In accordance with Section 611.54 of the Home Care Agency licensing regulations, you may be hired on a provisional basis pending receipt of a criminal history report if the following conditions are met.

I understand that while I am in provisional status:

I attest that the above information is true to the best of my knowledge and swear and affirm that
I have not been named or convicted of any crime that has not been disclosed and if I am so
named or convicted at any time during my employment, I will advise my employer, At Peace
Health Care Agency of that fact.
I understand that my employment may be terminated if I have been named or convicted of any
crimes so as described prior to employment or at any time during my employment.

Interview Conducted by: 

Basic Math Test

I have carefully read and understand this Employment Background Disclosure and Authorization Form. I understand that if At Peace Health Care Agency hires me, my consent will apply to all required reports and At Peace Health Care Agency may obtain reports throughout my employment.

I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining the required information. The types of information that may be obtained include, but are not limited to: social security number verifications; criminal records checks; public court records checks; driving records checks; educational records checks; employment verifications; personal and professional references checks; licensing and certification records checks; drug testing results; etc. The information contained in the reports will be obtained from private and public record sources including, as appropriate, personal interviews with sources, such as neighbors, friends and associates. 

By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, and other individuals and sources to furnish any and all information on me that is requested by At Peace Health Care Agency. By my signature below, I certify the information I provided on my employment application and/or resume, and this form to be true and correct. I also agree that falsified information or significant omissions may disqualify me and may be considered sufficient justification for dismissal if discovered at a later date. I agree that this Disclosure and Authorization Form in original, faxed, photocopied or electronic form (including electronically signed) will be valid for any reports that may be requested by or on behalf of At Peace Health Care Agency.

The following information is required by law enforcement agencies and other positive identification purposes when checking public records. It is confidential and will not be used for any other purpose.

3222 West Cheltenham, Suite A1, A2 · Philadelphia, PA 19150
Phone: (484) 468-1492

We are an equal opportunity employer that provides equal access to programs, services and employment to all persons. All qualified applicants will receive equal consideration for employment without regard to race, color, national origin, religion, sex, marital status, sexual orientation, age, physical or mental disability, or covered veteran status. Those applicants requiring reasonable accommodation to the application and/or interview process should notify At Peace Health Care Agency.

I understand that in processing my application with At Peace Health Care Agency, a background check will be conducted. Information may include, but is not limited to: employment history, education, criminal records, national sex offender check, child abuse clearance, motor vehicle records, personal references and any data provided on this application or during the interview process.

I authorize the appropriate individuals, companies, institutions, or agencies to release information and I release them from any liability as a result of such inquiries or disclosures.

I have read, understand, and by my signature, consent to these statements.  I hereby certify that all the statements and answers set forth on the application form, my resume and interview are true and complete to the best of my knowledge.  If this application leads to employment, I understand that if any statements and/or answers are found false or the information has been omitted, such false statements or omissions may be cause for rejection of my application or termination of my employment.

I authorize a photocopy of this release to be accepted with the same authority as the original, and if employed by At Peace Health Care Agency, this release will remain in effect throughout such employment.

PLEASE RETURN APPLICATION TO:
At Peace Health Care Agency
3222 West Cheltenham, Suite A1, A2 · Philadelphia, PA 19150
Phone: (484) 468-1492
Fax: (267) 604-0298

JOB TITLE: Caregiver                                     
DATE: {date}

REPORTS TO: Scheduling Coordinate

A. BASIC PURPOSE
The Caregiver is responsible for all aspects of the client’s care. These responsibilities include but are not limited to activities of daily living, program implementation, behavioral monitoring, community functions, and all required documentation.

B. PRIMARY RESPONSIBILITIES
1. Provides client’s personal hygiene by giving or helping with showers or baths; assisting with bedpans, urinals; providing backrubs, shampoos, and shaves; and assists clients to the bathroom.
2. Provides for activities of daily living by assisting with serving meals, feeding clients as necessary; and assisting clients with ambulating, turning, and positioning.
3. Promotes client comfort by utilizing resources and materials.
4. Maintains work operations by following agency policies and procedures.
5. Protects organization's value by keeping client information confidential.
6. Serves and protects At Peace Health Care Agency by adhering to professional standards, agency policies and procedures, federal, state, and local requirements.
7. Updates job knowledge by participating in educational opportunities; reading professional publications; participating in professional organizations; and maintaining licensure.
8. Enhances At Peace Health Care Agency’s reputation by accepting ownership for accomplishing new and different requests; and exploring opportunities to add value to job accomplishments.
9. Performs all duties as assigned.

C. HUMAN RELATIONS
1. Must maintain a professional attitude and demeanor and be able to communicate effectively and relate courteously and cooperatively with clients, caregivers, family members, colleagues, supervisor, co-workers and all others.
2. Must be able to demonstrate optimism, enthusiasm and willingness to work constructively with other home care team members and reflect concern for the well-being of clients and others.

D. PHYSICAL REQUIREMENTS (See Attached Physical Requirements Form)
Able to frequently sit, stand, bend, lift, carry, push and pull (minimum 25 lbs.) with or without reasonable accommodations to perform the essential responsibilities of the position.

E. QUALIFICATIONS

Education
1. High school diploma or G.E.D preferred
2. Reflects ability to read, write and communicate effectively.

Experience:
1. Minimum two years of related client care experience preferred.
2. Possesses excellent communication skills (written and oral).
3. Personal life experience/history relevant to the position is acceptable as a substitute for education and/or work experiences.

Licensure, Registration and/or Certification:
1. Valid driver’s license and reliable transportation that is insured in accordance with
Pennsylvania state laws and regulations
2. Satisfactory references from employers and/or professional peers.
3. Satisfactory criminal background check.

I have read, reviewed and understand the At Peace Health Care Agency Caregiver job description roles and responsibilities dated December 15, 2021.

7. When was your last tuberculin skin test or chest x-ray to rule out TB? (attach results)

The information above is true and complete to the best of my knowledge, and I am aware that deliberate misrepresentation may jeopardize my health. I understand that this information is confidential and will not be released without my knowledge and written permission.

All information below is to be completed by an approved screener

OSHA requires that all healthcare workers at risk of acquiring Hepatitis B have the opportunity to receive the Hepatitis B vaccination by their employer. At Peace Health Care Agency will provide the opportunity to you as is appropriate based upon your responses to the following:

A. If you have completed the vaccination series, please indicate where appropriate below.

B. If you are in the process of receiving the series, please indicate where appropriate below. Please indicate if you require a dose of the vaccine while working on an assignment with At Peace Health Care Agency.

C. If antibody testing indicates you to be immune, indicate where appropriate below.

D. If you decline to have the Hepatitis B vaccination, indicate where appropriate below.

E. If you would like to receive the Hepatitis B vaccination series, indicate where appropriate below.

My signature below certifies that I have been provided with general educational materials regarding exposure to bloodborne pathogens as required by OSHA regulations. Further, I understand that I will be provided appropriate training and will adhere to the policies and procedures of At Peace Health Care Agency.

I understand that due to my occupational exposure to blood and/or potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no cost to me, while on active assignment with At Peace Health Care Agency.

Choose the appropriate response from the options below; sign and date where indicated:

Please click link to download and review handbook dated 08/19/2025.

At Peace Health Care Agency maintains the confidentiality of protected health information as defined by HIPAA, as well as any other information that is deemed to be confidential by other laws. This information may include, but is not limited to, information on clients, employees, and financial and business operations. Confidential information may be information in any form including written, electronic, oral, overheard or observed. Employees may be exposed to information that is considered to be confidential. This information should not be discussed with anyone, including clients, client families, co- workers, or an employee's family or friends. (Additional information regarding specifics of the confidentiality of client records can be found in the Policy and Procedure Manual All employees of At Peace Health Care Agency must be alert to others overhearing professional discussions regarding clients/families or personnel information, or any other confidential situations. Disclosure of confidential information is grounds for disciplinary action up to and including termination. All clinicians and employees must read and sign the Notice of Privacy Practice information provided.