Agency Emergency Hire Affidavit 2

Agency Emergency Hire Affidavit

I have not been convicted of any of the following penal code offenses, which may potentially bar employment
I acknowledge that if i am 'found to have been convicted of any other offenses, they may cause my employment to be terminated. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.


If arrested/ convicted of any offense listed, please provide explanation.
Revised 6/25/2018
Agency Emergency Hire Affidavit
Due to the lack of sufficient personnel to adequately and safely care for our patients needs, we are hiring
I He/She has consented to a criminal history check to be performed
as part of our hiring process. During the sixty (60) days waiting period on the criminal history check, this document will serve as an acknowledgement that the above named person states that they have no conviction of an offense which would bar employment.
Offenses which would bar employment
Criminal homicide Kidnapping and false imprisonment
Indecency with a child Agreement to abduct from custody
Solicitation of a child Sale or purchase of a child
Arson Robbery
Offenses which potentially may bar employment
Assaultive offenses Burglary and criminal trespass
Theft Weapons
Fraud Public I .ewdness
Indecent exposure Public indecency
A felony violation of a statute intended to control the possession or distribution of a substance included in chapter 481. health and safety code (Indiana controlled substance act).
If we do not receive a response from the Indiana Department of Health within sixty (60) days, it is likely that no convictions were found. You would no longer be on an "emergency hire" status.
If however, a conviction is ibund, INDII will notify us as well as sending the same information to you. You will be given instructions as to what options you have available to you. INDI I will send us a notice of determination as to weather you arc employable. We will abide by this determination. All information concerning your criminal history will remain confidential.
I,consent to a criminal history check and further state that I have no conviction for any of the offenses listed above. I understand and agree to the terms of this agreement
Revised 6/25/2018
Form W-4 (2018)
Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.
Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.
Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply.
• For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and
• For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.
If you're exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.
General Instructions
If you aren't exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.
You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider using this calculator if you have a more
complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you're having withheld compares to your projected total tax for 2018. If you use the calculator, you don't need to complete any of the worksheets for Form W-4.
Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.
Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you're married and your
spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning.
Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/ W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P.
Nonresident alien. If you're a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.
Specific Instructions Personal Allowances Worksheet
Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.
Line C. Head of household please note:
Generally, you can claim head of
household filing status on your tax return only if you're unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.
Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.
Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don't qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of
Form W-4
Department of the Treasury Internal Revenue Service
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Employee's Withholding Allowance Certificate
► Whether you're entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
2018
Your first name and middle initial
Last name
2 Your social security number
Home address (number and street or rural route)
3 SingleMarriedMarried, but withhold at higher Single rate.

Note: If married filing separately, check "Married, but withhold at higher Single rate."
City or town, state, and ZIP code
4 if your last name differs from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card.

5 Total number of allowances you're claiming (from the applicable worksheet on the following pages).
6 Additional amount, if any, you want withheld from each paycheck 6 $
7 I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write "Exempt" here
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee's signature
8 Employer's name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of employment
10 Employer identification numner (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Cat. No. 102200
Form W-4 (2018)
AHC PERSONNEL AGREEMENT
BASE PAY: $8.00/hr
QLTY BONUS: +3.50/hr
TOTAL: $11.50/hr
OR
BASE PAY: $8.00/hr
ATT BONUS: +4.00/hr
$12.00/hr










BONUS
1. QUALITY BONUS- maintaining quality work ethic for your clients. Ensuring needs are met and daily task are completed.
a. Additional $3.50 per hour (s) for all hours worked in the pay period.
2. ATTENDANCE BONUS- applied when the caregiver has no call offs during the pay period.
b. Additional .50 cents per hour (s) worked up to 40 hours, paid for all hours worked per pay period.
3. BONUS will not apply to hours worked over 40 per week.
OVERTIME
Hours worked over 40 per week, will be paid at time and half of the hourly rate noted above.
MILEAGE
Mileage will be reimbursed at .38 cents per mile between clients only.
SEMIMONTHLY PAYROLL:
PAY DATES: THE 15TH OF THE MONTH AND THE LAST DAY OF THE MONTH
PAY PERIODS: 1sT-15TH OF THE MONTH 16TH- LAST DAY OF THE MONTH







