Inclusive Home Care Staff Record Inclusive Home Care Staff RecordContact informationPlease enter your full name* First name Middle names Last name Other names usedGender*MaleFemaleDate of birth (mm/dd/yyyy)*Social Security Number*HeightWeightLanguages other than EnglishAddress Street Address City State / Province / Region ZIP / Postal Code Email address Primary telephoneTypeHomeCellWorkSecond telephoneTypeHomeCellWorkThird telephoneTypeHomeCellWorkCell phone carrier:Select your cell phone carrier from the list to enable us to inform you of schedule changes and other events via text message. Messages will be sent to the first cell phone listed.AlltelAT&TBoost MobileConsumer CellularCricket WirelessGoogle FiMetro PCSSprintT-MobileU.S. CellularVerizonVirgin MobileRepublic WirelessApplicationAvailable to start* Date Format: MM slash DD slash YYYY Days available* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Times available* Daytime Evening 5:00-9:00 pm Nights 9:00 pm - 12:00 midnight Overnight Live-in Towns willing to travel to*Driver status*Licensed and insuredNot licensedLicensed drivers must provide a copy of driver's licensed and auto insuranced. Employees not licensed to drive or not insured agree to find transportation, such as public transportation, to scheduled visits.Employment typeFor each type of employment you are interested in, enter number of hours per week.Full timePart timePer diemPrevious IHC employee*NoYeswhen*Employment eligibility* US citizen Green Card Current visa How did you hear about us? Complete all applicableNewspaperWebsiteCurrent employeeOtherVaccination acceptanceInfluenza vaccination:* I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring Influenza infection. I have been given the opportunity to be vaccinated with the vaccine, at no charge to me. Check below to accept or decline influenza vaccination.Influenza vaccination*I hereby consent to the administration of the influenza vaccine and understand this will be at no charge to me. I know that I should not take this series if I am pregnant or nursing. I also understand that I should not take the vaccine if I have active infection present or have an allergy to the compound. I understand the risks and side effects of the injections and release the Agency from any liability that may arise from the effects of the vaccine.I decline the Influenza vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Influenza, a serious disease.I decline as I have previously received the vaccine series onI decline as I have previously received the vaccine series on*Hepatitis B vaccine:* I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring the Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the vaccine, at no charge to me. The series consists of 3 doses: an initial IM dose, a 2nd dose 30 days after and a 3rd dose at 6 months. Check below to accept or decline hepatitis B vaccination.Hepatitis B vaccine*I hereby consent to the administration of the hepatitis B vaccine series and understand this will be at no charge to me. I know that I should not take this series if I am pregnant or nursing. I also understand that I should not take the vaccine if I have active infection present or have an allergy to the compound. I understand the risks and side effects of the injections and release the HCSF from any liability that may arise from the effects of the vaccine.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 hepatitis B vaccination as I have previously received the vaccine series onI decline hepatitis B vaccination as I have previously received the vaccine series on*Medical historyCheck any diseases or illnesses you have or have had* Asthma Allergies Arthritis HBP Back condition Fatigue Joint pain LBP Bursitis Ulcers Heart condition Sinus Hernia Epilepsy Eye condition TB Diabetes Hearing Anxiety Vertigo Paralysis Migraines Depression Thyroid Drug use Alcohol use Bronchitis Pneumonia SOB Skin rashes Hay fever Weight loss HIV Hernia None of these Explain any hospitalizions for any of the above or any surgery.*Industrial accidents: Explain any industrial accidents you have had.*EducationHigh schoolLocationCourse of studyYears completedGraduatedCollegeLocationCourse of studyYears completedGraduatedOtherLocationCourse of studyYears completedGraduatedOtherLocationCourse of studyYears completedGraduatedMilitary serviceBranchFromToHighest rankCurrently in ReserveYesNoSpecial schooling or dutiesLicensesLicense or certificationID numberExpirationStateLicense or certificationID numberExpirationStateLicense or certificationID numberExpirationStateReferencesConsent* I authorize the HCSF to request and receive from all reference candidates any and all pertinent information regarding my character, employment history, work ethics, prior employment and its termination, including the reasons for such termination.CompanyTelephoneAddressCompanyTelephoneAddressEmployment historyAt least one year. List most recent employer first.Consent I authorize the HCSF to request and receive from all prior employers within one year of the date of this application, any and all pertinent information regarding my character, employment history, work ethics, prior employment and its termination, including the reasons for such termination.EmployerTelephoneFromToAddressPosition titleFinal salarySupervisorDutiesReason for leavingEmployerTelephoneFromToAddressPosition titleFinal salarySupervisorDutiesReason for leavingEmployerTelephoneFromToAddressPosition titleFinal salarySupervisorDutiesReason for leavingEmergency contactsEmergency contact nameRelationshipTelephoneTelephoneEmergency contact nameRelationshipTelephoneTelephoneGovernment forms All employees are required to complete the following forms. Click on the form name to download. I-9 Employment Eligibility Verification W-4 Employee's Withholding Allowance Certificate NJ-W4 State Withholding Certificate All employees are also required to submit the