PCA/HHA Application for Employment

Please print clearly. This application must be completed and all questions regarding your training and work experience answered. All information on this application is confidential. CarePro of NY Home Care Agency will not contact your present employer without your consent.

Full Name

City/State

Last Name

First Name

MI

Other Name (s)

SS#

Address

Time at this address

City

Home Phone

State

Cellphone

Zip

Are you a U.S. Citizen?

YesNo

Immigrant ID #

Position applying for

PCAHHAOther

Country of Birth

Referred By: (Name of referral person)

Transportation

CarBusTrainOther

First Contact Name

Relation

Cell phone number

Second Contact Name

Relation

Cell Phone number

EDUCATION

	Name and address of school	Did you graduate	Course of major	Year completed
High School
College
Graduate school
Training program

WORK AVAILABILITY

	Days	Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Comments

What languages do you speak?

Location references

Date available to start work

Have you ever been convinced of crime?

YesNo

Please explain

EMPLOYMENT HISTORY

	Name, Address, Phone Number	From: mm/yyyy	To: mm/yyyy	Job Title
1. Employer
2. Employer
3. Employer
4. Employer

CarePro of NY, Inc. is an equal employment opportunity without discrimination or harassment on the basis of race, color, religion, sex, sexual orientation, gender identity or expression, age, disability, marital status, citizenship, national origin, genetic information, or any other characteristic protected by law. CarePro of NY, Inc. prohibits any such discrimination or harassment and it is stated in and equal opportunity and nondiscrimination policy.

The information listed in my application is completed and true. I understand that if employed, false statements on this application are cause for dismissal. I will comply with all of the agency's rules and regulations regarding my employment. CarePro of NY, Inc. may request information regarding my background, which will include work and personal reference.

Reference Name or Company Name

Telephone Number

Fax

Applicant's Name: {fullName}

I hereby release from all liability the company or people named above and authorize them to release all information regarding my employment with them.

The above applicant has applied for assignments through our agency. As you have been submitted as reference, we would appreciate you filling out the information bellow and submitted it to us at 718-717-7463.

Email

First Name

Last Name

DOB

Last 4 of SSN

Address

Apt

City

State, zip code

Country of birth

Gender

Height

Weight

Eye color

Hair color

Phone Number

Did you do fingerprinting for another agency already?

YesNo

DOH CHRC form 102: Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

Last Name

First Name

MI

Maiden Name

Date of Birth

Alias/AKA

Mother's Maiden Name

Mailing Address (street)

City

State

ZIP Code

1. I have applied to an agency to provide direct care or supervision to residents or patients:) understand that as part of the application process, the Public Health Law (PHL) Article 28-E requir es that the New York State Department of Health perform a criminal historychecki on me with the New York State Division of Criminal (Justice Services (DCJS) and the Federal Bureau of Investigation (FBI).

2. I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI.

3. I have been advised that DOHT authorized by law to receive the results of the criminal history record check from DCJS and the FBI for thepurpose of developing a criminal history record summary. In accordance with applicable laws, DOH will) furnish appropriate summary information to the agency to which applied fora position to provide direct care or supervision to residents or patients have been advised that the criminal history record summary will indicate whether I have o criminal history, including convictions of o crime (felory or misdemeanor) or criminal charges which do not reflect a disposition. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the Information sholl) be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be disclosed to persons authorized by law. thave been informed that upon receiving notification from DCJS that there Isa subsequent pending criminal action or proceeding or conviction, the DOH shall promptyy notily an authorized person(s) of a provider of the additional allegation or new conviction.

4. I hereby consent to DOH sharing with any DCJS agency to which applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which was convicted or charged, the date of the arrest for such charge. and/or date of conviction, and the jurisdiction in which the arrest or conviction took place.

5. I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant toregulations and procedures established by the DCJS and the FBI If believe an errer has been made by DCJS for any New York State conviction/charge or the FBI for a non-New York State conviction/charge, I understand that should notify DCJS and/or the FBI to report and request correction of this error to the addresses below.