Responsibilit to Maintain & Complete Tasks

• Services to be provided.
• Rights, responsibilities, functions, and objectives of the coordination, supervision, and evaluation of the care or services provided.
• Submission of documentation to the agency for services provided.
Only the agency may accept clients to receive services rendered by the contract personnel. Individuals or organizations under contract with the agency shall bill
the agency directly for services provided to the clients at the negotiated rate. Contract personnel or organizations shall not bill the client directly for services
All contract personnel shall adhere to the client's established Plan of Care in the
rendering of any professional services to the client. Contract personnel may recommend changes in the Plan of Care, but all modifications thereof must have the written approval of the Director of Nursing.

Contract personnel shall complete clinical notes and progress reports on their clients for services performed. Documentation shall be submitted to the agency and filed in the clinical record.
Contract personnel shall report any significant changes in a client's condition or response to treatment or therapy immediately to the Director of Clinical Services or Nursing Supervisor and the client's physician.
Contract personnel shall appear neat and professional on all client visits and conduct themselves in a professional manner.
Contract personnel must comply with Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of'1975, the Title VI of' the Civil Rights Act of 1964, as well as all other agency rules. Contract personnel shall be responsible to the Director of Clinical Services or other such designee.
The Contractual Agreement shall continue and be binding upon the parties from year to year unless terminated by either party with thirty (30) days
written notice. If the contractor fails to perform according to the agreement, services will be terminated with twenty-four (24) hours' notice by the agency.
EMPLOYEE SIGNATURE
EMPLOYER REPRESENTATIVE
A& D HOME HEALTH CARE PERSONNEL AGREEMENT
BASE PAY: $9.00/hr
QLTY BONUS: +4.00/hr
TOTAL: $13.00/hr
OR
BASE PAY: $9.00/hr
ATT BONUS: +4.50/hr
$13.50/hr










BONUS
1. QUALITY BONUS- maintaining quality work ethic for your clients. Ensuring needs are met and daily task are completed.
a. Additional $3.50 per hour (s) for all hours worked in the pay period.
2. ATTENDANCE BONUS- applied when the caregiver has no call offs during the pay period.
b. Additional .50 cents per hour (s) worked up to 40 hours, paid for all hours worked per pay period.
3. BONUS will not apply to hours worked over 40 per week.
OVERTIME
Hours worked over 40 per week, will be paid at time and half of the hourly rate noted above.
MILEAGE
Mileage will be reimbursed at .38 cents per mile between clients only.
SEMIMONTHLY PAYROLL:
PAY DATES: THE 15TH OF THE MONTH AND THE LAST DAY OF THE MONTH
PAY PERIODS: 1sT-15TH OF THE MONTH 16TH- LAST DAY OF THE MONTH







Responsibility to Maintain & Complete Tasks

• Services to he provided.
• Rights, responsibilities, functions, and objectives of the coordination, supervision, and evaluation of the care or services provided.
• Submission of documentation to the agency for services provided.
Only the agency may accept clients to receive services rendered by the contract personnel. Individuals or organizations under contract with the agency shall bill
the agency directly for services provided to the clients at the negotiated rate. Contract personnel or organizations shall not bill the client directly lbr services
All contract personnel shall adhere to the client's established Plan of Care in the
rendering of any professional services to the client. Contract personnel may recommend changes in the Plan of Care, but all modifications thereof must have the written approval of the Director of Nursing.

