable laws. 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.

Applicant Signature: Reset Signature	Date (mm/dd/yyyy) : / /
Signature of Parent or Legal Guardian (if subject individual is under 18 years of age)

Agency Name:

Operating License Number (PFI):

Print Name of Authorized Person:	Title:
Signature of Authorized Person:	Date (mm/dd/yyyy): / /

This form is to be retained by the agency. Do not forward to the DOH CHRC

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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 DECLINE the Hepatitis B Vaccine inoculation

I have read and understand the information regarding Hepatitis B. My signature below indicates acknowledgment of this information and my decision to decline the Hepatitis B vaccination.

By signing below you are declining to participate. 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 *	Reset Signature
Date Signed *

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Please read all of the information on this form:

I authorize AccuCare Home Health Services to conduct a reference check with my present and/or previous employer(s). I understand that the reference information may include, but is not limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, positions held, and employment history.

My signature below authorizes my former/current employers and references to release information regarding my employment record with their organization and provide any additional information that may be necessary. I knowingly and voluntarily release all former/current employers, references, and AccuCare Home Health Services from any and all liability arising from their giving and receiving information about my employment history.

Name (Printed):

Signature: *

Reset Signature

Date:

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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 Accucare Home Health Care while caring for my patient throughout the Flu season.

I DECLINE to be vaccinated

I had/will get the influenza vaccine and will hand in a copy to the office

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

Applicant Signature *	Reset Signature
Date Signed *

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

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HR 10: Drug Free Workplace Policy

Purpose and Goal:
Elite Service NY Inc. (the “Company”) is committed to protecting the safety, health and wellbeing of all employees and other individuals in our workplace, a patient’s home, recruiting office and training center (“Workplace”). The Company recognizes that alcohol use and drug use pose a significant threat to our goals and people in the Workplace. We have established a drug-free workplace program that balances our respect for individuals with the need to maintain an alcohol and drug-free environment.

Covered Individuals:
Any individual who conducts business for the Company, employee, applicant, trainee, student, participant in “in-service” education or orientation, or conducts business on the Company’s premises (“Covered Individual”) is covered by our Drug-Free Workplace Policy.

Applicability:
This Drug-Free Workplace Policy applies to Covered Individuals whenever conducting business or representing the Company, while on call, while on Company property, while providing services in a patient’s home, while attending any training program, in-service education, orientation, all paid and unpaid breaks and meal periods, and while at any Company sponsored event.

Policy:
The Company is committed to providing a drug-free and alcohol-free, healthy, productive and safe Workplace for all of its Covered Individuals and patients. Working under the influence of alcohol, legal drugs, illegal drugs or controlled substances can adversely affect a Covered Individual’s productivity and efficiency and jeopardize the safety of the Covered Individual, co-workers, patients, and the public. Covered Individuals may not be under the influence of alcohol or unlawfully using controlled substances. The unlawful manufacture, distribution, dispensation, possession or use of controlled substances or the use of alcohol is prohibited.

A Covered Individual who possesses or uses a drug prescribed by a physician for the Covered Individual’s use while on the job, and whose performance is not noticeably impaired, will not be in violation of this policy. Covered Individuals are responsible for asking the prescribing practitioner about any side effects. In the event that the medication may affect performance, the Covered Individual is responsible to notify their immediate supervisor prior to reporting to work.

Controlled substances/drugs include but are not limited to narcotics, depressants, stimulants, hallucinogens, and any chemical compound added to Federal or State regulations and noted as a controlled substance.

The legal use of prescribed drugs is permitted on the job only if it does not impair a Covered Individual’s ability to perform the essential functions of their job effectively and in a manner that does not endanger the Covered Individual, a patient or other individuals in the Workplace. Even legal drugs may adversely affect the safety of the Covered Individuals, co-workers, patients, or members of the public. Therefore, Covered Individuals should not report to work, Company trainings or training programs under the influence of any legal drug that might affect their safety or the safety of others. “Legal Drugs” are those prescribed specifically for the Covered Individual or over-the-counter drugs that are legally obtained by the Covered Individual and used for the purpose for which they were prescribed and sold.

In New York State cannabis used in accordance with New York State Law is a legal consumable product. It will be considered a “Legal Drug” for purposes of this policy. The Company prohibits the use of marijuana on Company premises, while performing work functions, while participating in training programs, in-service education or orientation, or while providing direct patient care. Additionally, the Company prohibits being under the influence of marijuana while on Company premises, while performing work functions, while participating in training, in-service education, orientation and while providing direct patient care.

The Company will not discriminate based on a Covered Individual’s use of cannabis outside of the Workplace and outside of work hours. However, there are times when the Company may take action or prohibit Covered Individual conduct where:

The Company is/was required to take such action by state or federal statute, regulation or ordinance or other state or federal governmental mandate.
The Company would be in violation of federal law
The Company would lose a federal contract or federal funding
The Covered Individual while working, participating in a training program, participating in in-service education or orientation, or while providing direct patient care manifests specific articulable symptoms of cannabis impairment that decrease or lessen the Covered Individual’s performance of the tasks or duties
The Covered Individual while working, participating in a training program, participating in in-service education or orientation, or while providing direct patient manifests specific articulable symptoms of cannabis impairment that interfere with the Covered Individual’s obligation to provide a safe and healthy workplace as required by state and federal safety laws

The Company is not prohibited from taking employment or other action against a Covered Individual if the Covered Individual is impaired by cannabis while working, participating in a training program, participating in in-service education or orientation, or while providing direct patient, meaning the Covered Individual manifests specific articulable symptoms of impairment:

That decrease or lessen the performance of their duties or tasks or
Interfere with an employer’s obligation to provide a safe and healthy workplace, free from recognized hazards as required by state and federal occupational safety and health laws.

While there is no dispositive and complete list of symptoms of impairment, articulable symptoms of impairment are objectively indications that a Covered Individual’s performance of their essential duties or tasks are decreased or lessened.

The smell of cannabis on its own will not constitute evidence of articulable symptoms of impairment.

Communication:

Communicating the Company’s Drug-Free Policy is critical to its success. To ensure you are aware of your role in supporting our drug-free Workplace program:

All Covered Individuals will receive a written copy of the Drug-Free Policy.
The policy will be reviewed in orientation sessions with new Covered Individuals
The policy will be reviewed at the beginning of all training programs.
The policy will be reviewed at any employment interview and/or application process.
The policy will be reviewed at yearly in-service education.

I was given the opportunity to ask questions and my signature below indicates that I have read the above policy and understand its contents.

Signature *

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Date:*



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Employment Information

Never employed before or no employment history

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