NYS Division of Criminal Justice Services Criminal History Bureau
Record Review Unit-5th Floor
4 Tower Place, Albany, NY 12203
(518) 485-7675

Federal Bureau of Investigation

Criminal Justice Information services (CJIS) Division

1000 Custer Hollow Road Clarksburg, WV 26306

(304) 625-5590

6. I understand that have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency. DOH or have reviewed my criminal history information.

7. I certify to the best of my knowledge and belief that (check as appropriate):
Have   Have not   been convicted of a crime in New York State or any other jurisdiction
Do   Do not   have a final finding of patient or resident abuse.
If you checked either "Have" and/or "Do", please provide a brief explanation (Optional) Type your explaination here

8. My current mailing or home address Is indicated in Section 1 of this form, if any.

9. I have read this form and hereby consent to the request by the agency in use my lingerprints to obthin my criminal history record, if from the DCJS and the FBL Thereby consent to the of any ronvic tions or opent chorges on my Siminal bistory recouds rereivert by now from DOLS to the requesting angenty in accordance with applicable laws: declare and affirm that the information Ihave provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own.

Name and Signature of Parent or Legal Guardian: (if subject individual is under 18 years of age)

Date

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.

Last Name

First Name

MI

Other Last Names Used (if any)

Address (Street Num/Name)

Apt. No.

City or Town

State

ZIP Code

Date of Birth

SS No.

Employee's Email Add

Employee's Tel. No.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of falso 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
3. A lawful permanent resident(Enter USCIS or A-number:)
4. A noncitizen (other than item Numbers 2. and 3. above)      authorize to work until (exp date, if any):

If you check Number 4, check one of these:
USCIS A-Number:
OR
Form I-94 Admission Number:
OR
Foreign Passport Number and Country of Issuance:

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Your withholding is subject to review by the IRS.

(a) First name and middle initial

Last name

(b) SS number

Address

City or town, state, and ZIP code

(c) Marital status

Single or Married filing separatelyMarried filing jointly or Qualifying surviving spouseHead of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. (See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.)

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spousealso works. The correct amount of withholding depends on income earned from all of these jobs.

Do you hold more than one job at a time? Or are you married filing jointly and also have a spouse who works? (answer yes if either is true)*

YesNo

Which of the following will you do?

Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4);Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding;If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with is similar pay; otherwise more tax than necessary may be withheld.

Complete Steps 3-4(b) oon Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job)

Click yes to acknowledge that you know you must complete this section if you think your income will be $200,000 or less ($400,000 or less if married filing jointly):*

I acknowledge this.

Number of Qualifying Children under age 17

Number of Other Dependents

a. Multiply the number of qualifying children under age 17 by $2,000

b. Multiply the number of other dependents by $500

Add amounts of (a) and (b)

Click yes to acknowledge that you have read the below questions*

I acknowledge this.

(a). Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4(a)

(b). Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4(b)

(c). Extra withholding. Enter any additional tax you want withheld each pay period . . . . . .

4(c)

Signature

Date

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Employee Name

Type a question

Date

Have you lived in or otherwise spent at least one consecutive month in any country other than the United States, Canada, Australia, New Zealand, or countries in western or northern Europe?

YesNo

When was the most recent such occurrence?

Are you currently or do you plan to be immunosuppressed? (e.g. HIV infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist, chronic steroids or other immunosuppressive medication)

YesNo

Please explain in detail.

Have you had close contact with someone who has had TB disease during their lifetime?

YesNo

When was the most recent such occurrence?

Have you ever been diagnosed with active or latent TB infection, had a positive skin test or blood test for TB, or been treated with medication for TB or for a positive TB test?

YesNo

Details

Conditions

	YES	NO
Blood in sputum
Chest pain
Drenching night sweats
Lingering cough w/ sputum*

CONDITION

	YES	NO
Unexplained lingering fatigue*
Unexplained weight loss of 10 lbs. or more
Shortness of breath
Unexplained lingering fever*

Explanation of "YES" answers

All health care personnel must complete a tuberculosis risk assessment and symptom evaluation within three months prior to assuming patient care duties and annually thereafter. Even if there is no increased risk for TB, baseline testing with blood test or TST is required for all health care personnel, unless there is documentation of prior latent TB or TB disease. However, annual testing is not required, and personnel must be retested only if they experience symptoms suggestive of TB disease, or new risk for infection.

