Employment Application 1-Link

APPLICATION:

CONFIDENTIAL DOCUMENTS:

DOCUMENTATION:

Affidavit of Background ScreeningBackground Screening Privacy PolicyProfessional License (if applicable)License Verification (if applicable)Liability Insurance (if applicable)W-9Automobile Insurance (if applicable)

CERTIFICATES:

HIVCPRAlzheimers

COMPETENCY:

CompetenciesPerformance Evaluations

¹Required for individuals with direct patient contact
²Required when company working with state or federal program.

Desired Position:*

CNAHHAOther

Please type the 'Other' option here*

Date:*

Last:*

First:*

MI:*

SS#:*

Street:*

City:*

State:*

Zip:*

Home:*

Cell:*

Date of Birth:*

Email Address:*

Are you currently employed?*

YesNo

School Name*

From MO./YR.:*

Completed*

School Name*

From MO./YR.:*

Completed*

Professional Licensure(s)/Registration(s)/Certification(s) Name:*

State:*

Number:*

Yr. Received:*

Date of Expiration:*

Professional Licensure(s)/Registration(s)/Certification(s) Name:

State:

Number:

Yr. Received:

Date of Expiration:*

From:

To:

Employer’s Name:

Job Title:

Employer’s Address:

Position Responsibilities:

Supervisor’s Name & Title:

Phone No.:

Reason for Leaving:

May we contact this employer?

YesNo

From:

To:

Employer’s Name:

Job Title:

Employer’s Address:

Position Responsibilities:

Supervisor’s Name & Title:

Phone No.:

Reason for Leaving:

May we contact this employer?

YesNo

Have you ever been convicted of any law violation (except a minor traffic violation)?*

YesNo

If yes, give details.*

Are you now or do you expect to be engaged in any other business or employment?*

YesNo

If yes, when?*

Do you have a valid driver’s license?*

YesNo

Driver’s License Number:*

State of License:*

Class of License:*

Have you had your driver’s license suspended or revoked in the last three years?*

YesNo

Have you worked under any other name?*

YesNo

If yes, give names:*

Are you presently employed?*

YesNo

May we contact your current employer?*

YesNo

Have you ever been fired or asked to resign?*

YesNo

If yes, please explain:*

I certify that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation, willful omission, false or misleading information is grounds for rejection of this application form, refusal to hire, withdrawal of an offer of Employment, or immediate discharge whenever discovered. ELITE CARE HOME HEALTH AGENCY, LLC authorized to conduct investigations, including verification of prior employment history and education. I also understand that employment is dependent upon receipt of acceptable employment references and satisfactory completion of pre-employment health screening which will include illicit drug and alcohol testing and provision of documents required by the Immigration reform and Control Act of 1986. ELITE CARE HOME HEALTH AGENCY, LLC does not discriminate against any qualified person because of age, race, color, religion, sex, national origin, disability, sexual orientation, or any other applicable status protected by state or local law. By signing this application, I acknowledge that an offer of employment at ELITE CARE HOME HEALTH AGENCY, LLC should not be interpreted as an offer of continued or permanent employment. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

Employee Signature:*

Date:*

Type of Transportation you have / will use for Client Visits:*

Do you have any allergies that would affect your work?*

YesNo

Are you willing to work in a home with cats?*

YesNo

Are you willing to work in a home with dogs?*

YesNo

Do you have a problem working with a client who smokes?*

YesNo

How many hours are you willing to work per week?*

Locations willing to work:*

Please Check (✓) the Day and Time of the Week You ARE AVAILABLE*

	SUN	MON	TUE	WED	THUR	FRI	SAT
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Overnight

Company Name:

Telephone:

Address:

City:

State:

Zip:

Applicant Name:

Employment Start Date:

Employment End Date:

Status:

Present

Position/Title:

Reason for Leaving:

The above-named applicant has applied for a position at ELITE CARE HOME HEALTH AGENCY, LLC and has given your name as a previous or current employer. Please complete this reference request and submit it to us. Thank you for your prompt reply.

I, , on authorized and request my former/current employer, person given as a reference to answer all questions asked, and give all information requested concerning my work performance, character, and job-related skills.