Contract personnel shall complete clinical notes and progress reports on their clients for services performed. Documentation shall be submitted to the agency and filed in the clinical record.
Contract personnel shall report any significant changes in a client's condition or response to treatment or therapy immediately to the Director of Clinical Services or Nursing Supervisor and the client's physician.
Contract personnel shall appear neat and professional on all client visits and conduct themselves in a professional manner.
Contract personnel must comply with Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of'1975, the Title VI of' the Civil Rights Act of 1964, as well as all other agency rules. Contract personnel shall be responsible to the Director of Clinical Services or other such designee.
The Contractual Agreement shall continue and be binding upon the parties from year to year unless terminated by either party with thirty (30) days
written notice. If the contractor fails to perform according to the agreement, services will be terminated with twenty-four (24) hours' notice by the agency.
EMPLOYEE SIGNATURE
EMPLOYER REPRESENTATIVE

A& D HOME HEALTH CARE LPN PERSONNEL AGREEMENT

BASE PAY: $22.00/hr




MILEAGE
Mileage will be reimbursed at .38 cents per mile between clients only.
SEMIMONTHLY PAYROLL:
PAY DATES: THE 15TH OF THE MONTH AND THE LAST DAY OF THE MONTH
PAY PERIODS: 1sT-15TH OF THE MONTH 16TH- LAST DAY OF THE MONTH







Responsibility to Maintain & Complete Tasks

• Client admission process.
• Client assessment.
• Development, review, and revision of the Plan of Care.
• Care conferences.
• Scheduling of visits or hours.
• Discharge planning.
• Submission of documentation to the agency for services provided.
• Responsibility of the contracting agency or individual to adhere to all applicable policies, including personnel qualifications.
• Procedures for determining charges and reimbursement.
• Terms of the agreement and the conditions fbr renewal or termination.
Only the agency may accept clients to receive services rendered by the contract personnel. Individuals or organizations under contract with the agency shall bill
the agency directly for services provided to the clients at the negotiated rate. Contract personnel or organizations shall not bill the client directly lbr services
All contract personnel shall adhere to the client's established Plan of Care in the
rendering of any professional services to the client. Contract personnel may recommend changes in the Plan of Care, but all modifications thereof must have the written approval of the Director of Nursing.

Contract personnel shall complete clinical notes and progress reports on their clients for services performed. Documentation shall be submitted to the agency and filed in the clinical record.
Contract personnel shall report any significant changes in a client's condition or response to treatment or therapy immediately to the Director of Clinical Services or Nursing Supervisor and the client's physician.
Contract personnel shall appear neat and professional on all client visits and conduct themselves in a professional manner.
Contract personnel must comply with Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of'1975, the Title VI of' the Civil Rights Act of 1964, as well as all other agency rules. Contract personnel shall be responsible to the Director of Clinical Services or other such designee.
The Contractual Agreement shall continue and he binding upon the parties from year to year unless terminated by either party with thirty (30) days written notice. If
the contractor fails to perform according to the agreement, services will he terminated with twenty-four (24) hours' notice by the agency.
Personnel Agreement
DATE of HIRE:
SALARY/HOURLY/PER VISIT
Note: Please complete your charting before the deadline to prevent any delays with your check.
Semi-monthly Payroll System:
PAY DATE: 15TH OF THE MONTH FOR SERVICES 16TH TO 30TH OR 31TH
PAY DATE: 30TH OR 31TH FOR SERVICES 1ST TO 15TH







Responsibility to Maintain & Complete Tasks
• Client admission process.
• Client assessment.
• Development, review, and revision of the Plan of Care.
• Care conferences.
• Scheduling of visits or hours.
• Discharge planning.
• Submission of documentation to the agency for services provided.
• Responsibility of the contracting agency or individual to adhere to all applicable policies, including personnel qualifications.
• Procedures for determining charges and reimbursement.
• Terms of the agreement and the conditions renewal or termination.
Only the agency may accept clients to receive services rendered by the contract personnel. Individuals or organizations under contract with the agency shall bill
the agency directly for services provided to the clients at the negotiated rate. Contract personnel or organizations shall not bill the client directly lbr services
All contract personnel shall adhere to the client's established Plan of Care in the
rendering of any professional services to the client. Contract personnel may recommend changes in the Plan of Care, but all modifications thereof must have the written approval of the Director of Nursing.