Employee Name

Date

Since your last health assessment, have you experienced any of the following?

	YES	NO
Habituation or addiction to depressants, stimulants, narcotics, alcohol or other substances which may alter behavior

Set 2

	YES	NO
Allergies
Arthritis
Asthma
Back pain
Cancer
Change in bowel habits
Chest pain / pressure in chest
Diabetes
Disabling injury / other restriction in ability to work
Fainting or dizziness
Fractures
Frequent cough
Heart condition
Hernia
High blood pressure
Increased thirst

Set 3

	YES	NO
Kidney disease
Lumps or nodules in the breast
Mental illness
Migraine headaches
Pain in calf while walking
Pain when urinating / blood in urine
Persistent sores or lumps
Seizures / convulsions
Shortness of breath
Sinus conditions
Skin disease / rash
Surgery
Swelling in legs and feet
Treatment for an infectious condition
Treatment for other medical condition
Other medical complaint(s)

Explanation of "YES" answers

Do you Smoke?

YesNo

How much?

Do you drink Alcoholic Beverages?

YesNo

How much?

Do you take any depressants, stimulants, narcotics, or other drugs or substances that may alter behavior?

YesNo

Do you take prescription medications?

YesNo

Which ones?

Name of your Physician

Telephone Number

Employee Name

Employee's ID#

I have been advised that I should receive the influenza vaccine to protect myself and the patients I serve. I have read the Centers for Disease Control and Prevention's (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have had the opportunity to discuss the statement and have my questions answered by a healthcare provider. I am aware of the following facts:

Influenza is a serious respiratory disease that kills thousands in the United States each year.
Influenza vaccination is recommended for me and all other healthcare personnel to protect this facility's patients from influenza, its complications, and death.
If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
If I become infected with influenza, I can spread severe illness to others even when my symptoms are
I understand that the strains of virus that cause influenza infection change almost every year and, even if they don't, my immunity declines over time. This is why vaccination against influenza is recommended each year.
I understand that I cannot get influenza from the influenza vaccine.
The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including all patients in this healthcare facility, coworkers, my family and my community.

Because I have refused vaccination against influenza, I will be required to wear surgical or procedure masks in areas where patients or residents may be present during the influenza

I acknowledge that I have read this document in its entirety and fully understand it. Despite these facts, I have decided to decline the influenza vaccine by my signature below. I realize that I may re-address this issue at any time and accept vaccination in the future.

Witness

Signature

Date

I, {fullName}, acknowledge the receipt of flu mask.

New York State public health law has mandated that health care personnel, who do not receive the flu vaccine must wear surgical mask in areas of the facility where patients may be present (on campus and offsite) during the flu season. Personnel who are not vaccinated (including those medically exempt): Must wear surgical or procedure mask (provided by Care Pro of NY Home Care, INC. free of charge) during the flu season (time frame to be determine by the NYS Commissioner of Health). Pick up biweekly 40/week and as needed. Procedure mask must be work where patients may be present. Should change mask after leaving patient's room/home and/or whenever mask is soiled.

Failure to wear issued mask will result in disciplinary action.

I, {fullName}, declining the Hepatitis B Vaccination.

I understant that due to my occupational exposure to blood or other potential 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. I have been offered the opportunity to be vaccinated with the Hepatitis B vaccine at no charge to myself. I have also been asked if I have questions regarding this information and if I had questions, they were fully answered to my satisfaction.

I, {fullName} decline the Hepatitis vaccine at this time. I understand that by declining this vaccine, I continue to be at risk for acquiring Hepatitis B, a serious disease. If in the future while employed by CarePro of NY, INC., I continue to have occupatuinal exposure to blood or other potentially infectious material and I want to be vaccinated I can receive the vaccination series at no charge to myself.

Do you have any of these symptoms? Please select all that apply.