FOR OFFICE USE ONLY

	Excellent	Above Average	Average	Unsatisfactory (comment)
Quality of work
Time and attendance
Initiative/motivation
Relationship with coworker/supervisor
Job knowledge

Would you rehire this person?

YesNo

If no, why?

Other comments:

Supervisor Signature:

Date:

Company Name:

Telephone:

Address:

City:

State:

Zip:

Applicant Name:

Employment Start Date:

Employment End Date:

Status:

Present

Position/Title:

Reason for Leaving:

The above-named applicant has applied for a position at ELITE CARE HOME HEALTH AGENCY, LLC and has given your name as a previous or current employer. Please complete this reference request and submit it to us. Thank you for your prompt reply.

I, , on authorized and request my former/current employer, person given as a reference to answer all questions asked, and give all information requested concerning my work performance, character, and job-related skills.

FOR OFFICE USE ONLY

	Excellent	Above Average	Average	Unsatisfactory (comment)
Quality of work
Time and attendance
Initiative/motivation
Relationship with coworker/supervisor
Job knowledge

Would you rehire this person?

YesNo

If no, why?

Other comments:

Supervisor Signature:

Date:

Company Name:

Telephone:

Address:

City:

State:

Zip:

Applicant Name:

Employment Start Date:

Employment End Date:

Status:

Present

Position/Title:

Reason for Leaving:

The above-named applicant has applied for a position at ELITE CARE HOME HEALTH AGENCY, LLC and has given your name as a previous or current employer. Please complete this reference request and submit it to us. Thank you for your prompt reply.

I, , on authorized and request my former/current employer, person given as a reference to answer all questions asked, and give all information requested concerning my work performance, character, and job-related skills.

FOR OFFICE USE ONLY

	Excellent	Above Average	Average	Unsatisfactory (comment)
Quality of work
Time and attendance
Initiative/motivation
Relationship with coworker/supervisor
Job knowledge

Would you rehire this person?

YesNo

If no, why?

Other comments:

Supervisor Signature:

Date:

Name:*

Relationship:*

Address:*

City:*

State:*

Zip:*

Telephone:*

Alt. Telephone:*

Name:*

Relationship:*

Address:*

City:*

State:*

Zip:*

Telephone:*

Alt. Telephone:*

Name:

Relationship:

Address:

City:

State:

Zip:

Telephone:

Alt. Telephone:

Name:

Relationship:*

Address:

City:

State:

Zip:

Telephone:

Alt. Telephone:

APPROVED BY:

TITLE:

EFFECTIVE DATE:

DATE REVIEWED:

It is the policy of ELITE CARE HOME HEALTH AGENCY, LLC that all its employees be free of the influence of alcohol and drugs. All employees must be fit for the duty physically and mentally, as is necessary to perform work in a safe and competent manner.

Possession, trading, manufacture and sale of illegal drugs or alcohol on the job is therefore a violation of this policy.

Also, it is a violation of this policy to work under the influence of illegal drugs or alcohol.
Violations of this policy are subject to disciplinary action up to and including termination.

I, certify that I am not under the influence of drugs or alcohol, nor will I use or possess in anyway controlled substances (marijuana, heroin, cocaine, crack, hash etc.) I understand that these examples do not cover all controlled substances. Failure to comply with this agreement may result in termination of my employment with ELITE CARE HOME HEALTH AGENCY LLC. I have been briefed and fully understand ELITE CARE HOME HEALTH AGENCY LLC drug and alcohol policy and I agree to fully comply with the provisions herein.

Employee Signature:*

Date:*

I, the undersigned, understand the importance of observing strict confidentiality policies. Therefore, I agree not to discuss / release any information obtained within the agency, any ELITE CARE HOME HEALTH AGENCY, LLC client, their medical records, or any client’s condition with any individual not directly associated with the client. I also agree that any information that is released regarding the client or the client’s record will only be done with proper authorization and / or in accordance with established agency policy for the release of the information.

