Apply OnlineEmployment Application:*Name*Social Security*Date:Current Address:*Home Telephone*Zip Code*Daytime Telephone*Date of birth*Position(s) desired: Personal Care Assistance/ Home health aide Certified nursing assistant Licensed practical nurse Registered Nurse Homemaker/ companion *Date of availability*Preferred Work Schedule Day Evening Night *Please provide your availability Monday Tuesday Wednesday Thursday Friday Saturday Sunday *Are you permitted to work in the United States for any employer? Yes No Education:1 High School/ Equivalent:*Completed? Yes No MajorFrom Mo/Yr to Mo/YrFeb 2020 to feb 2021Degree ReceivedAdditional Education:Profession:1)Professional Licensure(s)/Registration(s)/Certification(s)NumberYr. ReceivedDate of Expiration2)Professional AssociationsEmployment History:*period of Employment (Mo. & Yr.)*From*To*Job TitlePosition Responsibilities*Employer’s NameEmployer’s Address*Supervisor’s Name & Title*Phone No.Reason for LeavingAcknowledgementI certify that the information on this application is true and complete to the best of my knowledge i understand that any misrepresentation willful omission false or misleading information is grounds for rejection of this application form refusal to hire withdrawal of an offer of employment or immediate discharge whenever discovered you are authorized to conduct investigations including verification of prior employment history and education i also understand that employment is dependent upon receipt of acceptable employment references and satisfactory completion of pre-employment health screening which will include illicit drug and alcohol testing and provision of documents required by the immigration reform and control act of 1986 1st americare llc home health does not discriminate against any qualified person because of age race color religion sex national origin disability or sexual orientation by signing this application i acknowledge that an offer of employment at 1st americare llc home health should not be interpreted as an offer of continued or permanent employment*Type your name and Date of Birth to certifyEg. John Doe 22/08/1999REQUEST FOR REFERENCE:1:Eg. John Doe 22/08/1999Tel:Address:Zip*Applicant Name:Employment Period*position/titleReference 2:TelephoneAddressApplicant NameEmployment periodInformation CertificationThe above named applicant has applied for a position at 1st Americare LLC. and has given your name as a previous or current employer. Please complete this reference request and submit it to us. Thank you for your prompt reply. I authorized and request my former/current employer, person given as a reference to answer all questions asked, and give all information requested concerning my work performance, character, and job related skills.*Type your name and birth date to certifyDRUG AND ALCOHOL POLICY AGREEMENTIt is the policy of 1ST AMERICARE LLC Home Health Care that all its employees be free of the influence of alcohol and drugs. All employees must be fit for the duty physically and mentally, as is necessary to perform work in a safe and competent manner. Possession, trading, manufacture and sale of illegal drugs or alcohol on the job is therefore a violation of this policy. Also, it is a violation of this policy to work under the influence of illegal drugs or alcohol. Violations of this policy are subject to disciplinary action up to and including termination. I certify that I am not under the influence of drugs or alcohol, nor will I use or possess in anyway controlled substances (marijuana, heroin, cocaine, crack, hash etc). I understand that these examples do not cover all controlled substances. Failure to comply with this agreement may result in termination of my employment with 1ST AMERICARE LLCHome Health Care. I have been briefed and fully understand 1ST AMERICARE LLCHOME HEALTH drug and alcohol policy and I agree to fully comply with the provisions herein.*Type your Name and Birth date to certifyEMPLOYMENT STATEMENT OF CONFIDENTIALITYI the undersigned understand the importance of observing strict confidentiality policies therefore i agree not to discuss release any information obtained within the agency any 1st americare llc client their medical records or any clients condition with any individual not directly associated with the client i also agree that any information that is released regarding the client or the clients record will only be done with proper authorization and or in accordance with established agency policy for the release of the information my signature on this document indicates that i understand and agree to abide by the aforementioned policies and that any breach in the aforementioned policies will result in implementation of the disciplinary procedure up to and including possible immediate dismissal from employment at 1st americare llc*Type your name and birth date to certifyEg. John Doe 22/08/19991ST AMERICARE LLC HEPATITUS B VACCINE DECLINATION FORMI understand that due to the occupational exposure of blood or other potential infectious materials i may be at risk of acquiring hepatitis b hbv infection i have been informed about the importance of being vaccinated against hepatitis b i understand that by declining this vaccine i continue to be at risk of acquiring hepatitis b if in the future i want to be vaccinated against hepatitis b arrangements will be made for me to acquire the vaccine*Type in name and Birth date to certifyEg. John Doe 22/08/1999Note:to all employees of 1st americare llc subject timesheets as a reminder timesheets are due in this office no later than tuesday before 100 pm each week note that any timesheets submitted after 1200 noon is considered late and would be due for payment after six weeks also timesheets submitted with errors would be rejected and be paid six weeks after any necessary corrections have been made take time and make sure that your timesheets are done appropriately consent below by signing this notice Be aware that 1 all employees must abide by 1st americare llc policies while in the clients home 2 if you report to work and the client does not answer knock on the door or answer home telephone 1st americare llc home care must be notified immediately 3 call outs must be done 2-3hrs prior to the scheduled time to work all call outs must be forwarded to the staffing coordinator no call outs should be done to the client if you call the client and not the agency that will be considered no call no show which is subject to disciplinary actions 4 if you call out you are not allowed to go to that clients home for any reason during your time off 5 you are not allowed to switch shifts with another aide unless authorized by the staffing coordinator 6 all employees must be in complete uniform and wear 1st americare llcs id badge while in the care of the client at all times please be aware that the id badge is only good for one year and must be returned to the office if you are no longer employed by 1st americare llc if you misplace this badge 1st americare llc will charge 10 for replacement 7 employees are not allowed to accept gifts or gratuities from clients and their families 8 you are