Temperature

Purple Folder

Application/References
HHA/PCA Manual Attendant form (Employee copy)
Acknowledge form Position Description
Acknowledge of Personal Policy (Hiring PCA, code of conduct, ID Badge)
NYS Wage/ Pay Rate Form
Paid Sick Leave Acknowledgment
NYC Notice of Employee Rights
Affidavit Form
CarePro of NY, INC. Patient Transferal Agreement (Attestation Excluder provider compliance)

Green Folder

HHA/PCA Certificate
NYS HCR Verification form
General Orientation for Employment
Evaluation
In-Service

Envelope (CHRC)

Background Investigation Confidentiality Acknowledgment (HRC Submission)
DOH CHRC 102 form. CHRC Determination Letter

Envelope (MEDICALS)

Physical form/PPD/Quantiferon. Labs: Rubella, Ruebola, Drug test, TB Screen
Flu vaccine/Declination form/Receipt of Flu Mask
Hepatitis B Vaccine Declination Flu
W-4 form (binders)
I-9 FORM (BINDERS) OMIG-OIG-SAM

1. Employer Information

Name: CAREPRO OF NY, INC

Doing Business As (DBA) Name(s): SAME AS ABOVE

FEIN (optional):

Physical Address: 1712 Kings Hwy Ste 100, Brooklyn, NY 11229

Mailing Address: SAME AS ABOVE

Phone: 718-717-7750

2. Notice given: At hiring

Note: Live-in employees must be paid at least 13 hours for each 24 hour period, provided they receive 8 hours of sleep, with five hours of uninterrupted sleep and 3 hours off for meals. If an employee does not receive 5 hours of uninterrupted sleep, the employee must be paid for all 8 hours. If the employee does not receive meal periods free from duty, the employee must be paid for all 3 hours designated for meals.

3. Employee's Rate(s) of Pay for Each Type of Work Shift:

$ 17 per hour for all shifts

3a. Wage Parity Rates:

$ 17 per hour for regular wage

$ 0.57 per hour for additional wage

$ 3.52 per hour for supplemental wages*

4. Allowances: None

5. Reqular Payday: Friday

6. Pay is: Weekly

7. Overtime Pay Rate(s) for each type of work or shift:

Single Pay Rate: $ 25.5 per hour

This must be at least 1.5 times the worker's regular rate with few exceptions.

Wage Parity Pay Rate: $ 25.5 per hour

This must be at least 1.5 times the worker's regular rate with few exceptions.

Multiple Pay Rates: $ TBD per hour

This must be at least 1.5 times the worker's Weighted average of the multiple rates of pay for the week, with few exceptions.

8. Employee Acknoledgement:

On this date, I have been notified of my pay rate, overtime rate (if eligible), allowances, supplements and designated payday. I told my employer what my primary language is.

Is your primary language English?

YesNo

Primary Language*

I have been given this pay notice in English, because it is my primary language.

My primary language is {primaryLanguage}. I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary language.

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

Please note: It is unlawful for an employee with protected class status to be paid less than an employee without protected class status, if they are performing substantially equal work. Employers also may not prohibit employees from discussing wages with their co-workers.

*If wage supplements are paid as a single payment owed to multiple plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits includedi in the package, e.g., pension, health and welfare, or other, (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

List any additional benefits and attach listing to this document.

Copies of the above listed agreements or summaries may be obtained by: compliance@careprony.com

On this day, I have been notified of my payrate, overtime rate, allowances, supplements/benefits, and designated payday provided on this form (LS62) attached and this addendum on the date given below.

My primary language is:

I have been given this notice in my primary language

YesNo

HHA/PCA Name:

I am being given the opportunity to enroll myself in the Minimum Essential Coverage / ACA Complaint group health benefits plan(s) offered by CarePro of NY, Inc at an Affordable Level and I decline this coverage.

I decline this coverage, because I have coverage from:

My spouse's employerMedicareMedicaidUnion health plan

My Spouse's Employer Insurance Name

Policy Number

Medicare Insurance Name

Policy Number

Medicaid Insurance Name

Policy Number

Union Health Plan Insurance Name

Policy number

Another source of coverage (please specify)

Insurance Name

Policy Number

I certify that all information provided in this form is true and complete. By declining group health benefits, I acknowledge that I may have to wait until the plan's next open enrollment period to request group coverage and that I may not qualify for a subsidy on the PPACA Health Exchange.