My signature on this document indicates that I understand and agree to abide by the aforementioned policies, and that any breach in the aforementioned policies will result in implementation of the Disciplinary procedure up to and including possible IMMEDIATE DISMISSAL from employment at ELITE CARE HOME HEALTH AGENCY, LLC.

Employee Signature:*

Date:*

Agency Representative Title:

Agency Representative Signature:

Date:

I have been formally instructed in maintaining the confidentiality and privacy of the medical records and understand that the medical information regarding the patient may not be discussed with anyone, either inside or outside the company (except as needed to conduct the business of the day).

I understand that no medical records are to be removed from the company unless a “Release of Information” form has been completed and signed by the patient. It is my understanding that such discussion of release of information is cause for dismissal.

I have been formally instructed in the policies and procedures of the company regarding full compliance with all HIPAA regulations.

I understand that I am being assigned patients which belong to the company and will not attempt to influence the patients to which I am assigned in an attempt to lure them away from the contract with the company.

Signature:*

Date:*

PLEASE MARK ONE:*

I understand that due to my occupational exposure to blood or other 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 hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

ORI decline to receive a Hepatitis B Vaccination because I have been previously vaccinated. I agree to provide the company with a record of the vaccination and any antibody testing that may have been performed.

Signature:*

Date:*

My employer or affiliated health facility, (the "Organization"), has recommended that I receive influenza vaccination to protect the patients I serve.

I acknowledge that I am aware of the following facts:

Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
Influenza vaccination is recommended for me and all other healthcare workers 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, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.
I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t change, 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
- my coworkers
- my family
- my community

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:

I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available.

I have read and fully understand the information on this declination form

Signature:*

Date:*

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.

Last Name (Family Name):*

First Name (Given Name):*

Middle Initial (if any):

Other Last Names Used (if any):

Address (Street Number and Name):*

Apt. Number (if any):

City or Town:*

State:*

ZIP Code:*

Date of Birth (mm/dd/yyyy):*

U.S. Social Security Number:*

Employee's Email Address:

Employee's Telephone Number:

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status*

A citizen of the United StatesA noncitizen national of the United StatesA lawful permanent residentA noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)

Enter USCIS or A-Number:*

Authorized to work until:*

exp. date, if any

If you check Item Number 4., enter one of these:

USCIS A-Number:

Form I-94 Admission Number:

Foreign Passport Number:

Country of Issuance:

Signature of Employee:*

Today's Date (mm/dd/yyyy):*

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

Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions.

List A

	Data
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date (if any)
Document Title 2 (if any)
Issuing Authority
Document Number (if any)
Expiration Date (if any)
Document Title 3 (if any)
Issuing Authority
Document Number (if any)
Expiration Date (if any)

OR List B

	Data
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date (if any)

AND List C

	Data
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date (if any)

Additional Information:

Checkbox:

Check here if you used an alternative procedure authorized by DHS to examine documents

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

First Day of Employment:

Last Name, First Name and Title of Employer or Authorized Representative

Signature of Employer or Authorized Representative:

Today's Date (mm/dd/yyyy):

Employer's Business or Organization Name:

Employer's Business or Organization Address, City or Town, State, ZIP Code:

For reverification or rehire, complete Supplement B, Reverification and Rehire.

LISTS OF ACCEPTABLE DOCUMENTS
All documents containing an expiration date must be unexpired.
* Documents extended by the issuing authority are considered unexpired.
Employees may present one selection from List A or acombination of one selection from List B and one selection from List C.
Examples of many of these documents appear in the Handbook for Employers (M-274).

LIST A
Documents that Establish Both Identity and Employment Authorization

U.S. Passport or U.S. Passport Card
Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa
Employment Authorization Document that contains a photograph (Form I-766)
For an individual temporarily authorized to work for a specific employer because of his or her status or parole:
1. Foreign passport; and
2. Form I-94 or Form I-94A that has the following:
  1. The same name as the passport; and
  2. An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

OR LIST B
Documents that Establish Identity

Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
School ID card with a photograph
Voter's registration card
U.S. Military card or draft record
Military dependent's ID card
U.S. Coast Guard Merchant Mariner Card
Native American tribal document
Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

