Alberta Care Nursing Services, LLC. Employee Application

EMPLOYEE APPLICATION
Tel: 215-973-9724

Email: albertacarenursing@gmail.com | Web: www.albertacarenursing.com

ALBERTA CARE NURSING SERVICES, LLC.
Employment Checklist & Requirements
Thank you for your interest in joining our team at Alberta Care Nursing Services, LLC. To ensure compliance with staff regulations set forth by the Pennsylvania Department of Health and Federal Law, the following is a list of documentation that must be completed by each individual applying for employment at Alberta Care Nursing Services, LLC.: 1. Employment Application Form duly signed and completed 2. Proof of Credentials that are current, (High School Diploma or higher) 3. Most recent resume 4. Social Security Card 5. Driver’s License 6. Criminal Background check 7. CPR Certification within the last two (2) years 8. Completed W-4, and/or – Completed I9 – Employment Eligibility Verification Form (Contractors)
BEFORE DIRECT CARE WORKER PROVIDES SERVICES TO A CUSTOMER:
1. PRIOR TO PROVIDING DIRECT CARE SERVICES TO CLIENT’S ALL EMPLOYEES ARE REQUIRED TO GO THROUGH THE AGENCY’S TRAINING ORIENTATION PROGRAM AND PASS ITS COMPETENCY TEST (§ 611.55. Competency requirements 2. Is a Photo Badge prepared and issued to the employee? 3. Does the employee have Agency issued uniform(s)? 4. Has the employee reviewed the Patient’s Intake Form 5. Has the employee reviewed the Patient’s Emergency Plan? 6. Does the employee have adequate transportation to and from Patient’s home? As a licensed Home Care Agency in the state of Pennsylvania, we are required and mandated by the Pennsylvania Department of Health to maintain photocopies of the aforementioned documents on file at our office for all full-time, part-time and intermittent employees and contractors. At Alberta Care Nursing Services, LLC., we do take security of your information very seriously. Please be assured that all information provided to us will be kept private, safe and confidential and would be divulged only when mandated by the law or government regulations.

YOUR AVAILABILITY:
Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.
What date are you available to begin work?

MonthDayYear
Date
Check availability that best applies*

MorningsAfternoonsEveningsOvernightsWeekdaysWeekends

Please indicate the days of the week as well as the earliest and latest times that you are available for work.*

	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
From:
To:

JOB RELATED SKILLS:
Describe any training or life skills you have that apply to caring for adults: *
Describe any work history you have that would apply to caring for adult’s:*
What do you like (or think you would like) most about caring for people?*
What do you like (or think you would like) least about caring for adults?*

EDUCATION:
For employment our minimum education requirement is either a GED or High School diploma
Please check highest grade completed:*

Grade School: 6th-8thHigh School: 9th-12thUndergraduate College: Freshman to SeniorGraduate SchoolOther

School Type Questions *

	School Name	City, State	Major/Subject	#Years of Attendance	GraduateYes or No
High School
Vocational/ Technical
College/University

WORK HISTORY:
Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.
MOST RECENT EMPLOYER:
Company Name*
Company Phone
Please enter a valid phone number.
City, State*
Dates Employed:*

MonthDayYear
Date
Job Title*
Duties*
Salary blanks per blank
Reason for Leaving
Supervisor's Name

First NameLast Name
Are you currently working for this employer? If yes, please provide contact information*

YesNo
Employer Name

First NameLast Name
Employer Phone
Please enter a valid phone number.
Employer Email
example@example.com
SECOND MOST RECENT EMPLOYER:
Company Name
Company Phone
Please enter a valid phone number.
City, State
Dates Employed:

MonthDayYear
Date
Job Title
Duties
Salary ($) per Hour, Week, or Month
Reason for Leaving
Supervisor's Name

First NameLast Name
Are you currently working for this employer? If yes, please provide contact information

YesNo
Employer Name

First NameLast Name
Employer Phone
Please enter a valid phone number.
Employer Email
example@example.com
THIRD MOST RECENT EMPLOYER:
Company Name
Company Phone
Please enter a valid phone number.
City & State
Dates Employed:

MonthDayYear
Date
Job Title
Duties
Salary ($) per Hour, Week, or Month
Reason for Leaving
Supervisor's Name

First NameLast Name
Are you currently working for this employer? If yes, please provide contact information

YesNo
Employer Name

First NameLast Name
Employer Phone
Please enter a valid phone number.
Employer Email
example@example.com

SECURITY:
****Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.
As a condition of employment all employees must be “Bondable” & “Insurable”. Are you at least 19 years of age?*

YesNo
List states and counties of residence for the past seven years:*
Have you had any moving traffic violations?*

YesNo
If yes, please describe:
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?*

YesNo

REFERENCES:

Do not include relatives
Please complete all six references. Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 6 references, you will be asked to provide additional references.