We are pleased to offer you the opportunity to participate in our retirement savings plan for the year 2023. A retirement plan provides valuable benefits. You have two options to choose from:

IRA (Individual Retirement Account):

The IRA is an individual retirement account that allows you to save for your retirement on a tax-advantaged basis. You can contribute a portion of your earnings into this account, and the earnings on your investments grow tax-free until you withdraw them during retirement. IRAs offer flexibility and a wide range of investment options, including stocks, bonds, and mutual funds.

Benefits:

- Tax advantages: Contribution made to an IRA are tax-deductible, which can reduce your taxable income for the year, potentially lowering your tax bill.

- Investment flexibility: You have the freedom to choose from a variety of investment options, allowing you to tailor your retirement savings to your financial goals.

- Long-term growth: The tax-free growth of your investments over time can potentially lead to significant long-term savings.

The IRA plan allows you to have full control over your retirement savings. You can choose from various investment options, including stocks, bonds, and mutual funds. One of the significant advantages of an IRA is the tax-deductible contributions, providing potential tax savings as you save for retirement.

Please make your choice:

choose the IRA (Individual Retirement Account).choose not to participate in either plan at this time

If you have any questions or need more information to make an informed decision, please do not hesitate to reach out to our HR Department.

Thank you for your dedication to CarePro and for taking steps to secure your financial future through one of these retirement plans.

Sincerely,

CarePro Agency

ORIENTATION CHECKLIST:

I have read my job description and understand that I will be evaluated based on the performance criteria in my job description. I acknowledge having completed all of the orientation in service curriculum.

PAID SICK LEAVE FORM:

I have been informed today by CarePro of NY, Inc. regarding the Paid Sick Leave rules and regulations as per the New York State Labor Law and the Domestic Workers’ Bill of Right.

I am aware that I will start accumulating Paid Sick Leave hours from my first day of employment on a “1 hour for every 30 hours worked” rate of accrual. The maximum hours that I can accumulate and use is 56 hours annually.

I have read and understand the information provided.

AFFIDAVIT:

I have applied for a position as a {position} with CarePro of NY. All of the information I have submitted is true to the best of my knowledge. All certificates are valid (or copies of originals) and all background information is correct. I authorize CarcPro of NY to obtain any information regarding and pertaining to my employment and health status. I understand that this may include contacting the following to obtain information to verify signatures, dates, forms and data.

Medical providers (M.D. lab, etc.)
Previous employers
Schools and training programs
Personal and professional references

I further release CarePro of NY of any liability that may occur as a result of my personal negligence or as a result ofany information that I wrongfully or fraudulently submitted to CarePro of NY, or in the course of applying for aposition during my association with them. 1 understand that any information fraudulently submitted will result in my immediate termination.

As a job applicant/employee of CarePro of NY, I hereby attest to the fact that I have received no special inducements, remuneration, or promises thereof to work for this agency, I understand that I will receive a salary commensurate and also in line with what other employee of this agency are receiving for similar work and experience. All other benefits that I may be eligible for will be in accordance with policies established by

Hiring of personnel, salaries and benefits are awarded without regard to racc, religion, disability, marital status, or sexual orientation CarePro of NY is an equal opportunity employer. I have read the preceding statement and I understand and agree with its contents.

EXCLUDED PROVIDER COMPLIANCE:

I was compared with the exclusion lists maintained by:

The New York State Office of the Medicaid Inspector General (OMIG) - lists individuals or entities whose participation in the Medicaid Program has been restricted, terminated or excluded under the provisions of 18 NYCRR 504./(b)-(h), 18 NYCRR 515.3 OR 18 NYCRR 515.7
US Department of Health and Human Services' Office of the Inspector General (OIG) - The List of Excluded Individuals/ Entities (LEIE) names individuals and entities currently excluded from participation in Medicare, Medicaid and all Federal health care programs; under sections 1128 and 1156 of the Social Security Act and Section 42 CFR 1001.3001-3005
General Services Administration (GSA) - The Excluded Parties List System (EPLS) lists those individuals or entities who have been disqualified from receiving Federal contracts, certain subcontracts, and certain Federal financial and nonfinancial assistance and benefits, pursuant to the provisions of 31 U.S.C.6101,note,F.O. 12549, E.O. 12689, 48 CFR 9.404, and each agency's codification of the Common Rule for No procurement suspension and debarment as published by the General Service Administration (GSA).