School record or report card
Clinic, doctor, or hospital record
Day-care or nursery school record

AND LIST C
Documents that Establish Employment Authorization

A Social Security Account Number card, unless the card includes one of the following restrictions:
1. NOT VALID FOR EMPLOYMENT
2. VALID FOR WORK ONLY WITHINS AUTHORIZATION
3. VALID FOR WORK ONLY WITHDHS AUTHORIZATION
Certification of report of birth issued by theDepartment of State (Forms DS-1350,FS-545, FS-240)
Original or certified copy of birth certificateissued by a State, county, municipalauthority, or territory of the United Statesbearing an official seal
Native American tribal document
U.S. Citizen ID Card (Form I-197)
Identification Card for Use of ResidentCitizen in the United States (Form I-179)
Employment authorization documentissued by the Department of HomelandSecurity

For examples, see Section 7 and Section 13 of the M-274 onuscis.gov/i-9-central.

The Form I-766, EmploymentAuthorization Document, is a List A, Item Number 4. document, not a List Cdocument.

Acceptable Receipts
May be presented in lieu of a document listed above for a temporary period.
For receipt validity dates, see the M-274.

Receipt for a replacement of a lost, stolen, or damaged List A document.
Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the individual.
Form I-94 with RE notation or refugee stamp issued to a refugee.

OR Receipt for a replacement of a lost, stolen, or damaged List B document.

Receipt for a replacement of a lost, stolen, or damaged List C document.

Last Name (Family Name) from Section 1:

First Name (Given Name) from Section 1:

Middle initial (if any) from Section 1:

Instructions: This supplement must be completed by any preparer and/or translator who assists an employee in completing Section 1 of Form I-9. The preparer and/or translator must enter the employee's name in the spaces provided above. Each preparer or translator must complete, sign, and date a separate certification area. Employers must retain completed supplement sheets with the employee's completed Form I-9.

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator:

Date (mm/dd/yyyy):

Last Name (Family Name):

First Name (Given Name):

Middle Initial (if any):

Address (Street Number and Name):

City or Town:

State:

ZIP Code:

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator:

Date (mm/dd/yyyy):

Last Name (Family Name):

First Name (Given Name):

Middle Initial (if any):

Address (Street Number and Name):

City or Town:

State:

ZIP Code:

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator:

Date (mm/dd/yyyy):

Last Name (Family Name):

First Name (Given Name):

Middle Initial (if any):

Address (Street Number and Name):

City or Town:

State:

ZIP Code:

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator:

Date (mm/dd/yyyy):

Last Name (Family Name):

First Name (Given Name):

Middle Initial (if any):

Address (Street Number and Name):

City or Town:

State:

ZIP Code:

Last Name (Family Name) from Section 1:

First Name (Given Name) from Section 1:

Middle initial (if any) from Section 1:

Instructions: This supplement replaces Section 3 on the previous version of Form I-9. Only use this page if your employee requires reverification, is rehired within three years of the date the original Form I-9 was completed, or provides proof of a legal name change. Enter the employee's name in the fields above. Use a new section for each reverification or rehire. Review the Form I-9 instructions before completing this page. Keep this page as part of the employee's Form I-9 record. Additional guidance can be found in the Handbook for Employers: Guidance for Completing Form I-9 (M-274)

Date of Rehire (if applicable):

Last Name (Family Name):

First Name (Given Name):

Middle Initial:

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title:

Document Number (if any):

Expiration Date (if any):

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative:

Today's Date (mm/dd/yyyy):

Additional Information (Initial and date each notation.):

Checkbox:

Check here if you used an alternative procedure authorized by DHS to examine documents

Date of Rehire (if applicable):

Last Name (Family Name):

First Name (Given Name):

Middle Initial:

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title:

Document Number (if any):

Expiration Date (if any):

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative:

Today's Date (mm/dd/yyyy):

Additional Information (Initial and date each notation.):

Checkbox:

Check here if you used an alternative procedure authorized by DHS to examine documents

Date of Rehire (if applicable):

Last Name (Family Name):

First Name (Given Name):

Middle Initial:

Reverification: If the employee requires reverification, your employee can choose to present any acceptable List A or List C documentation to show continued employment authorization. Enter the document information in the spaces below.

