Career application - SALES


Fill all the information in the steps. Click on next button at the bottom to proceed to the next form

Step - Compliance dates

# Car Insurance Expiration Driver's License Expiration Annual Competency Evaluation 90 Day Performance Evaluation 1 Year Performance Evaluation Professional’s License Expiration CPR Expiry Date Annual Background Check Misconduct
Compliance Date

Step - Employee personnel

Step - EMPLOYMENT APPLICATION

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

Step - EMPLOYMENT APPLICATION 2

List the last five years employment history, starting with the most recent employer.

Step - EMPLOYMENT APPLICATION 3

Step - EMPLOYMENT APPLICATION 4

Persons who can furnish information about your job performance.

Step - EMPLOYMENT APPLICATION 5

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time..

Step - INTERVIEW REVIEW

Step - APPLICANT REFERENCE CHECK 1

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

I hereby authorize the following information to be released. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

To be completed by previous employer:

Step - APPLICANT REFERENCE CHECK 2

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

I hereby authorize the following information to be released. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

To be completed by previous employer:

Step - ORIENTATION CHECK LIST 1

The following orientation topics will be used for all full-time, part-time and per-diem workers:

Initial upon completion

Step - ORIENTATION CHECK LIST 2

Step - JOB ACCEPTANCE STATEMENT 1

I further understand that this job description and rate of payment may be reviewed at any time and that I will be provided with a revised copy.

1. Overtime pay is entitled to Non-Exempt (Clerical) employees only. This excludes employees at supervisory level.

2. This agency provides Workers’ Compensation Insurance for all its employees.

Performed for anyone who is in direct contact with patients This skills evaluation is performed on hire and thereafter once per year.

Step - JOB ACCEPTANCE STATEMENT 2

For each task observe the HHA’s technique with a patient Evaluate the Task Satisfactory Unsatisfactory For tasks rated unsatisfactory retrain & reevaluate. Note date of satisfactory rating
Personal hygiene and grooming, including: bed bath; sponge, tub or shower bath, shampoo--sink, tub, or bed; nail , skin care; oral hygiene; toileting and elimination
Safe transfer techniques and ambulation
Communication skills
Observation, reporting & documentation of patient status & the care/service provided
Basic infection control process
Elements of body function and changes in body function that must be reported to a supervisor
Maintenance of a safe clean healthy environment
Recognizing emergencies and knowledge of emergency procedures
Physical, emotional and developmental needs of and ways to work with patients incl. respect for the patient and his/her privacy and property
Adequate nutrition and fluid intake
I certify that I am the agency Administrator/manager and have determined that has successfully passed this checklist.

Step - JOB ACCEPTANCE STATEMENT 3

Step - CORPORATE COMPLIANCE STATEMENT

The Corporate Compliance Statement provided below is to be acknowledged and signed by every Agency employee as well as every employee working for the Agency on a contract basis.

CORPORATE COMPLIANCE POLICY
Acknowledgment of Receipt and Understanding
As you know, our Home Care Agency and our Staff members have always been committed to providing exceptional health care and upholding ethical conduct standards and legal compliance
Our policy formally and clearly states that there is a zero tolerance to any form of fraud or misconduct. This Agency believes that every employee or agent plays a key and active role in maintaining its image and reputation.
I hereby acknowledge that I have apprised of and agree to comply with the Agency’s Corporate Compliance Policy. I understand that in no way does this create an obligation or contract of employment and that I, as well as the Agency, have the right to end the employment relationship at any time.

Step - EMPLOYEE COUNSELING REPORT

Step - EMPLOYEE INSERVICE LOG

Required: HIPAA, Bloodborne Pathogens, Medical Device Reporting, Infection Control, TB-Respiratory Disorders

DATE EMPLOYEE NAME SIGNATURE INSERVICE CEU HOURS

Step - CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION

It is both the Agency's and the employee's responsibility to ensure that every patient's health information is protected at all times. By signing below you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency's policy regarding patient's Protected Health Information will be provided to you upon hire.