following forms Record of Mantoux Results Record of Medical Examination Criminal historyCriminal convictions: List all criminal convictions of violating any law. Include dates and locations. If none enter none. Omit minor traffic violations.The presence of a criminal record is not an automatic rejection of your application. I attest that the above referenced information is true and accurate to the best of my knowledge.Consent I authorize the HCSF to perform a criminal background check for the purpose of employment.Direct depositConsent I authorize my employer to deposit my wages or salary into the bank account specified below. My signature below indicates that I am agreeing that I am either the account holder or have the authority of the account holder to authorize my employer to make direct deposits into the account.Bank nameRouting numberAccount numberAccount typeCheckingSavingsEqual Employment OpportunityInclusive Home Care, LLC an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap or military status. To help us comply with federal and state equal employment opportunity recordkeeping and reporting requirements, we request that you answer the following questions. Completion of this section is VOLUNTARY on your part and will not preclude you from employment consideration. This information will be kept in a confidential.Ethnic identity/Race Hispanic or Latino Not Hispanic or Latino American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Disability identification: Do you wish to identify yourself as an individual with a disabling condition and be considered under our Affinnative Action Plan?yesnoVeteran identification: Do you wish to identify yourself as a Special Disabled Veteran or a Vietnam-era veteran and be considered under our Affirmative Action Plan? Special Disabled Veteran Vietnam-era veteran Definition: Special Disabled Veteran means (i) a veteran of the U.S. military ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under the laws administered by the Department of Veterans Affairs for disability (A) rated at 30 percent or more, or (B) rated at 10 or 20 percent in the case of a veteran who has been determined under 38 U.S.C. 3106 to have a serious employment handicap; or (ii) a person who was discharged or released from active duty because of a service-connected disability. Definition: Veteran of the Vietnam-era means a person who served on active duty in the U.S. military ground, naval, or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such duty was performed (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975, or (B) between August 5, 1964, through May 7, 1975, in all other cases.Non-discrimination/LEP statementInclusive Home Care, LLC complies with applicable Federal civil rights laws and does not discriminate in hiring or admissions, on the basis of race, color, national origin, age, disability, or sex. Our HCSF does not exclude people or treat them differently because ofrace, color, national origin, age, disability, or sex. Inclusive Home Care, LLC provides free aids and services to patients with disabilities to communicate effectively with us, such as: Qualified sign language interpreters, written information in other formats (large print, audio, accessible electronic formats, other formats). Inclusive Home Care, LLC provides free language services to patients whose primary language is not English (LEP) such as: Qualified interpreters, information written in other languages. If you need these services, contact Syeda Lubna Haroon. If you believe that Inclusive Home Care, LLC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: HCSF Name: Inclusive Home Care, LLC HCSF Civil Rights Coordinator: Syeda Lubna Haroon HCSF Address: 3444 Quakerbridge Road, Suite 11B, Hamilton NJ 08619 HCSF Phone: (609) 578-8451 You can file a grievance in person or by mail or fax. If you need help filing a grievance, Syeda Lubna Haroon is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/porta/lobby.jfs or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, 1-800-368-1019,800-537-7697 (TDD)AgreementsHIPAA privacy policy: I have read and understand this policy on Protected Health Information (PHI) and security. I understand that should any situation arise where I breach patient privacy I will be disciplined up to and including termination. I hereby agree to maintain patient confidentiality in the strictest manner possible, sharing or discussing patient information only with those designated care providers or supervisors who have "a need to know" and are actively involved in the care of services provided to the patients. I further acknowledge that I have been trained in the provisions and laws related to HIPAA compliance during orientation and those patients must sign written permission to allow their health information (PHI) to be disclosed. I further agree that I will protect PHI while servicing patients and will not allow any PHI to be visible anytime; I will not bring any PHI related to another patient into the setting of patients I am servicing Corporate compliance policy: Our Agency is committed to providing the highest ethical health care and upholding conduct standards and corporate legal compliance. Our policies and Corporate Compliance Plan clearly support a 'zero' tolerance to any form of fraud or misconduct. This applies to all employees, direct and contracted, regardless of position or title. I, as an employee of the Agency, acknowledge that I have been 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. Incident reporting policy: I have been thoroughly informed by the Agency that I MUST report ALL incidents, accidents and any medical, physical, or mental changes in my clients immediately to the Supervisor/office. I further understand that in the event that I become injured, even a minor injury, I am required to report that incident to my office as soon as possible after an injury. Our agency is available by phone 24 hours a day. The answering service will respond after 5:00 pm weekdays and on weekends and holidays. Zero Tolerance Sexual Abuse Policy: I acknowledge that I have received and read the sexual abuse policy and/or have had it explained to me. I understand that the organization will not tolerate any employee, volunteer, board member or third party who commits sexual abuse. Disciplinary actions will be taken against those who are found to have committed sexual abuse. I understand that it is my responsibility to abide by all rules contained in the policy. I also understand how to report incidents of sexual abuse as set forth in the abuse policy, including retaliating against any employee or volunteer exercising his or her rights under the policy. Confidentiality agreement 1. As a condition of employment the employer requires that all new employees agree to enter into this Confidentiality Agreement (the Agreement). The Employee acknowledges that employment with Employer is sufficient consideration for the Employee to entering into the Agreement. 2. The Employee acknowledges that, in the course of employment, the Employee will, and may in the future, come into possession of certain confidential information belonging to the Employer including but not limited to trade secrets, data, materials, products, technology, computer programs, specifications, manuals, business plans, software, marketing plans, financial information, and other information disclosed or submitted. This confidential information may be embodied in hand written notes by the Employee, computer disks, tapes, paper, or any other media. 3. The Employee hereby covenants and agrees that she or he will at no time, during or after the term of employment with the Employer, use for his or her own benefit or the benefit of others, or discloses or divulge to others, any such confidential information. 4. Upon termination of employment, the Employee will return, retaining no copies or notes, all documents relating to the Employer's business including, but not limited to, reports, lists, correspondence, information, computer files, computer disks, and all other material and all copies of such material, obtained by the Employee during employment nor will the employee attempt to contact or solicit any patients that the employee may have worked with during employment. 5. The Employee recognizes that the Employer may be irreparably damaged by breach of this Agreement and that the Employer shall be entitled to seek an injunction to prevent such competition or disclosure, and will entitle the Employer to other legal remedies, including attorney's fees and costs. 6. The obligations of Recipient herein shall be effective from the date Owner last discloses any Confidential Information to Recipient pursuant to this Agreement. 7. If any part of this Agreement is adjudged invalid, illegal or unenforceable, the remaining parts shall not be affected and shall remain in full force and effect. 8. This instrument, including any attached exhibits and addenda, constitutes the entire Agreement of the parties. No representation or promises have been made except those that are set out in this Agreement. This Agreement may not be modified except in writing signed by all parties. 9. This agreement shall take effect as a sealed instrument and shall be construed, governed and enforced in accordance with the laws of the State of NJ, without regards to its conflicts of law provisons. 10. The descriptive headings used herein are for convenience of reference only and they are not intended to have any effect in determining the rights or obligations under this agreement. Conflict of interest policy: No employee or member of the Board of Directors, Advisory Committee, or other individual, committee, or entity shall derive any profit or gain directly or indirectly by reason of their association with the HCSF, without the prior knowledge and approval of the Board of Directors. All board members and/or employees, at the discretion and specific request of the board, will be required to submit a disclosure statement annually. If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Administrator and Board of Directors. In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the HCSF and a board member shall not participate in discussions unless requested by the board nor vote on such transactions. The abstention and the reason for it shall be recorded in the minutes. Field staff in any capacity understands that all patients are patients of the HCSF not personal patients of the field staff. Patients may never be serviced privately by an employee of Our HCSF for the financial gain of the employee. Should an employee terminate employment with Inclusive Home Care, LLC, the field staff understands that the patient may not be encouraged or otherwise moved from our HCSF to another HCSF.Check the box beside the statement: I have read and am fully familiar with the HCSF' s policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other matter in which I would profit or gain directly or indirectly as a result of my membership on the HCSF's board of Directors or its committees or my employment. Furthermore, I agree to disclose any such interest which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the HCSF's business that might result in any profit or gain directly or indirectly, for myself.I agree to comply with HIPAA privacy policy Corporate compliance policy Incident reporting policy Zero tolerance sexual abuse policy Confidentiality agreement Conflict of interest policy Employee Handbook Agency's Dos & Don'ts Job description Other HCSF employment: Enter the names of any other HCSFs you currently work for. If none enter none.Staff signatureCheck the box beside the statement: I certify that the information I have provided is complete and accurate to the best of my knowledge.Signature*Date* Date Format: MM slash DD slash YYYY