Type a question*

	Full Name (First, Last)	Phone Number (cell & work)	Best Time of Day to Call	Relationship	Years Known
Reference 1
Reference 2
Reference 3
Reference 4
Reference 5
Reference 6

APPLICANT NOTICE:
It is illegal in Philadelphia for employers to ask about your criminal background during the job application process. Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depend on the results of your background check Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting time of incarceration Arrests that did not lead to conviction cannot be used in any employment decisions. If your background check reveals a conviction, the employer must consider: The type of offense and the time that has passed since it occurred. Its connection to the job you are applying for; and Your job history, character references, and any evidence of rehabilitation. Employers can reject you based on your criminal record ONLY if you pose an unacceptable risk to the business or to other people. If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision. You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.
APPLICANT CERTIFICATION AND RELEASE:
I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
APPLICANT SIGNATURE*

Clear
DATE*

MonthDayYear
Date

DIRECT CARE WORKER AVAILABILITY FORM:
Please complete the following schedule and provide times that you are able to work for Alberta Care Nursing Services, LLC.. We provide services 24 hours a day, 7 days a week. How you complete this form is very important. The work hours that are provided for you by Alberta Care Nursing Services, LLC. are driven by two primary business issues; the needs of the Patients and your availability to work.

Availability Chart*

	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
12:00 AM
Overnight
Live-In Care

Total Requested Hours Per Week
Include: ideal, minimum & maximum hours
l understand that the more I am available to work the greater likelihood that my hours request will be met.*

Yes
Are you available to be On-Call for additional income?*

YesNo
Are you willing to work with Patients who smoke?*

YesNo
Are you willing to work with Patients who have pets?*

YesNo
This sheet designates the times that I am committing myself to be available to work for Alberta Care Nursing Services, LLC. By signing this sheet, I acknowledge that the decision to hire me will be based in part on the above availability. I agree any changes to my availability must be approved and signed by my supervisor. I understand that there is no guarantee of hours if I am offered a position with Alberta Care Nursing Services, LLC. I understand that it can take time to reach and sustain my desired number of hours per" week and that multiple factors affect this goal including my availability, Patient requests, my stalls, and my ability to please the Patient to whom I am assigned. Nothing in this statement is to be construed as a direct, implied or inferred contract of employment. I understand I am not authorized to provide medical care independently and agree that if a medical emergency arises while I am with a Patient, I will call 911 and follow their instructions accordingly.
Signature*

Clear
DATE*

MonthDayYear
Date

FOR OFFICE ONLY
DATE OF HIRE

MonthDayYear
Date
APPROVED BY:

First NameLast Name
REFERENCES VERIFIED BY:

First NameLast Name

MANDATORY BACKGROUND/CRIMINAL CHECK:
Alberta Care Nursing Services, LLC. requires all employees prior to any offer of employment; all employees must successfully pass a state mandatory criminal background check. Alberta Care Nursing Services, LLC. is prohibited from hiring and or retaining any individual(s) with a prohibited conviction or Department of Aging ineligibility determination. Alberta Care Nursing Services, LLC. Background Check Investigation adheres to the Background Investigation guidelines as required under PA Code § 611.52 (a-j (a) General rule. The home care agency or home care registry. An applicant for employment as a member of the office staff for the home care agency or home care registry and the owner or owners of the home care agency or home care registry also are required to obtain a criminal history report in accordance with requirements contained in this section. (b) State Police criminal history record. If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record. (c) Federal criminal history record. If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a Federal criminal history record and a letter of determination from the Department of Aging, based on the individual’s Federal criminal history record, in accordance with 6 Pa. Code 15.144(b) (relating to procedure (d) Proof of residency. The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents: Motor vehicle records, such as a valid driver’s license or a State-issued identification. Housing records, such as mortgage records or rent receipts. Public utility records and receipts, such as electric bills. Local tax records. A completed and signed, Federal, State or local income tax return with the applicant’s name and address preprinted on it. (6) Employment records, including records of unemployment compensation. (e) Prohibition. The home care agency or home care registry may not hire, roster or retain an individual if the State Police criminal history record reveals a prohibited conviction listed in 6 Pa. Code § 15.143 (relating to facility responsibilities), or if the Department of Aging letter of determination states that the individual is not eligible for hire or roster. (f) Records maintained. The home care agency or home care registry shall maintain files for direct care workers and members of the office staff which include copies of State Police criminal history records or Department of Aging letters of determination regarding Federal criminal history records. The files shall be available for Department inspection. The agency or registry shall maintain copies of the criminal history report for the agency or registry owners, which shall be available for Department inspection. (g) Confidentiality. The home care agency or home care registry shall keep the information obtained from State Police criminal history records and Department of Aging letters of determination regarding Federal criminal history records confidential and use it solely to determine an applicant’s eligibility to be hired, rostered or retained. (h) Opportunity to appeal. If the decision not to hire, roster or retain an individual is based in whole or in part on State Police criminal history records, Department of Aging letters of determination regarding Federal criminal history records, or both, the home care agency or home care registry shall provide an affected individual with information on how to appeal to the sources of criminal history records if the individual believes the records are in error. (i) Exceptions. A direct care worker who has complied with this section and who transfers to another agency or registry owned and operated by same entity is not required to obtain another criminal history report. A direct care worker employed or rostered by an entity that undergoes a change of ownership is not required to obtain another criminal history report to submit to the new owner. (j) Individuals currently employed or rostered. A direct care worker and each member of the agency or registry office staff who is employed by or rostered by a home care agency or home care registry as of December 12, 2009, shall obtain and submit a State Police criminal history record or Department of Aging letter of determination, as applicable, to the home care agency or home care registry by April 12, 2010. This subsection does not apply if the home care agency or home care registry obtained a criminal history report meeting the requirements of this subsection when the direct care worker or office staff member was hired or rostered and a copy of the report is included in the individual’s file. In connection with my application for employment, my continued employment, or in connection with my desire to engage in home care services for Alberta Care Nursing Services, LLC., I have been advised and I hereby consent and authorize either Alberta Care Nursing Services, LLC. and its agent, at any time during my application process and/or employment, to obtain a investigative consumer report that will include, but not be limited to, a criminal record check, employment and education verifications, verifications of personal references and reputation; and driving record. (k) Employee Authorization and Consent. I do hereby consent and authorize either Alberta Care Nursing Services, LLC. or its agent to use any information provided on this form or during the application process in obtaining the investigative consumer report. I have been informed that I have the right to review and challenge any negative Information that would adversely impact me or adversely affect a decision to offer employment. I agree to release, indemnify and hold harmless either Alberta Care Nursing Services, LLC. or any consumer reporting agency used by either Alberta Care Nursing Services, LLC. with regard to any information reported by the consumer reporting agency. I understand that I am to be provided the name, address and telephone number of the consumer reporting agency and the nature and scope of the investigative report will be disclosed to me. I acknowledge that facsimile, copy or email of this document shall have the same validity, force and effect as the original.

PROOF OF RESIDENCY:
Name*

First NameLast Name
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH*

MonthDayYear
Date
DRIVER LICENSE NO.
STATE LICENSED ISSUED
PROOF OF RESIDENCY DOCUMENT(S): (Please check box for the document you are submitting)*

A valid driver’s license or a State-issued identification. (REQUIRED)Housing records, such as mortgage records or rent receipts.Public utility records and receipts, such as electric bills.Local tax records.A completed and signed, Federal, State or local income tax return with the applicant’s name and address preprinted on it.Employment records, including records of unemployment compensation.
Valid Driver's License or State Issued ID (REQUIRED)*

Cancelof
Other Proof of Residency Documents:

Cancelof
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

EMPLOYEE APPLICATION

Employment Checklist & Requirements

BEFORE DIRECT CARE WORKER PROVIDES SERVICES TO A CUSTOMER:

EMPLOYMENT APPLICATION

PERSONAL INFORMATION:

YOUR AVAILABILITY:

PREFERENCES:

JOB RELATED SKILLS:

EDUCATION:

WORK HISTORY:

MOST RECENT EMPLOYER:

SECOND MOST RECENT EMPLOYER:

THIRD MOST RECENT EMPLOYER:

SECURITY:

REFERENCES:

APPLICANT NOTICE:

APPLICANT CERTIFICATION AND RELEASE:

DIRECT CARE WORKER AVAILABILITY FORM:

FOR OFFICE ONLY

MANDATORY BACKGROUND/CRIMINAL CHECK:

PROOF OF RESIDENCY: