Attestation of Compliance with Background Screening Requirements

Authority: This form may be used by all employees to comply with:

- The attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2. background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer, AND

- The proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which requires proof of compliance with level 2 screening standards that have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S, or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S., and in accordance with the standards in Section 408.809(2), F.S., if that agency is not currently implemented in the Care Provider Background Screening Clearinghouse.

This form must be maintained in the employee's personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application.


Employee/Contractor Name:    First Name *     Last Name *    
Health Care Provider / Employer Name: Welcome Back Home Care, Inc.
Address of Health Care Provider: 100 E Linton Blvd. 153-A Delray Beach, FL 33483


I hereby attest to meeting the requirements for employment and that I have not been arrested for or been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:


Criminal offenses found in section 435.04, F.S.


(a) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.


(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.


(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.


(d) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.


(e) Section 782.04, relating to murder.


(f) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.

(g) Section 782.071, relating to vehicular homicide.

(h) Section 782.09, relating to killing of an unborn quick child by injury to the mother.

(i) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.

() Section 784.011. relating to assault, if the victim of the offense was a minor.

(k) Section 784.03, relating to battery, if the victim of the offense was a minor.

(I) Section 787.01, relating to kidnapping.

(m) Section 787.02, relating to false imprisonment.

(n) Section 787.025, relating to luring or enticing a child.

(o) Section 787.04(2), relating to taking, enticing. or removing a child beyond the state limits with criminal intent pending custody proceedings.

(p) Section 787.04(3). relating to carrying a child beyond the stale lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person.

(g) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.

(r) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school properly.

(s) Section 794.011, relating to sexual battery.

(t) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority.

(u) Section 794.05, relating to unlawful sexual activity with certain minors.

(v) Chapter 796, relating to prostitution.

(w) Section 798.02, relating to lewd and lascivious behavior.

(x) Chapter 800, relating to lewdness and indecent exposure.

(y) Section 806.01, relating to arson.

(z) Section 810.02, relating to burglary.

(aa) Section 810.14, relating to voyeurism, if the offense is a felony.

(bb) Section 810.145, relating to video voyeurism, if the offense is a felony.

(cc) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.

(dd) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.

(ee) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.

(ff) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.

(gg) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.


(hh) Section 826.04, relating to incest.

(ii) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.

(jj) Section 827.04, relating lo contributing to the delinquency or dependency of a child.

(kk) Former s. 827.05, relating to negligent treatment of children.

(Il) Section 827.071, relating to sexual performance by a child.

(mm) Section 843.01, relating to resisting arrest with violence.

(nn) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.

(oo) Section 843-12, relating to aiding in an escape.

(pp) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.

(qq) Chapter 847, relating to obscene literature.

(rr) Section 874.05(1), relating to encouraging or recruiting another lo join a criminal gang.

(ss) Chapter 893, relating to drug abuse prevention and control, only if the flense was a felony or if any other person involved in the offense was a minor.

(tt) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.

(uu) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.

(vv) Section 944.40, relating to escape.

(ww) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.

(xx) Section 944.47, relating to introduction of contraband into a correctional facility.

(yy) Section 985.701, relating to sexual misconduct in juvenile justice programs.

(zz) Section 985.711, relating to contraband introduced into detention facilities.

(3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction.


Criminal offenses found in section 408.809(4). F.S.

(a) Any authorizing statutes, if the offense was a felony.

(b) This chapter, if the offense was a felony.

(c) Section 409.920, relating to Medicaid provider fraud.

(d) Section 409.9201, relating to Medicaid fraud.

(e) Section 741.28, relating to domestic violence.

(f) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.

(g) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.

(h) Section 817.234, relating to false and fraudulent insurance claims.

(i) Section 817.481, relating lo obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony.

(j) Section 817.50, relating to fraudulently obtaining goods or services from a health care provider.

(k) Section 817.505, relating to patient brokering.

(I) Section 817.568, relating to criminal use of personal identification information.

(m) Section 817.60, relating to obtaining a credit card through fraudulent means.

(n) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.

(o) Section 831.01, relating to forgery.

(p) Section 831.02, relating to uttering forged instruments.

(9) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.

(r) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.

(s) Section 831.30, relating to fraud in obtaining medicinal drugs.

(t) Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony.

(u) Section 895.03, relating to racketeering and collection of unlawful debts.

(v) Section 896.101, relating to the Florida Money Laundering Act.

If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.

Purpose of Prior Screening:   Please type the purpose of Prior Screening    
Screening conducted by:    Please Select Type Option 1Type Option 2Type Option 3    
Date of Prior Screening:    Date    

Attestation

Under penalty of perjury, I,    First Name *     Last Name *    hereby swear or affirm that I meet the
requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.

Employee / Contractor Signature:    Signature *    
Title:    Title *    
Date:    Date *    

I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse.

I understand and agree that I will read and comply with the guidelines contained in the privacy policies.

Caregiver's Name:    First Name *     Last Name *    
Caregiver's Signature:    Signature *    
Date:    Date *    

The Home Health Aid provides personal care and related services to clients in their homes or assisted living facilities.

Reports to: CEO/Owner

Responsibilities
1. Assists clients with personal hygiene, dressing, bathing, and other daily tasks.
2. Performs basic health care services for patients, including checking vital signs or assists with self-administered prescription medication, under the direction of a registered nurse.
3. Perform general light housekeeping as requested.
4. Observes and reports on patient’s condition and communicates with client’s family, care managers and company Client Coordinator.
5. Helps family members care for client by teaching appropriate ways to lift, turn, and re-position the client.
6. Creates a safe and healthy environment to prevent slips, falls and encourages positive mental and physical health activities.
7. Records client information by making entries into timekeeping software applications or timesheets.
8. Adheres to professional standards, homecare policies and procedures and federal, state, and local regulations.
9. May be requested to provide transportation to appointments and errands or make necessary transportation arrangements.
10. Other job-related duties as requested.

Qualifications
1. High school diploma or equivalent.
2. Completion and maintenance of appropriate health care certification or licensure, such as Home Health Aide, Certified Nursing Assistant, Licensed Practical Nurse or Registered Nurse.
3. Minimum three years’ experience as a home health professional preferred.
4. Current CPR certification required and must be maintained.
5. Must have a valid driver's license and insurance if required to transport clients.
6. May be required to lift and move a minimum of 100 pounds.
7. Must complete a physical completed by a MD or DO which verifies absence of communicable diseases.

Acknowledgement of receipt and review of responsibilities as outlined in the job description.

Caregiver's Name:    First Name *     Last Name *    Caregiver's Signature:    Signature *  Today's Date: Date *    

I,     First Name *     Last Name *    the undersigned, have read and understood the Welcome Back Home Care, Inc. policy on confidentiality of personal health information (PHI) as described in the Confidentiality Policy which is in accordance with state and federal legislation.

I also acknowledge that I am aware of and understand the Policies regarding the security of personal health information including the policies relating to the use, collection, disclosure, storage, and destruction of personal health information. In consideration of my employment or independent contractor status with Welcome Back Home Care and as an integral part of the terms and conditions of my employment or contractor status, I hereby agree, pledge and undertake that I will not at any time, during my employment or association with Welcome Back Home Care or after my employment or association ends, access or use personal health information or reveal or disclose to any persons within or outside, any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicable legislation, and policies governing proper release of information.

I understand that my obligations outlined above will continue after my employment / contract / association / appointment with Welcome Back Home Care ends.

I further understand that my obligation concerning the protection of the confidentiality of PHI relate to all personal health information whether I acquired the information through my employment or contract or association or appointment with Welcome Back Home Care or with any of the entities that have an association with this organization. I also understand that unauthorized use of disclosure of such information will result in a disciplinary action up to and including termination of employment or contract or association or appointment, the imposition of fines pursuant to relevant state and federal legislation, and a report to my professional regulatory body.

Caregiver's Signature:    Signature *          , on today's date:    Date *    

INDEPENDENT CONTRACTOR AGREEMENT

THIS AGREEMENT executed on    Date    , but agreed to be effective from and after _____________, by and between Welcome Back Home Care, Inc. (hereinafter "Company"), and    First Name *     Last Name *    (hereinafter "Contractor").

NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises and agreements contained herein, Company hires Contractor, and Contractor agrees to work for Company under the terms and conditions hereby agreed upon by the parties:

SECTION 1 – WORK TO BE PERFORMED
1.1 Term. Company agrees to hire Contractor, at will, for a term commencing on    Date  and continuing until terminated in accordance with Section 4.
1.2 Duties. Contractor agrees to perform work for the Company on the terms and conditions set forth in this agreement, and agrees to devote all necessary time and attention (reasonable periods of illness accepted) to the performance of the duties specified in this agreement. Contractor's duties shall be as described in the Home Health Aide Job Description (attached in this form). Contractor further agrees that in all such aspects of such work, Contractor shall comply with the policies, standards, regulations of the Company from time to time established, and shall perform the duties assigned faithfully, intelligently, to the best of his/her/their ability, and in the best interest of the Company.

SECTION 2 – CONFIDENTIALITY
2.1 Confidentiality. Contractor acknowledges and agrees that all financial and accounting records, lists of property owned by Company, including amounts paid therefore, client and customer lists, and other Company data and information related to its business (hereinafter collectively "Confidential Information") are valuable assets of the Company. Except for disclosures required to be made to advance the business of the Company and information which is a matter of public record, Contractor shall not, during the term of this Agreement or after the termination of this Agreement, disclose any Confidential Information to any person or use any Confidential Information for the benefit of Contractor or any other person, except with the prior written consent of the Company.
2.2 Return of Documents. Contractor acknowledges and agrees that all originals and copies of records, reports, documents, lists, plans, memoranda, notes and other documentation related to the business of the Company or containing any Confidential Information shall be the sole and exclusive property of the Company, and shall be returned to the Company upon the termination of this Agreement or upon the written request of the Company.
2.3 Injunction. Contractor agrees that it would be difficult to measure damage to the Company from any breach by Contractor of Section 2.1 or 2.2 and that monetary damages would be an inadequate remedy for such breach. Accordingly, Contractor agrees that if Contractor shall breach Section 2.1 or 2.2, the Company shall be entitled to, in addition to all other remedies it may have at law or equity, to an injunction or other appropriate orders to restrain any such breach, without showing or proving actual damages sustained by the Company.
2.4 No Release. Contractor agrees that the termination of this Agreement shall not release Contractor from any obligations under Section 2.1 or 2.2.

SECTION 3 – COMPENSATION
3.1 Compensation. In consideration of all services to be rendered by Contractor to the Company, the
Company shall pay to the Contractor the sum of $ _________  per hour worked. Said compensation shall be paid on a bi-weekly basis.   
3.2 Withholding; Other Benefits. Compensation paid pursuant to this Agreement shall not subject to the customary withholding of income taxes and other employment taxes. Contractor shall be solely responsible for reporting and paying any such taxes. The Company shall not provide Contractor with any coverage or participation in the Company's accident and health insurance, life insurance, disability income insurance, medical expense reimbursement, wage continuation plans, or other fringe benefits provided to regular employees.
3.3 Expenses. Company shall reimburse Contractor all reasonable and necessary expenses incurred by Contractor in connection with the performance of his duties hereunder, provided, the President or Managing Director of the Company has approved such expenses in advance.

SECTION 4 – TERMINATION
4.1 Termination at Will. This Agreement may be terminated by the Company immediately, at will, and in the sole discretion of the President of the Company. Contractor may terminate this Agreement upon fourteen (14) days written notice to the Company. This Agreement also may be terminated at any time upon the mutual written agreement of the Company and Contractor.
4.2 Death. In the event Contractor dies during the term of this Agreement, this Agreement shall terminate, and the Company shall pay to Contractor's estate the salary which would otherwise be payable to Contractor.

SECTION 5 – INDEPENDENT CONTRACTOR STATUS
Contractor acknowledges that he is an independent contractor and is not an agent, partner, joint venture nor employee of Company. Contractor shall have no authority to bind or otherwise obligate Contractor in any manner nor shall Contractor represent to anyone that it has a right to do so. Contractor further agrees that in the event that the Company suffers any loss or damage as a result of a violation of this provision Contractor shall indemnify and hold harmless the Company form any such loss or damage.

SECTION 6 – REPRESENTATIONS OF WARRANTIES OF CONTRACTOR
Contractor represents and warrants to the Company that there is no employment contract or other contractual obligation to which Contractor is subject which prevents Contractor from entering into this Agreement or from performing fully Contractor's duties under this Agreement.

SECTION 7 – MISCELLANEOUS PROVISIONS
7.1 The provisions of this Agreement shall be binding upon and inured to the benefit of the heirs, personal representatives, successors and assigns of the parties. Any provision hereof which imposes upon Contractor or Company an obligation after termination or expiration of this Agreement shall survive termination or expiration hereof and be binding upon Contractor or Company.
7.2 In the event of a default under this Agreement, the defaulted party shall reimburse the non-defaulting party or parties for all costs and expenses reasonably incurred by the non-defaulting party or parties in connection with the default, including without limitation, attorney's fees. Additionally, in the event a suit or action is filed to enforce this Agreement or with respect to this Agreement, the prevailing party or parties shall be reimbursed by the other party for all costs and expenses incurred in connection with the suit or action, including without limitation, reasonable attorney's fees at the trial level and on appeal.
7.3 No waiver of any provision of this Agreement shall be deemed, or shall constitute, a waiver of any other provision, whether or not similar, nor shall any waiver constitute a continuing waiver. No waiver shall be binding unless executed in writing by the party making the waiver.
7.4 This Agreement shall be governed by and shall be construed in accordance with the laws of the State of Florida.
7.5 This Agreement constitutes the entire agreement between the parties pertaining to its subject matter and it supersedes all prior contemporaneous agreements, representations and understandings of the parties. No supplement, modification or amendment of this Agreement shall be binding unless executed in writing by all parties.

WITNESS OUR SIGNATURES, today,    Date *    
Contractor Signature    Signature *    

As an Independent Contractor of Welcome Back Home Care (WBHC), you agree to not solicit any clients of WBHC for any services or work that is not facilitated through the office of WBHC. Furthermore, if any Independent Contractor of WBHC is asked by any existing client of WBHC to be retained for private Home Health Services, the Independent Contractor will decline and immediately inform the WBHC office of this.This addendum shall serve as a Non-Compete Clause for all Independent Contractors of WBHC. Upon breach of this agreement, the independent contractor agrees to be responsible to pay three thousand dollars ($3,000.00) to Welcome Back Home Care, Inc.

Caregiver's Signature: Signature *    

By their signatures below, the parties hereto agree that any controversy, dispute, or claim arising out of Contractor's performance of services for Welcome Back Home Care, Inc., whether contractual, in fort, or based upon statute, shall be exclusively decided by binding arbitration held pursuant to the Federal Arbitration Act ("FA/") before the American Arbitration Association (*AAA") Palm Beach County, and shall be administered by a neutral arbitrator agreed upon by the parties pursuant to the AA/'S Employment Arbitration Rules and Mediation Procedures, and that the arbitrator shall be permitted to award any relief available in a court of law. The parties hereby waive any right to litigate such controversies, disputes, or claims in a court of law, and waive any right to trial by jury. Either party, without waiving any remedy, may seek from any court having jurisdiction any interim or provisional relief, including injunctive relief that is necessary to protect the party's rights or property.Claims subject to arbitration, include, without limitation claims arising under the Age Discrimination in Employment Act of 1967, Title VIl of the Civil Rights Act of 1964, the Civil Rights Act of 1866, the Americans with Disabilities Actof 1990, the Family and Medical Leave Act of 1993, the Genetic Information Nondiscrimination Act of 2008, the Employee Retirement Income Security Act of 1974 (except for vested benefits under any tax qualified benefit plan), the Fair Labor Standards Act of 1938, the Florida Civil Rights Act, the Florida Gencral Labor Regulations, and any other applicable Florida wage and overtime laws, all of the above as amended, and any other Federal, State or local law, Executive Order or regulation, and any other claims (including but not limited to breach of contract and common law claims) arising out of or related to Contractor's performance of services for, and/or the termination of his or her contract with, Welcome Back Home Care, Inc.In arbitration all parties have the right to be represented by legal counsel, the arbitrator shall permit reasonable discovery, the parties shall have the right to subpoena witnesses in order to compel their attendance at hearings and to cross-examine witnesses the proceedings shall be conducted in accordance with rudimentary due process, and the arbitrator's decision shall be in writing and shall contain findings of fact and conclusions of law. The parties agree that the arbitrator's decision will be final, subject only to review under the FAA. Welcome Back Home Care will pay the initial filing fees. Any award by the arbitrator may be entered as a judgment in any court having jurisdiction.The parties agree that any judgment, order, or ruling arising out of a dispute between the parties shall to the extent permitted by applicable law, award costs incurred for the proceedings and reasonable attorney's fees to the prevailing party.All claims or disputes between the parties (and any other persons or entities associated with Welcome Back Home Care, Inc) will be arbitrated individually; Contractor understands and agrees that he or she will not consolidate his or her claims with the claims of any other individual; will not seek class or collective action treatment for any claim that he or she may have; and will not participate in any class or collective action against Welcome Back Home Care, Inc or against any persons or entities associated with Welcome Back Home Care, Inc. If at any time the Contractor is made a member of a class in any proceeding, he or she will "opt out" at the first opportunity, and should any third party pursue any claims on the Contractor's behalf, the Contractor must waive his or her rights to any such monetary recovery.

Caregiver's Name:    First Name *     Last Name *    
Caregiver's Signature:    Signature *    
Today's Date:    Date *    

I    First Name *     Last Name *    acknowledge that I am at risk of exposure or have been
unknowingly exposed to Hepatitis B as a result of my contract and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost.

I,    First Name *     Last Name *      , understand that my application will only be complete if I receive an in-office interview and provide all necessary documentation to Welcome Back Home Care.

I understand that I must provide all of the following relevant documents to Welcome Back Home Care in person at my interview if I have not uploaded them to this form:

- HHA Certification / CNA License
- CPR Certification, CEUS (Continuing Education Units)
- Driver's License / ID
- Work Authorization
- Social Security Card
- Physical Form
- Palm Beach County HHA ID Badge
- Liability Insurance
- Car Insurance
- W9 Form
- I9 Form
- 2 Professional References

Signature