Contract personnel shall complete clinical notes and progress reports on their clients for services performed. Documentation shall be submitted to the agency and filed in the clinical record.
Contract personnel shall report any significant changes in a client's condition or response to treatment or therapy immediately to the Director of Clinical Services or Nursing Supervisor and the client's physician.
Contract personnel shall appear neat and professional on all client visits and conduct themselves in a professional manner.
Contract personnel must comply with Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of'1975, the Title VI of' the Civil Rights Act of 1964, as well as all other agency rules. Contract personnel shall be responsible to the Director of Clinical Services or other such designee.
The Contractual Agreement shall continue and he binding upon the parties from year to year unless terminated by either party with thirty (30) days written notice. If
the contractor fails to perform according to the agreement, services will he terminated with twenty-four (24) hours' notice by the agency.
Employment Eligibility Verification
Department of Homeland Security

U.S. Citizenship and Immigration Services
USCIS
Form 1-9

OMB No. 1615-0047
Expires 08/31/2019
START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
Employee's E-mail Address Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)
Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9:
An Alien Registration Number/USCIS Number OR Form 1-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
OR
2. Form 1-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:
QR Code - Section 1
Do Not Write in This Space
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section knowledge the information of this form and that to the best of my is true and correct.
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town | State ZIP Code
Employment Eligibility Verification
Department of Homeland Security

U.S. Citizenship and Immigration Services
USCIS
Form 1-9

OMB No. 1615-0047
Expires 08/31/2019
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. 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.')
Employee Info from Section 1
List A
Identity and Employment Authorization
OR List B
Identity
AND List C
Employment Authorization
















Additional Information




QR Code - Sections 2 & 3
Do Not Write in This Space
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.
The employee's first day of employment: (See instructions for exemptions)









ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)




C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes ;continuing employment authorization in the space provided below.
Document Title


I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative


LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
Documents that Establish
Both Identity and
Employment Authorization OR
LIST B
Documents that Establish
Identity
LIST C
Documents that Establish
Employment Authorization
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien Registration Receipt Card (Form 1-551)
3. Foreign passport that contains a temporary 1-551 stamp or temporary 1-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form 1-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
a. Foreign passport; and
b. Form 1-94 or Form I-94A that has the following:
(1) The same name as the passport; and
(2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the
proposed employment is not in conflict with any restrictions or limitations identified on the form.
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form I-94A indicating
nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
3. School ID card with a photograph
4. Voter's registration card
5. U.S. Military card or draft record
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
9. Driver's license issued by a Canadian government authority
For persons under age 18 who are unable to present a document listed above:
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
(1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Native American tribal document
5. U.S. Citizen ID Card (Form 1-197)
6. Identification Card for Use of Resident Citizen in the United States (Form 1-179)
7. Employment authorization document issued by the Department of Homeland Security
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Application for Employment
Employment desired Full time Part time Temp Seasonal
Are you employed now? If so may we inquire of your present employer? Yes No
Ever applied for this company before? Yes No
Are you on layoff and subject to recall? YesNo. Will you travel if required? YesNo
Will you relocate if job requires it? YesNo. Will you work if Short Notice? YesNo
Are you able to meet the attendance requirements of this position? YesNo. Have you ever been
bonded? YesNo. Have you ever been convicted of a felony in the past 7 yrs YesNo
Such conviction may be relevant if job related, but does not bar you from employment. If yes — explain
Education Name and location
Of School
# of years
Completed
Did you
Graduate?
Subjects
Studied
Academic Currently Attending

Last Completed

Trades of
Business
Currently Attending

Last Completed

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with this company.
Revised 6/25/2018
EMPLOYMENT APPLECATION
Date

Month and Year
Name and address of
employer
Salary Job Reason for
Leavino.
From

To

From

To

From

To

References: Give the names of three persons not related to you to whom you have known at least 1 year
Name Address Phone Yrs acquainted
List any foreign language(s) and check the box that best describes your skill level.
Language Read and write Read and speak Speak only
INITIAL Conditions of Employment — please read carefully