Document Title:

Document Number (if any):

Expiration Date (if any):

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented documentation, the documentation I examined appears to be genuine and to relate to the individual who presented it.

Name of Employer or Authorized Representative:

Today's Date (mm/dd/yyyy):

Additional Information (Initial and date each notation.):

Checkbox:

Check here if you used an alternative procedure authorized by DHS to examine documents

Authority: This form may be used by all employees to comply with:

the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND
the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which requires proof of compliance with level 2 screening standards that have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S., or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S., and in accordance with the standards in Section 408.809(2), F.S., if that agency is not currently implemented in the Care Provider Background Screening Clearinghouse.

This form must be maintained in the employee’s personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application.

Employee/Contractor Name:*

Health Care Provider/ Employer Name:

Address of Health Care Provider:

I hereby attest to meeting the requirements for employment and that I have not been arrested for or been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:

Criminal offenses found in section 435.04, F.S.

Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.
Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.
Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.
Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
Section 782.04, relating to murder.
Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.
Section 782.071, relating to vehicular homicide
Section 782.09, relating to killing of an unborn quick child by injury to the mother.
Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.
Section 784.011, relating to assault, if the victim of the offense was a minor.
Section 784.03, relating to battery, if the victim of the offense was a minor.
Section 787.01, relating to kidnapping.
Section 787.02, relating to false imprisonment.
Section 787.025, relating to luring or enticing a child.
Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.
Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person.
Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.
Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.
Section 794.011, relating to sexual battery.
Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority.
Section 794.05, relating to unlawful sexual activity with certain minors.
Chapter 796, relating to prostitution.
Section 798.02, relating to lewd and lascivious behavior.
Chapter 800, relating to lewdness and indecent exposure.
Section 806.01, relating to arson.
Section 810.02, relating to burglary.
Section 810.14, relating to voyeurism, if the offense is a felony.
Section 810.145, relating to video voyeurism, if the offense is a felony.
Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.
Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.
Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.
Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.
Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.
Section 826.04, relating to incest.
Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child
Section 827.04, relating to contributing to the delinquency or dependency of a child.
Former s. 827.05, relating to negligent treatment of children.
Section 827.071, relating to sexual performance by a child.
Section 843.01, relating to resisting arrest with violence.
Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.
Section 843.12, relating to aiding in an escape.
Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.
Chapter 847, relating to obscene literature.
Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang.
Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor.
Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.
Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.
Section 944.40, relating to escape.
Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.
Section 944.47, relating to introduction of contraband into a correctional facility.
Section 985.701, relating to sexual misconduct in juvenile justice programs.
Section 985.711, relating to contraband introduced into detention facilities.

The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction.

Criminal offenses found in section 408.809(4), F.S.

Any authorizing statutes, if the offense was a felony.
This chapter, if the offense was a felony.
Section 409.920, relating to Medicaid provider fraud.
Section 409.9201, relating to Medicaid fraud.
Section 741.28, relating to domestic violence.
Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.
Section 817.234, relating to false and fraudulent insurance claims.
Section 817.481, relating to obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony.
Section 817.50, relating to fraudulently obtaining goods or services from a health care provider.
Section 817.505, relating to patient brokering.
Section 817.568, relating to criminal use of personal identification information.
Section 817.60, relating to obtaining a credit card through fraudulent means.
Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
Section 831.01, relating to forgery.
Section 831.02, relating to uttering forged instruments.
Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.
Section 831.30, relating to fraud in obtaining medicinal drugs.
Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony
Section 895.03, relating to racketeering and collection of unlawful debts.
Section 896.101, relating to the Florida Money Laundering Act

I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA)
Date of Decision:

I have been granted an Exemption from Disqualification through the Florida Department of Health.
Date of Decision:

**A copy of the Exemption from Disqualification decision letter must be attached**

If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.

Purpose of Prior Screening:
Date of Prior Screening:
Screening conducted by:
Agency for Healthcare Administration
Department of Health
Agency for Persons with Disabilities
Department of Elder Affairs
Department of Financial Services Department of Children and Family Services

Attestation
Under penalty of perjury, I, , hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.