CarePro of NY, Inc. assumes the information provided by OMIG, OIG and GSA to be accurate. However, CarePro of NY, Inc. cannot guarantee --- either expressed or implied --- the accuracy of the OMIG, OIG or GSA's websites (which were used to access this information).

ACKNOWLEDGEMENT OF RECEIPT OF THE POSITION DESCRIPTION:

I have received Care Pro of NY, Inc.’ position description. All qualification, position description, specific duties and responsibilities functions that will not be performed under any circumstances and confidentiality statement regarding this position has been discussed.

ACKNOWLEDGEMENT OF RECEIPT OF THE PERSONAL POLICY:

My questions regarding this notice have been answered. I have received CarePro of NY's all information that who can be hired as Personal Care Aide State regulations allow certain relatives to become the personal care aide, which in this program means being hired by the licensed home care services agency (LHCSA) that has a contract with the MLTC plan, certified home health agency, managed care plan, or local district. These relatives MAY NOT BE the personal care aide: spouse, parent, son, son-in-law, daughter or daughter-in-law. Another relative may be the aide " if that other relative(i) is not residing in the patient's home; or(ii) is residing in the patient's home because the amount of care required by the patient.

I have received CarePro of NY's established a written code of conduct in order to protect you, our clients and the agency. As an employee for CarePro of NY, I will take the Code of Conduct very seriously, and you must too. Under the Code, I can be disciplined or terminated if I violatethe prohibitions. If I know of others who are violating these terms and don't report them to us, you can be disciplinedor terminated. Please read this letter carefully.

As an employee of CarePro of NY, I acknowledge receipt of the agency issued photo identification badge. As required by regulation and agency policy, I agree to wear the ID when working where it is visible to the eye immediately by the patient, all the patient's family members and Supervising Nurse. If card is lost be advised you MUST PAY a $10.00 lost card fee. The identification badge is the property of CarePro of NY and will be returned to the agency upon termination of employment. I know I can contact CarePro of NY at the above address or telephone number if I have any other questions regarding this form.

HOME ATTENDANT MANUAL ACKNOWLEDGEMENT:

I acknowledge that I have received a copy of the CarePro of NY Inc. (The "Employer") Home Attendant Manual (the "Handbook" I understand that this Handbook supersedes all previous descriptions of the Employer's policies, procedures, and employee benefits.

I understand that the Handbook describes important information about the Employer, and I agree to read the entire Handbook. I agree to abide by all the policies and procedures contained in the Handbook. If I have any questions about the Handbook, or about other issues regarding my employment, I will consult with the Personnel Manager.

I understand that the Employer's personnel policies and benefits are regularly reviewed and may be modified or supplemented without notice. Although I understand that the Employer will strive to keep me posted of any changes, I understand and agree that the Employer does not intend by this Handbook to create contractual obligations, express or implied, on the part of the staff or the Employer. I understand and agree that the Employer retains the sole right to interpret the Handbooks provisions.

I understand and agree that, unless I am subject to an employment contract, my employment with the Employer is "at will", that is, that both Employer and I are free to terminate my employment at any time, with or without cause or advance notice. I understand that, while other personnel policies, procedures and benefits of the Employer may change from the time to time in the Employer's discretion, this at-will employment relationship can only be changed by an express written employment contract signed by the Program Director.

24-HOUR SHIFT POLICY:

The following policy applies only to paraprofessional staff who are on duty for 24-hours or more. You will be paid for all hours worked. During each full 24-hour period during which you are required to be on duty, you will have the ability to take Meal Periods of up to 3 hours and Sleep Time of up to 8 hours, 5 hours of which are uninterrupted, in adequate sleeping facilities, and these hours will not count as hours worked. All other hours during the course of such period will be considered hours worked.

It is expected that you will have the ability to enjoy 3 hours of Meal Periods and 8 hours of Sleep Time (5 of which are uninterrupted) for each full 24-hour shift. Where you receive 3 hours of Meal Periods and 8 hours of Sleep Time, you will be credited with 13 hours of work for the 24-hour shift, consistent with the written agreement you signed concerning working 24-hour shifts. Please note that if you are provided sufficient Bona Fide Meal and Sleep Time of sufficient length but voluntarily choose not to sleep or eat and to instead spend your time, free of work duties, in other ways or enjoying other non- work activities (reading, watching television, using a mobile device, etc, you will be deemed to have been provided the required Bona Fide Meal and Sleep Time.