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.
It is understood and agreed upon that any misrepresentation by me in this
application will be sufficient cause for cancellation of this application and/or separation from the employer's service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.
Revised 6/25/2018
EMPLOYMENT APPLICATION
I give the employer the right to investigate all police, driving, and personal records
and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.
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.
Any controversy of any kind arising between the parties under this agreement or
otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company.
Panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section i-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.
This application is current for 60 days. At the conclusion of this time, if I have not
heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.
AGENCY MANAGEMENT NOTES
Revised 6/25/2018
Reference Consent and Results
Mr./Mrs. is seeking employment
with our company. It is our policy to ask for references prior to employment. Please complete this form for our records and sign below.
We would greatly appreciate your assistance.
PLEASE VERIFY EMPLOYMENT DATES:
YES/NO
Information received by:
Reference Consent and Results
Mr./Mrs. is seeking employment
with our company. It is our policy to ask for references prior to employment. Please complete this form for our records and sign below. We would greatly appreciate your assistance.
PLEASE VERIFY EMPLOYMENT DATES:
YES/NO
Information received by:
Employee Consent for Insurance Verification
To Whom it May Concern:
I give my insurance broker,authorization to release to my employer the following information:
1. Automobile insurance policy information;
2. Copies of automobile policies and certificates of insurance.
I also give authorization to advise my employer of any changes in my automobile insurance.
I am aware and acknowledge the information referred to above is not shared with any third parties except the employer if requested at any time for audit. The information is used by the employer to confirm adequate and proper insurance coverage of my automobile while being used during the course of my employment. By signing below, I give the employer consent to collect the information contained herein and use for the purpose specified. By signing below, I also give consent to my insurance broker to provide the employer with above-mentioned information.
SEXUAL HARASSMENT







POLICY
Agency will not tolerate conduct by any employee/client who harasses, disrupts, or interferes with another's work or creates an offensive or hostile work environment.
While all forms of harassment are prohibited, Agency emphasizes that sexual harassment is specifically prohibited.
PURPOSE
To ensure an effective means by which an employee who believes that he/she has been subject to sexual harassment in the workplace can report the incident.
SPECIAL INSTRUCTIONS
1. Any employee who believes that he/she has been subject to sexual harassment in the workplace, by a manager, co-worker, or client, should report the incident to the Administrator as soon as possible. If the employee feels uncomfortable discussing the incident with the Administrator or the incident relates to or involves the Administrator, the Director of Clinical Services shall be notified.
2. Any employee who violates the policy against sexual harassment, or encourages another to violate the policy, will be subject to appropriate disciplinary action, depending on the severity and type of violating behavior, up to and including discharge. The following behavior is considered a violation of this policy:
a. Threatening or insinuating that an applicant or employee should submit to sexual advances or that refusal to submit to sexual advances will adversely affect employment, including evaluation, wages, promotional opportunities, or assignments.
b. Giving favorable treatment in any way to an applicant or employee because that person has shown a willingness to perform sexual activities.
c. Making unwelcome or unwanted sexual advances. This includes patting, pinching, brushing up against, hugging, cornering, kissing, fondling, or any other similar physical contact considered unacceptable by another individual.
d. Verbally abusing or kidding that is sex-oriented and considered unacceptable by another individual. This includes:

• Comments about an individual's body or appearance (where such comments go beyond a mere compliment).

• Off-color jokes that are clearly unwanted or considered offensive by others.

• Any other tasteless, sex-oriented comments, innuendoes, or offensive actions.
e. Displaying sexually suggestive objects or pictures, including nude photographs, in the workplace.
f. Any other sexually oriented conduct that would seriously interfere with another's work performance.
Social Media & Internet Postin
Your employer understands the benefits of social media to share information with friends and family.

However, as an employee of the company, your employer requires a signed commitment to use social media responsibly. These requirements preserve the company's reputation and are intended to protect the interests of all employees, clients and their families.

For the purposes of this section., the following activities are classified as -social media" or "internet postings:"
• Multi-media and social networking websites including: Twitter, Facebook, YouTube, Instagram„ Snap Chat, Linkedln and any other multi-media or social media websites.
• Any internal or external blogs
Wikis such as Wikipedia and any other site where text can be posted.

SOCIAL MEDIA/INTERNET POSTINGS
Employees are not permitted to mention or tag your employer in any social media or internet postings without prior written approval from the director. This includes disclosing information regarding your employer, its employees or its clients and their flimilies.