I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated for use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with HIPAA Rule and Regulations.

Step - FIELD EMPLOYEE STANDARDS AND PROCEDURES

Welcome! This Agency requires adherence to the following Standards and Procedures:

1. All employees are expected to dress in a manner appropriate to the health care environment, or as directed by the patient/client/family. This includes personal hygiene, jewelry, hair and makeup.

2. Please do not smoke in the presence of a patient/client.

3. Always wear your ID Badge. Licensed personnel must always carry their current nursing license and CPR care while on assignment.

4. You are expected to arrive on time to all assignment that you have accepted. However, if an emergency or any situation should cause you to be five minutes late, or more or to be totally absent from the assignment you must notify the Agency immediately. PLEASE DO NOT CALL YOUR PATIENT DIRECTLY. You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment. A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION!

5. If you have any problem, incident or accident on the job, do not discuss it with the patient/client, but call the Agency immediately.

6. If the patient/client asks you to stay longer than your assignment or to leave earlier, you must call the Agency first, for approval.

7. All Personnel hereby acknowledge that they WILL NOT, UNDER ANY CONDITIONS, DISPENSE OR ADMINISTER ANY MEDICATION.

8. UNDER NO CIRCUMSTANCES are you to ask for, or accept any money from your patient/client or take home property that belongs to the patient client.

9. There shall not be any involvement with the patient/client’s financial affairs (i.e. check writing).

10. You are expected to honor the confidentiality of any patient/ client information which is obtained in the regular course of your employment.

11. No personal telephone calls should be made or received by you while on assignment.

12. Please do not discuss your pay or any other personal affairs with the patient/client/family.

13. As an employee of this Agency, you are not authorized to accept any direct employment that may be offered to you by your patient/client/family. If you are requested to do so, please have the patient/client contact us.

14. It is imperative that all signed notes and documentation including Daily Log, be filled out properly and returned to the office as per our schedule. If the patient/client is unable to sign your note, a family member or responsible party may sign.

15. During the course of employment, this Agency’s proprietary materials (i.e. forms, medical records) will be used only in connection with employment and will not be disclosed to anyone without authorization from the Agency.

16. Never leave your patient/client unattended.

Step - CONFIDENTIALITY AND NON-COMPETITION AGREEMENT

The Agency requires that the Employee avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition.

The Employee agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding employees, clients and the Agency business.

The Employee will have access to information not generally made available to the public, such as identity of clients, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purposes other than for the Agency's own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to Agency administration and/or projects, or outside investigations of the Agency. The employee is prohibited from disclosing any defaming information regarding Agency personnel and/or personnel incidents related to any violations of the personnel policies.

During the course of employment and for a twelve month period thereafter the Employee is prohibited from engaging in any of the following: induce any employee of the Agency to resign, encourage any client or entity to discontinue any relationship with the Agency, solicit any client of the Agency (current and within the past twelve month period), enter into competitive employment or seek to provide competitive services while employed within twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source.

Upon termination of employment or at the request of the Agency, the Employee is required to return all of the Agency's property including keys, client records, forms, manual, beeper, etc. to the Agency and will not retain copies. Failure to return a key will result in a $25.00 charge and failure to return a beeper will result in a $50.00 charge deducted from the paycheck.

Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, cost of replacing and training employees improperly solicited for competitive employment, etc suffered by the Agency. Employee will be required to reimburse the Agency for all legal fees, costs and other expenses.

This agreement is in effect during the Employee's employment and for twelve months thereafter. It does not modify the right of the Employee to resign at any time or of the Agency to terminate employment without prior cause, notice or liability and does not modify any other Agency policy.

Step - EMPLOYEE POLICIES AND PROCEDURES

I understand that copies of policy and procedure manuals are available and that it is my responsibility to read, understand and conform to all applicable Agency policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions.

I have read the Agency’s Policy and Procedure on Abuse, Neglect and Exploitation and agree to Comply with and be bound by the Policy.

I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its employees, nor is it an expression of my term of employment.

I affirm that I have auto insurance coverage as required by this state and the Agency and I agree to keep it fully in force on any vehicle I use for the conduction of Agency business during the term of my employment. The Agency has the right to request proof of insurance at any time during the term of employment and that I am required to follow all Agency requirements and state and local laws.

I understand that only the Agency has the authority to admit clients and will supervise with appropriate personnel all services provided.

As a caregiver, I will carry out the plan of treatment, submit time sheets as appropriate and, at a minimum, on a weekly basis, I will participate in developing and reviewing plans of care, periodic client evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend required staff meeting and inservice training. Attendants are required to have eight hours of in-service training annually.

I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided. I understand that all information, both written and verbal, regarding client and employee health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease; testing, results or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, drug or alcohol abuse is protected under specific law. All information in connection with the examination, care or provision of services to any client will not be disclosed without the individual's written consent except as may be necessary to provide services as required by law. Information may be used in statistical or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of client/ employee confidentiality is subject to civil and criminal penalties.

If I mistakenly exceed my accrued or earned sick or vacation leave balance, I authorize the Agency to deduct any amount from my paycheck(s) to correct my accrued or earned sick or vacation leave balance. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will.

Step - PERSONAL PROTECTIVE

I understand a Personal Protective Equipment (PPE Kit) is available in the office and contains the following:

1. Barrier Safety Goggles

2. CPR Shield Face Barrier

3. Fluid Resistant Gown

4. Gloves

5. Biohazard Bag

6. Sharps Container

7. 3M Respirator Mask (N95 or similar purchased from Uline.com)

I have been instructed in the use of this equipment and understand that I must comply with Policies and Procedures regarding use of personal protective equipment.

Step - EXIT INTERVIEW

Step - HEALTH STATEMENT

AIDS Anthrax Chickenpox Cholera
Diphtheria Encephalitis Hepatitis, Types A, B and C Influenza
Leprosy (Hansen’s Disease) Leptospirosis Malaria Measles (Rubeola)
Meningitis Mononucleosis Mumps Whooping Cough
Plague Poliomyelitis Psittacosis (Ornithosis) Rabies
Rocky Mountain Spotted Fever Rubella (German Measles) Shigellosis Smallpox
Tetanus Tularemia Tuberculosis Typhoid Fever
COVID-19

Step - HEPATITIS VACCINE REQUIREMENT


Step - TB TARGETED MEDICAL QUESTIONNAIRE FORM


Step - CRIMINAL CHECK ATTESTATION

I will also be denied if the Agency becomes informed of any conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed under State Code.

I understand that if I am listed in the nurse aide registry as unemployable due to findings of abuse, neglect or mistreatment of a consumer of any agency or facility licensed under Health and Safety Code or misappropriation of a consumer’s property, if I am listed as an offender in the National Sex Offender Registry or on OIG’s exclusion list or listed in the employee misconduct registry as unemployable due to a finding that I have committed an act that constitutes ‘reportable conduct as described in the State Code.

Disqualifying Crimes other than those listed in Terminable Offenses below are categorized as TABLE A and TABLE B crimes for the purpose of the criminal check. I understand that if I have been convicted of a TABLE B crime and completed my sentence more than five years ago for a misdemeanor or ten years ago for a TABLE B felony; such crimes will not be considered by the Agency in their employment decision.

If I was convicted in any other time period of a TABLE A or B crime, the Agency will weigh the seriousness of the crime against mitigating factors spelled out in 101 CMR 15.09, before making a decision to accept or reject my employment.

I also understand that If the Criminal Check reveals an outstanding warrant for any offense, I will be ineligible for employment at the Agency unless the warrant is removed.

  • Criminal homicide
  • Indecency with a child
  • Injury to a child, elderly individual, or disabled individual
  • Abandoning or endangering children
  • Arson robbery
  • Kidnapping and false imprisonment
  • Aggravated assault
  • Agreement to abduct from custody, sale or purchase of a child
  • Aiding suicide
  • Aggravated robbery