To ensure that you are paid for all hours you work, if you do not have the ability to enjoy 3 hours of Meal Periods and 8 hours of Sleep Time for each full 24-hour shift, contact your Coordinator within 24 hours of the conclusion of the shift and complete a "Sleep Time and Meal Period Exception Certification Form" and return the form to your Coordinator within 48 hours. A blank Sleep Time and Meal Period Exception Certification Form is attached to this Handbook and additional forms are available from any Coordinator.

Any Aide who enters or submits a false record concerning their Meal Periods or Sleep Period will be subject to immediate disciplinary action, up to and including termination of employment.

In Service Literature Acknowledgement – Mandatory Topics:

I have received the in-service literature and acknowledge understanding of the following policies, as they should be practiced, in addition to any further policies and procedures, which are to be followed:

Training Content
HIPAA
Resident Rights
Sexual Abuse Policy and Prevention
Accident Prevention
Emergency and Disaster Preparedness
Infection Control
Fire Safety
Advance Directives

EVV TRAINING ACKNOWLEGEMENT:

I have received the Electronic Verification System, Orientation, and Training Information. I acknowledge understanding of the following as they should be practiced, in addition to any further policies and procedures, which are followed:

I must Clock in and out from my clients home via call in and out system (if not using HHA Exchange mobile app).
I must call the agency if the EVV is not accepted and speak to my coordinator
I must follow the plan of care and enter the tasks that were performed for the visit.
A timesheet is required if the EVV is not accepted or the clients phone is not working (if not using HHA mobile app)

HIV CONFIDENTIALITY STATEMENT:

I understand the importance of observing strict confidentiality policy. I agree not to discuss or release any information obtained within the agency regarding any CarePro of NY, client, their medical record or any condition with anyone not directly associated with CarePro of NY Employees who are not directly associated with the client's record, will only be done with proper authorization as/or in accordance with established agency policy for release of information.

In the event that you are made aware that your patient is HIV positive, you can not disclose this information to another individual. Start law prohibits you from making any further disclosure of this information without the specific written consent of the person it pertains to or as permitted by law. Any further disclosure is a violation of state law and may result in a fine or jail sentence or both. General authorization for the release of medical record or any other information is not sufficient authorization for future disclosure.

I understand and agree to abide by the aforementioned policy, and that any breach in the policy will result in the implementation of the disciplinary procedure up to and including possible IMMEDIATE DISMISSAL from employment at CarePro of NY.

MEDICARE FRAUD & ABUSE – PREVENT, DETECT, REPORT ACKNOWLEDGEMENT STATEMENT:

I have been informed regarding Medicare Fraud & Abuse: Prevent, Detect, Report from CarePro of NY, Inc. and acknowledge to comply with the rule. I acknowledge that I was informed with all pertaining to the Federal False Claims Act. Well as where to report these issues should they suspected or uncovered.

I understand rules for Fraud and Abuse in Medicare programs is to prohibit the fraudulent conduct addressed by these laws.

HIPAA ACKNOWLEDGEMENT STATEMENT:

I have been informed regarding HIPAA Privacy Rule from CarePro of NY, Inc. and acknowledge to comply the rule.

I understand that the major goal of the privacy rule is to assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and protect the public's health and well-being.

VERIFICATION OF TRAINING IN UNIVERSAL PRECAUTIONS:

I have been trained and/or in-serviced on the proper techniques for caring for patients with communicable disease. The procedure known as Universal Barrier Precautions has been taught to me through CarePro of NY, Inc. programs. I am a knowledgeable as to proper utilization of supplies needed to handle care for such patients.

SEXUAL HARRASSMENT ACKNOWLEDGEMENT STATEMENT:

I have been informed regarding Sexual Harassment, and I acknowledge to comply with this policy and regulation describe bellow. Sexual harassment will not be tolerated. It is a flagrant violation if CarePro of NY, Inc. policy to sexually harass any employee either verbally or physically. This is an invasion of the employee's individual rights, and it is against the Law. Employment Opportunity Commission (EEOC) has written guidelines defining acts of sexual harassment by that constitutes a violation of the Civil Rights Act when tolerated by the employer.