Furthermore, within or after employment, employees and former employees are prohibited from using social media or the internet to potentially harm A your employer's reputation. This includes:

• Sharing confidential or proprietary information concerning your employer and its employees, clients or their families.
• Posting derogatory, deffimatory or inflammatory comments or content related to your employer its employees, clients or their families.
• Posting pictures or other information that may implicate your employer: employee was involved in illegal or inappropriate activities.

EMPLOYEE AGREEMENT OF TERMS
I certify that I have read my employers social media and interne
posting policy and understand that failure to comply with these requirements may result in disciplinary action, up to and including termination of employment.


Furthermore, I understand that in the event my employment is voluntarily or involuntarily terminated, this policy still applies to me as a former employee of the company. In addition, your employer may seek legal action against me for violating this agreement.
CONFIDENTIALITY OF INFORMATION
AGREEMENT
Confidentiality of Information
• All information designated confidential that is obtained or generated as a result of any or all of the operations of the agency will be dealt with in a confidential manner.
• All information that is gathered maintained or stored by the agency becomes the agency's property and cannot be released without proper authorization from the administration.
• Altering information is prohibited by the agency and by law. Correction of any identified erroneous information must he done
according to agency policy.

WHAT WE CAN DO TO MAINTAIN CONFIDENTIALITY OF INFORMATION
• In order to protect any individual from invasion of privacy and to protect the interest of the agency, any information gathered for patient care or operations will be gathered, maintained and stored in such a manner as to assure confidentiality.
• Access to information will be limited to a need to know basis to perform the scope of one's duties and responsibilities.
• Dissemination of information will be handled according to agency policy, and staff will be informed during orientation, will sign the confidentiality statement and it will be placed in the employee's file.
• Proven violation of breech of the confidentiality agreement may be cause for immediate termination.
I understand that I am responsible for following this Confidentiality Policy Agreement & The Guidelines, Both Written and Verbal.
A IT C
Al-lwiablp 31nrr.w Care
Maintain your independent lifestyle
www.IN-ahccom

AFFORDABLE HOME CARE LLC CAREGIVER AGREEMENT
This agreement is made this day of , 20 between Affordable
Home Care LLC referred to as " A H C" and referred to as "Applicant':
1. Proprietary Information. Applicant recognizes that Applicant may have access to A H C"s client records, financial records, business forms and the list of A H C's customers and Applicants. Applicant understands that all such information is a valuable and unique asset of A H C's business, and agrees to consider all such information to be proprietary. Applicant agrees, at all times and all circumstances, to keep such information confidential. Applicant understands that this commitment survives the termination of Applicant's relationship with A H C.
2. Solicitation. Applicant agrees that during the period of work assigned by A H C and for a period of one (1) year after the termination of Applicant"s work assignment(s), Applicant will not, on behalf of Applicant or on behalf of any other applicant, firm, corporation, or entity, call on any of the clients of A H C for the purpose of soliciting and/or providing to any of such clients any senior citizen domestic care services. Applicant shall not, in any way, directly or indirectly, for Applicant, or on the behalf of any other applicant, firm, corporation, or other entity, solicit, divert, or take away any client of A H C, nor shall Applicant directly perform any senior care domestic care services for any client of A H C during the aforementioned period. Failure to comply with this term will result at a minimum in a $10,000 penalty fine imposed on the Applicant and possible further legal action.
3. Position Duties, Procedureponsibilities. Applicant agrees and certifies that they have at
least two years prior experience and training in the following Personal Caregiver duties targeted at Special Needed and our Seniors citizen: Companionship & Conversation, Bathing, Dressing, Grooming, Light Housecleaning, Alzheirner"s & Dementia Care, Meal Planning and Preparation, Running Errands, Medication Reminders, Laundry and Linen, Incontinence Care, and Reloading a Feeding Tube. Applicant agrees that in the event A H C discovers that in some way caregiver does not have two years prior experience and training in one or more of the above Personal Caregiver duties, caregiver may be dismissed for providing false information.

