Texas Quality One Medical Services Employment Application

TEXAS QUALITY ONE MEDICAL SERVICE

Required Base Wages of Persons Providing Personal Attendant Services Effective from January 1, 2014, to September 1, 2023

In addition, providers are required to notify, by January 15, 2014, all persons hired as personal attendants on or before August 31, 2013, of the required base wage. Newly employed or contracting attendants hired on or after January 1, 2014, must be notified of the required base wages within three days of being hired.

Beginning January 01, 2014, the required minimum base wage is $7.50

Beginning September 01, 2014, the required minimum base wage is $7.86 per hour.

Beginning September 01, 2015, the requires minimum base wage is $8.00 per hour.

Beginning January 01, 2022, the required minimum base wage is $8.11 per hour.

Beginning September 01, 2023, the required minimum base wage is $10.60 per hour.

TEXAS QUALITY ONE MEDICAL SERVICES, INC.

2646 South Loop West #250 Houston, Texas, 77054 Phone: 713-784-5255

Fax: 713-838-0356 www.texasqualityone.com

Last Name*

First*

MI

Date of Birth*

Date

Address*

Street Address

Apartment/Unit#

CityState

ZIP

Phone*

Email*

example@example.com

Social Security*

Position Applied for:*

Client youre applying for

If you are applying to work for a specific client, name them here.

Your Gender:*

MaleFemale

Are you a citeizen of the United States?*

YesNo

If no, are you authorized to work in the United States?

YesNo

Have you worked for Texas Quality One before?*

YesNo

If so when

Have you worked for any home health agency before?*

YesNo

If so when

Have you ever been convicted of a felony?*

YesNo

If yes explain

High School you went to:*

From*

Date

To*

Date

Did you graduate?*

YesNo

List the college/university attended?

If you have more than one degree, list the most relavent one.

From

Date

To

Date

Did you graduate?

YesNo

If yes, what is your degree in?

Do you have any other relavent licenses or certifications? List them here:

Please list three references. We may call some or all of them to discuss your qualifications for this position.

Reference One: Full Name*

Relationship*

Phone*

Reference Two: Full Name*

Relationship*

Phone*

Reference Three: Full Name*

Relationship*

Phone*

Company*

Job Title*

Phone*

Manager*

Responsibilities*

From*

Date

To*

Date

Reason for Leaving*

May we contact your previous supervisor?*

YesNo

Company*

Phone*

Job Title*

Manager*

Responsibilities*

From*

Date

To*

Date

Reason for Leaving*

May we contact your previous supervisor?*

YesNo

Company

Phone

Job Title

Manager

Responsibilities

From

Date

To

Date

Reason for Leaving

May we contact your previous supervisor?

YesNo

Can you lift at least 50lbs?*

YesNo

Do you have reliable transportation?*

YesNo

What days are you available to work?*

Are you related to the client?*

YesNo

I certify that my answers are true and complete to the best of my knowledge. I understand that a complete background check and employment verification will be conducted. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my termination.

Signature*

Date*

Date

Criminal Background Check, NAR & EMR Registry Check

Prior to employment, we must conduct a State of Texas Criminal History Check and search the Nurse Aide and Employee Misconduct Registry to determine if you have a criminal conviction or if you have committed certain conduct that bars employment with our agency. If you have been convicted of any of the following offenses or are listed in the registry you may NOT be employed by our agency.

Sec.250.006. CONVICTIONS BARRING EMPLOYMENT

Subsection A: A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in these subsections:

(1) an offense under Chapter 19, Penal Code (criminal homicide);

(2) an offense under Chapter 20, Penal Code (kidnapping and unlawful restraint);

(3) an offense under Section 21.02, Penal Code (continuous sexual abuse of young child or children),

(3b) an offense under Section 21.11, Penal Code (indecency with a child);

(4) an offense under Section 22.011, Penal Code (sexual assault);

(5) an offense under Section 22.02, Penal Code (aggravated assault);

(6) an offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);

(7) an offense under Section 22.041, Penal Code (abandoning or endangering child);

(8) an offense under Section 22.08, Penal Code (aiding suicide);

(9) an offense under Section 25.031, Penal Code (agreement to abduct from custody);

(10) an offense under Section 25.08, Penal Code (sale or purchase of a child); (11) an offense under Section 28.02, Penal Code (arson);

(12) an offense under Section 29.02, Penal Code(robbery);

(13) an offense under Section 29.03, Penal Code (aggravated robbery);

(14) an offense under Section 21.08, Penal Code (indecent exposure);

(15) an offense under Section 21.12, Penal Code (improper relationship between educator and student);

(16) an offense under Section 21.15, Penal Code (improper photography or visual recording);

(17) an offense under Section 22.05, Penal Code (deadly conduct);

(18) an offense under Section 22.021, Penal Code (aggravated sexual assault);

(19) an offense under Section 22.07, Penal Code (terroristic threat);

(20) an offense under Section 32.53, Penal code (exploitation of child; elderly individual, or disabled individual);

(21) an offense under Section 33.021, Penal Code (online solicitation of a minor);

(22) an offense under Section 34.02, Penal Code (money laundering);

(23) an offense under Section 35A.02, Penal Code (Medicaid fraud);

(24) an offense under Section 36.06, Penal Code (obstruction or retaliation); (25) an offense under Section 42.09, Penal Code (cruelty to animals); or under Section 42.092, Penal Code (cruelty to non-livestock animals)

(26) a conviction under the laws of another state, federal' law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.

(27) an offense that the Agency determines to be a contra-indication to employment with the

Subsection B: A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date the person is convicted of:

(I) an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;

(2) an offense under Section 30.02, Penal Code (burglary);

(3)an offense under Chapter 31, Penal Code (theft), that is punishable as a felony; (4)an offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;

(5) an offense under Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;

(6)an offense under Section 37.12, Penal Code (false identification as peace officer; misrepresentation of property); or

(7)an offense under Section 42.01(a7), (8), or (9), Penal Code (disorderly conduct).

ADDITIONAL BARS TO EMPLOYMENT: Bars pursuant to Texas Administrative Code, title 40, Part 1, Chapter3, 3.201 Texas Health and Safety Code.

Chapter 481 - Texas Controlled Substances Act: a conviction that is punishable as a felony (involving manufacture, delivery, intent to distribute, conspiracy to possess or produce with intent to distribute, distribution to a minor, illegal expenditure or investment, or transfer or receipt of chemical laboratory apparatus

15.01 - Criminal attempt of any offense listed as a bar 43.03 - Promotion of Prostitution 43.04 - Aggravated Promotion of Prostitution 43.05 - Compelling Prostitution

TEXAS QUALITY ONE MEDICAL SERVICES QUALITY CARE YOU CAN TRUST PROVIDED IN HOME SETTING FOR YOUR