Direct Deposit e-form (ND)

Direct Care Worker Demographics
Name*

First NameLast Name
Email - Please make sure it's the same email you used during your initial application.
example@example.com
Phone Number*
Please enter a valid phone number.

Employment History
Which agency/organization did you complete your 40 hours of work with?*
Agency Name
Date of hire:*

MonthDayYear
Date
Full name of your direct manager:*

First NameLast Name
Email address of your direct manager:*
Phone number of your direct manager:*

Area CodePhone Number
Please upload documentation that you worked forty (40) hours for a home care, home health, or hospice agency. This can be a picture of a paystub or a written letter from your employer verifying you completed the 40 hours.*

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Are you currently employed with this same agency?*

YesNo
If no, can you please explain the reason for leaving?
Were you assigned a Mentor?*

YesNoUnsure
Approximately, how many hours did you spend with your mentor?*

Evidence of Training
Please upload your My Learning Center certificates or a picture of your dashboard showing successful competition of all training videos.*

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Please upload your face-to-face training certificate signed by an RN verifying your 16 hours of classroom training.*

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Grant Satisfaction Survey
Thank you for participating in our mentorship and training program. Your feedback is valuable to us and will help us improve the program.

How effective do you feel the grant program was in preparing you for a career in home-based healthcare?*

	1	2	3	4	5

1 is Not Effective at All, 5 is Extremely Effective

How would you rate the agency that you completed your 40 hours of work experience? *

	1	2	3	4	5

1 is Poor, 5 is Excellent

How satisfied were you with the content in the My Learning Center training videos?*

	1	2	3	4	5

1 is Very Dissatisfied, 5 is Very Satisfied

How satisfied were your face to face classroom training?*

	1	2	3	4	5

1 is Very Dissatisfied, 5 is Very Satisfied

Did you receive a job offer through the grant program?*

Yes, I used the PHA Job Board to find a jobNo, I was newly employed and was referred to the program

How much did this grant help you in advancing your career?*

	1	2	3	4	5

1 is No impact, 5 is Extremely Impactful

How likely are you to participate in future training programs related to the home-based healthcare field?*

	1	2	3	4	5

1 is Not Likely, 5 is Very Likely

How likely are you to continue working in the home-based healthcare field?*

	1	2	3	4	5

1 is Not Likely, 5 is Very Likely

On a scale of 1 to 10, how likely are you to recommend the grant program to a friend, family member, or colleague?*

	1	2	3	4	5	6	7	8	9	10

1 is Not Likely, 10 is Very Likely

Overall, how would you rate the HHA Learning Track of the Grant Program?*

5 stars = the best

Authorization for Direct Deposit
Authorization for Direct Deposit

This authorizes Pennsylvania Homecare Association to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my account indicated below and to other accounts I identify in the future (the "Account"). This authorizes the financial institution holding the account to post all such entries.
Bank Account Type (choose one)*

CheckingSavings
Name of Bank*
Bank Routing #*
VERIFY IF CORRECT
Re-enter Bank Routing #*
VERIFY IF CORRECT
Bank Account #*
VERIFY IF CORRECT
Re-enter Bank Account #*
VERIFY IF CORRECT
Term of Authorization

This authorization will be in effect until the Pennsylvania Homecare Association receives a written termination notice from myself and has a reasonable opportunity to act on it.
Authorized signature*

Clear
Name*

First NameLast Name
Phone number*

Area CodePhone Number
Email*
example@example.com
Authorization date *

MonthDayYear
Date
Bank Check / Bank info form*

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Upload image of voided check or bank deposit info Cancelof

Department of Labor Satisfaction Survey
The Department of Labor and Industry is asking for participation in their grant completion questionnaire regarding this grant program.

The purpose of the survey is to gather insights on your current experiences and perceptions of your job and employer. Your feedback will be valuable in assessing your satisfaction, as well as identifying strengths and potential areas for improvement in your workplace.

Please click here to be redirected to the Direct Care Worker Job Quality - Grant Completion Questionnaire. Please note, this will open in a new tab for you to complete once you submit your application.

Participation is strongly encouraged.
I have received the Department of Labor and Industry's Direct Care Worker Job Quality - Grant Completion Questionnaire.*

Yes, I received the link to participate.
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Home Health Aide (HHA) Grant Completion & Direct Deposit Form