Texas Quality One Medical Services New PCA Orientation and New Hire Paperwork 7-25-2025

Policy & Procedure Training
Attendant Name*

First NameLast Name
Youtube
Name of client you are applying for if you have one
Signature. By signing below, you understand and agree to abide by everything within this orientation as a condition of employment. *
Date*

MonthDayYear
Date

PAYROLL DIRECT DEPOSIT FORM

We only pay through direct deposit
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Select the type of account*

Pre-paid Debit CardBank Checking Account
Account Number*
Routing Number*
Name of Bank or Institution*
Account Number*
Routing Number*
Name of Bank or Institution*
Signature*
Date*

MonthDayYear
Date

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

USCISForm I-9OMB No. 1615-0047Expires 10/31/2022
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.
Section 1

(Employees must complete and sign Section 1 of Form I-9 no laterthan the first day of employment, but not before accepting a job offer.)
Name*

First NameLast Name
Middle Initial
Other Last Names Used (if any)
Address*

Street Address

Apt Number (if any)

CityState / Province

Postal / Zip Code
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
U.S. Social Security Number*
Employee's E mail Address*
example@example.com
Employee's Telephone Number*
I attest, under penalty of perjury, that I am (check one of the following boxes):*

1. A citizen of the United States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident (A Number/USCIS Number):4. An noncitizen authorized to work until (continue below)
If you are a lawful permanent resident enter your A Number or USCIS Number:
A noncitizen (other than Numbers 2 and 3 above) authorized to work until (expiration date, if applicable, mm/dd/yyyy):

MonthDayYear
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An A Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. A Number/USCIS Number:
2. OR Form I 94 Admission Number:
3. OR Foreign Passport Number:
Country of Issuance:
Signature of Employee*
Today's Date (mm/dd/yyyy)*

MonthDayYear
Date
If a preparer and/or translator assisted you in completeing Section 1, that person MUST complete the Preparer and/or Translator Certification.

Form 8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit

OMB No. 1545-1500
Click Here to view Form 8850 and its instructions.
Name*

First NameLast Name
Social security number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Telephone number*
If you are under age 40, enter your date of birth (month, day, year)

MonthDayYear
Date
1.

Check here if you received a conditional certification from the state workforce agency (SWA) or an participating local agency for the work opportunity credit.
2. Check here if any of the following statements apply to you:

*I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months. *I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3 month period during the past 15 months. *I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. *I am at least age 18 but not age 40 or older and I am a member of a family that: a. Received SNAP benefits (food stamps) for the past 6 months; or b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them. *During the past year, I was convicted of a felony or released from prison for a felony. *I received supplemental security income (SSI) benefits for any month ending during the past 60 days. *I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
3.

Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
4.

Check here if you are a veteran entitled to compensation for a service connected disability and you were discharged or released from active duty in the US Armed Forces during the past year.
5.

Check here if you are a veteran entitled to compensation for a service connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
6. Check here if you are a member of a family that:

*Received TANF payments for at least the past 18 months; or *Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18 month period beginning after August 5, 1997, ending during the past 2 years; or *Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
7.

Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
For Privacy Act and Paper Reduction Act Notice, see page 2.
Job applicant's signature: Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.*
Date*

MonthDayYear
Date

Employee's Withholding Certificate. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

OMB No. 1545-0074
Click here to view paper form and instructions
Name*

First NameLast Name
Middle Initial
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Marital Status*

Single or Married filing separatelyMarried filing jointly (or Qualifying widow(er))Head 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.)
(c) 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 similar pay; otherwise, more tax than necessary may be withheld
Step 3: Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
Multiply the number of other dependents by $500
Add the amounts above and enter the total here
Step 4 (optional): Other Adjustments
(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
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here
(c) Extra withholding. Enter any additional tax you want withheld each pay period
Employee's signature: Under penalty of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete. (This form is not valid unless you sign it.)*
Date*

MonthDayYear
Date

Policy & Procedure Training

PAYROLL DIRECT DEPOSIT FORM

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

Section 1

Form 8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Individual Characteristics Form (ICF) Work Opportunity Tax Credit

Employee's Withholding Certificate. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Step 3: Claim Dependents

Step 4 (optional): Other Adjustments

Health Insurance Enrollment Form