In addition, Applicant agrees that they are willing to perform at a minimum all the duties outlined above and are willing to travel within the boundaries of A H C client service area (Fort Wayne, Indianapolis, Richmond and 60 minutes surround area that including West of Ohio) to an assignment given by A H C with a minimum of two hours a day. Applicant agrees that they are responsible for paying any and all commuting expenses to and from their place of work assignment.

In addition, applicant agrees that they understand that A H C is running a 24x7 business that requires immediate response to client care needs and therefore applicant agrees to be called anytime of day or night any day of the week regarding getting scheduled on a job. Applicant agrees that the contact phone number provided to A II C is the best way to reach them and will update A H C immediately if that phone number should change. Applicant understands that providing caregiver services is part of the healthcare related field (similar to an extension of a hospital setting - but assisting with non medical activities of daily living) and care needs to be provided to A II C patients on a 24x7 basis. Applicant understands and agrees that they need to have a very flexible schedule that will allow them to work any
A IT C
Atnirci,,ship I lome "7ro.
Maintain your independent lifestyle
www.IN-ahc.com

day of the week and work during any hours of each day.
Applicant understands and agrees to work any shifts assigned to them (up to 40 hrs a week) by A H C no matter what the days/hours of the shift(s) as long as the work assignment(s) are in the previously specified client service area. Applicant understands that they may be required to travel up to 60 miles to work a two hour shift and then travel another 60 miles to work another two hour shift in any given day during any time of the day. Also, applicant agrees and understands that this position is an on-call position and that there is therefore no guaranteed number of working hours each week with A H C clients. Applicant understands and agrees that they may only get scheduled for a minimum of two hours per month or may get scheduled for full time work depending on the on call work available within A H C clientele week to week. A
C cannot predict the health or the personal requests of its clientele, so changes to applicant's schedule may happen unexpectedly and within only a few hours notice. Applicant agrees and understands that A H C is not responsible for providing consistent hours week to week with this on-call position.

Applicant also understands and agrees that any form of dishonest act or criminal offense is strictly prohibited at Affordable Home Care and will result in termination from A H C. Accepting or taking money or possessions from a senior citizen client is strictly prohibited. Employees found accepting or taking money or possessions from any A H C client will result in termination.
Applicants not willing to travel at least 60 miles each way from their place of residence (within A H C work areas) to a work assignment that has a minimum of two work hours during a 24hr period from A If C, or is not willing to work potentially irregular on-call as needed hours any time or day of the week, or disagrees with the performance improvement program, or disagrees with any other item stated in this contract should nonign this agreement as applicant will be dismissed for willful or gross misconduct if they do not comply with A H C policy or accept a work assignment within the guidelines stated above from A H C. Initial

4. Truth of All Information Given By Applicant. I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false in any respect, I will be dismissed. Initial

DO NOT SIGN UNTIL YOU HAVE READ & UNDERSTOOD THE ABOVE STATEMENTS AND AGREEMENT. I hereby acknowledge that I have read the above statements and understand the same.
In witness of the above, each party to this agreement has caused it to be executed at on the date indicated below.
FOLLOWING INFECTION CONTROL AGREEMENT
Your employer wants to improve patient outcomes by identifying and reducing the risk of infection in patients and agencystaff.

The agency will document infections that are acquired while the patient is receiving services from the agency. The documentation will include at a minimum the date that the infection was detected, patient's name or number, primary diagnosis, signs/symptoms, type of infection, pathogens identified and treatment.

The infection control program will include surveillance, identification, prevention, control, and reporting. Targeted surveillance of infections will focus on specific patient population or procedures.

Infection Control Standards are established in compliance with the recommendations of the National Center for Disease Control in Atlanta, Georgia. All staff are educated on these standards and they are practiced consistently. Any incidents of infection related to care and service are reported.

I recognize, and am fully aware of the fact that any patient may be contagious at any time and that this may not always be a known fact while care is being provided. I will follow all Infection Control and Universal Precautions Procedures of the agency. I also state that currently I am in excellent health and have no impairments that may alter my job performance.
4
A H C
Affordable Home Care
Nei:twin your indepentfent lifestyle
www.IN-ahc. corn

PCAIHMK Job Description
Place of Employment: Client homes, work sites outside of the client home as required and other work sites as required Affordable Home Care management.

Accountable to Affordable Home Care Director, Administrator, Manager, Supervisor.

Job Summary: The Caregiver is a front line position acting as a representative Affordable Home Care providing the services offered by the company. The Caregiver duties are not limited to those listed as the position has a wide scope of duties at times dependent on the client and always under the auspices of the company. The Caregiver will mostly work independently of co-workers or supervisors and therefore must balance good judgement and initiative along with the policies of the company.

It should be noted that emphasis is for the Caregiver to involve the client in the care program to help provide the client with the basic standards of healthy living as follows:
• Physical Activity • Nutrition
• Mental Stimulation • Relaxation
• Personal Contact • Humour
Work Hours: This position may require various shifts at various times (including nights, weekends, and sleep-over) in one or more work sites.

Duties: The following list of duties is a guideline of possible duties to be performed independently or as a group of duties in the course of working with the client. The Caregiver duties are not limited to those listed.

A. Companionship
One of the most important aspects of Affordable Home Care will be providing customers with a strong sense of self-esteem and independence. Taking a genuine interest in the client, their life arid their environment will help create true sense of companionship. Whether it is playing a favourite board game Or card game, reading, taking a stroll or visiting with friends arid neighbours, companionship provides the depth of our services

B. Housekeeping, Laundry, and Pet Care
The CAREGIVER will provide dusting, washing hardwood and flooring, vacuuming carpets arid furniture, changing bedding, scrubbing the
bathroom; pre-washing, washing, drying, Ironing and folding laundry; defrosting refrigeratorstfreezers; cleaning ovens/stoves and china cabinets; caring for house plants; taking out garbage and general tidying of living spaces as required or requested. It also includes caring for pets including grooming, feeding, exercising, walking, playing, cleaning up after the pet.

C. Kitchen Work
Grocery shopping, preparing menus and meals, cooking, baking, serving, assisting with eating, washing and drying dishes and general tidying up is included.

D. Transportation and Escort
A CAREGIVER may drive their car and transport a client to an appointment or errand if the CAREGIVER has written authorization from the company to do so. The CAREGIVER may also escort the client to appointments or errands providing a helping hand or shoulder to lean on.

Qualifications:
1. Current certificate in standard first aid
2. Valid driver's licence arid reliable transportation
3. Ability to work independently.
4. Excellent communication and listening skills.
5. Compassionate, patient and caring nature.
6. Able to work in a stressful environment
7. Must be physically and mentally fit to handle the demands of care giving,

General Notes:
The Caregiver will be required to maintain a safe working environment for themselves and their clients.
There may be emergency situations where the Caregiver will have to react quickly with sound judgement.
The scope of duties described in this document may not include all duties to be performed by the Caregiver and is subject to change.
Request or Decline the Hepatitis B Vaccine
I hereby request the series of Hepatitis B Vaccinations
I hereby decline the series of Hepatitis B vaccine injections.

• Please check the reason that you are declining the vaccination.

1. I have previously received the series of Hepatitis vaccine injections.
2. I have been determined to have antibodies against Hepatitis B.
3. I shouldn't have the Hepatitis B vaccine due to medical reasons.

I 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) infections. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to me; however, I decline the 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 the Hepatitis B vaccine, I can receive the series at no charge to me.

DISCLAIMER AND WAIVER OF LIABILITY
acknowledge and will adhere to the rules and regulations as set forth by the Department of Aging and Disability Services and Medicare and Medicaid. I understand that the falsification of documents, particularly those pertaining to the submission of visit notes where in fact no visit was made, is considered to be fraud and is subject to filing of a criminal grievance, civil and/or criminal prosecution, and immediate termination. I therefore hold the Home Health agency, its shareholders, directorsand officers, harmless from any falsified documents.
I have read and understand the above information. I understand that the falsification of documents, particularly those pertaining to the submission of visit notes where in fact no visit was made, is considered to be fraud and is subject to filing of a criminal grievance, civil and/or criminal prosecution. and immediate termination.
In case of a serious medical emergency

EMERGENCY CONTACT NUMBERS