not allowed to buy alcohol or drugs for clients you are not allowed to consume alcohol while caring for the client 9 you are not allowed to administer any form of medication tablets syrups ointments eye drops or injections to the client do not fill medication planners for the client you are expected to follow your job description on the time sheet if the client asks you to do something and you are unsure about it call the office for clarification 10 all time sheets should be signed by the client or their representatives if you sign your own time sheet or forge the client's signature it is fraud and you will be terminated and reported to the dc aides registry and to medicaid in addition you will be expected to pay such monies back 11 all aides are expected to report to the clients home on time and stay the entire shift if you are asked to do errands for the client you must notify the staffing coordinator or the office manager about such errands 12 aides are not allowed to do their own schedules you must only work hours assigned by the nurse and staffing coordinator if the client request that you work any other hours you must notify the staffing coordinator and such hours must be approved 13 all time sheets must be sent to the office by 12pm every tuesday time sheets can only be dropped off after your shift has ended or use the drop off slot to drop off your time sheets before or after working hours no client should be left unattended while you drop off your timesheet 14 time sheets must be completed in black ink it must be signed by both you and the client it is your responsibility to make sure that your timesheet is done correctly 15 pay checks are distributed every other friday from 2p- 7p and on saturdays from 9a- 1p you will not be allowed to leave your client unattended to pick up your check you can designate someone to pick up your check but a signed authorized letter with that person's name and picture id must be on file in the office 16 you are expected to attend mandatory in- services conducted by 1st americare llc or required to bring in service certificates from approved institutions in- service certificates from other institutions must meet standards set for by dc department of health and regulatory administration 17 all aides must provide the office with current telephone numbers and addresses 1st americare llc will not be held responsible for mails sent to the wrong address 18 you are expected to update all documents such as physical work authorization police clearance etc before they expire you will be pulled away from work until such documents are updated or renewed 19 any employee who provides fraudulent paperwork such as work authorization will be reported to the ins any employee who provides fake certificates such as physical police clearance home health aide certificates etc will be reported to the dc aide registry and to medicaid 20 clients phone should be used only to conduct business related to the client any violation will lead to termination and you will be asked to pay the clients phone bill 21 clients should be addressed as ms mrs or mr no client should be addressed with pet names such as sweetheart mama mom pops papa etc 22 only english or spanish should be spoken in the client's presence 23 report any changes in clients condition such as redness to the nurse or call the office and ask for the director of nursing 24 call 911 if the client is unresponsive is losing blood or fluid has difficulty breathing stops breathing falls and complains of pain notify the agency after paramedics transfer the client to the emergency room 25 if the client is admitted into the hospital please notify the staffing coordinator or the director of nursing immediately*Name of EmployeeEmployee Emergency Information: Fill the following detailsPerson(s) to contact in case of EmergencyNameRelationshipTelephone1ST AMERICARE LLC SUBJECT: JOB DESCRIPTION HOME HEALTH AIDE/CAN/PCA/LPNprovides personal care services under the direction of the registered nurse or therapist the home health aide is assigned to specific clients by the registered nurse or other appropriate professional and performs services for clients as necessary to maintain their personal comfort reports to rn case manager clinical supervisor therapist qualifications 1 successful completion of a formal certification training program and or a written skills test and competency evaluation approved by the vdh 2 be at least eighteen 18 of age 3 minimum of six 6 months work experience in a supervised setting preferably health care facility a plus 4 demonstrated ability to read write and follow a written plan of care 5 good interpersonal skills 6 current drivers license good driving record and reliable transportation 7 must successfully complete and score a 70 or better on the written competency exam essential functions areas of accountability 1 performs simple procedures as an extension of therapy services under the direction and supervision of the therapist a range of motion exercises b assistance in ambulation or exercises 2 performs personal care activities including but not limited to a bathing b shampooing c skin care nail care d oral hygiene e shaving f dressing 3 performs household services essential to health care at home including but not limited to a meal preparation feeding b laundry c light housekeeping 4 assists in the administration of medications that are ordinarily self- administered under the direction and supervision of the registered nurse 5 reports any observed or reported changes in the clients condition and or needs to the registered nurse 6 documents cares provided and complete the forms required for the clients records complete the appropriate records to document cares given and pertinent observations 7 promotes personal safety and a safe environment for clients by observing infection control practices following agency guidelines and reporting unsafe situations to the supervisor case manager 8 demonstrates safe practice in the use of equipment does not use equipment until orientation has been provided notifies supervisor of educational needs 9 communicates effectively with all members of the interdisciplinary team through verbal reports participation in staff meetings and team conferences as requested 10 maintains confidentiality in all aspects of the job 11 participates in the development implementation and evaluation of the agency quality improvement program and pertinent activities 12 performs other related duties and responsibilities as deemed necessary physical environmental demands i have read and understand the above job description of the home health aideList of supporting documents Please submit following with application of employment. Thank you1. Copy of Passport page with your name (List A Form I – 9 )Max size 20 MBOrCopy of green cardMax size 20 MB2 Driver licenseMax size 20 MB3 Upload social SecurityMax size 20 MB4 Latest proof of PPD OR Chest X RayMax size 20 MB5 Professional License Copy ( RN/LPN/PT/OT)Max size 20 MB6 Copy of void bank check for Direct Deposit formMax size 20 MB7 Copy of CPR/ACLS cardMax size 20 MBFields with (*) are compulsory.