The following statement expresses the position of the EEOC, and CarePro of NY, Inc. will not tolerate such conduct: unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when:

Submission to such conduct is made either explicitly or implicitly a term or condition of an individual's employment.
Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual.
Such conduct has the purpose or effect of substantially interfering with an individual's work performance or creating an intimidating, hostile or offensive working environment.

Violation of the above rule will be the basis for appropriate corrective action, up to and including discharge for serious violation if this policy.

It is the responsibility of all CarePro of NY, Inc. management personnel to inform all employees within their respective areas of this policy statement. This information must include instructions of action to take if the employee feels subjected to sexual harassment Further, it is the obligation of every employee in all departments to understand this policy and prevent sexual harassment in the work-place. All employees are expected to demonstrate the same commitment to the Sexual Harassment Policy as to all other policies.

Any CarePro of NY, Inc. employee who has, in his/her opinion, been subjected to sexual harassment, or who has witnessed the same, is encouraged to report such action to his/her immediate Supervisor or Department Head. If the employee prefers to report to someone other than his/her supervisor, the Director of Nursing or Agency Administrator has been designated by the Board of Directors to take such reports.

Report documentation

The individual taking the report, referred to above, will interview and obtain written statements from every party involved in the incident, including any witnesses, and have such statements signed by each individual. A copy of the complaint will be given to the Agency Administrator or Director of Nursing. Because of the sensitive nature of such reports and any resulting investigation or action, care should be taken to protect the confidential nature of the proceedings as far as possible.

Reporting to Hoard of Directors

The Agency Administrator or Director of Nursing will notify the Board of Directors when a sexual harassment complaint has been brought to his/her attention. Progress reports of the investigation will also

Resolution: When the investigation is completed, the complete file will be reviewed by the Director of Nursing, Agency Administrator and Legal Counsel and a recommendation of action will be made.

OSHA INFORMATION ACKNOWLEDGEMENT:

I have received the OSHA Orientation and information and I acknowledge understanding of the following as they should be practiced, in addition to any further policies and procedures, which are to be followed:

Personal Protective Equipment
Infection Control, Exposures & Universal Precautions
OSHA Blood-home Pathogen Standard
Tuberculosis & Exposure, Risk Management
HIV Confidentiality Protection
Hippa Acknowledgement Information
Disaster Preparedness: Fire Safety & Emergencies
COVID-19 Infection Control Procedures

BACKGROUND INVESTIGATION CONFIDENTIALITY ACKNOWLEDGEMENT:

I understand my information obtained during my backgroung investigation is confidential and will not be shared without written consent from myself, or in accordance with the laws governing the United States of America and/or New York State. Furthermore, I understand that I reserve the right to withdraw my application at any time by submitting a signed letter stating my desire to withdraw from the employee application process. Upon receipt of the aforementioned letter by CarePro of NY, Inc., no further inquiries into my background will continue.

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PCA/HHA Application for Employment

PERSONAL INFORMATION

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EDUCATION

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EMPLOYMENT HISTORY

REFERENCE FORM

CHRC SUBMISSION REQUEST INFORMATION

CRIMINAL HISTORY RECORD CHECK

SECTION 1 - SUBJECT INDIVIDUAL INFORMATION

SECTION 2 - ATTESTATION

USCIS FORM I-9

Section 1. Employee Information and Attestation

W-4 Employee's Withholding Certificate

Step 1: Enter Personal Information

Step 2: Multiple Jobs or Spouse Works

Step 3: Claim Dependents

Step 4 (optional): Other Adjustments

Step 5: Sign Here

TUBERCULOSIS RISK ASSESMENT

Annual Health Status Assessment

Declination of Influenza Vaccination

Receipt of flu mask

Hepatitis B Vaccine Declination

COVID-19 Screening

Employee Checklist for Employment

Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law for Home Care Aides Wage Party and Other Jobs

Employment Acknowledgement

ACA BENEFIT WAIVER FORM

Retirement Choice Letter

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