Title:*

Employee/Contractor Signature:*

Date:*

I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse.

I understand and agree that I will read and comply with the guidelines contained in the privacy policies.

Employee/Contractor Name (Printed):*

Employee/Contractor Signature*

Date:*

NOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL RECORD RESULTS WILL BECOME PART OF THE CARE PROVIDER BACKGROUND SCREENING CLEARINGHOUSE

NOTICE OF:

SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES,
RETENTION OF FINGERPRINTS,
PRIVACY POLICY, AND
RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD

This notice is to inform you that when you submit a set of fingerprints to the Florida Department of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history records that may pertain to you, the results of that search will be returned to the Care Provider Background Screening Clearinghouse. By submitting fingerprints, you are authorizing the dissemination of any state and national criminal history record that may pertain to you to the Specified Agency or Agencies from which you are seeking approval to be employed, licensed, work under contract, or to serve as a volunteer, pursuant to the National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. "Specified agency" means the Department of Health, the Department of Children and Family Services, the Division of Vocational Rehabilitation within the Department of Education, the Agency for Health Care Administration, the Department of Elder Affairs, the Department of Juvenile Justice, and the Agency for Persons with Disabilities when these agencies are conducting state and national criminal history background screening on persons who provide care for children or persons who are elderly or disabled. The fingerprints submitted will be retained by FDLE and the Clearinghouse will be notified if FDLE receives Florida arrest information on you.

Your Social Security Number (SSN) is needed to keep records accurate because other people may have the same name and birth date. Disclosure of your SSN is imperative for the performance of the Clearinghouse agencies’ duties in distinguishing your identity from that of other persons whose identification information may be the same as or similar to yours.

Licensing and employing agencies are allowed to release a copy of the state and national criminal record information to a person who requests a copy of his or her own record if the identification of the record was based on submission of the person’s fingerprints. Therefore, if you wish to review your record, you may request that the agency that is screening the record provide you with a copy. After you have reviewed the criminal history record, if you believe it is incomplete or inaccurate, you may conduct a personal review as provided in s. 943.056, F.S., and Rule 11C8.001, F.A.C. If national information is believed to be in error, the FBI should be contacted at 304-625-2000. You can receive any national criminal history record that may pertain to you directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the right to obtain a prompt determination as to the validity of your challenge before a final decision is made about your status as an employee, volunteer, contractor, or subcontractor.

Until the criminal history background check is completed, you may be denied unsupervised access to children, the elderly, or persons with disabilities.

The FBI’s Privacy Statement follows on a separate page and contains additional information.

PRIVACY STATEMENT

Authority: The FBI’s acquisition, preservation, and exchange of information requested by this form is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include numerous Federal statutes, hundreds of State statutes pursuant to Pub.L. 92-544, Presidential executive orders, regulations and/or orders of the Attorney General of the United States, or other authorized authorities. Examples include, but are not limited to: 5 U.S.C. 9101; Pub.L. 94-29; Pub.L. 101-604; and Executive Orders 10450 and 12968. Providing the requested information is voluntary; however, failure to furnish the information may affect timely completion or approval of your application.

Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

Principal Purpose: Certain determinations, such as employment, security, licensing, and adoption, may be predicated on fingerprint based checks. Your fingerprints and other information contained on (and along with) this form may be submitted to the requesting agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing the submitted information to available records in order to identify other information that may be pertinent to the application. During the processing of this application, and for as long hereafter as may be relevant to the activity for which this application is being submitted, the FBI may disclose any potentially pertinent information to the requesting agency and/or to the agency conducting the investigation. The FBI may also retain the submitted information in the FBI’s permanent collection of fingerprints and related information, where it will be subject to comparisons against other submissions received by the FBI. Depending on the nature of your application, the requesting agency and/or the agency conducting the application investigation may also retain the fingerprints and other submitted information for other authorized purposes of such agency(ies).

Routine Uses: The fingerprints and information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b)) and all applicable routine uses as may be published at any time in the Federal Register, including the routine uses for the FBI Fingerprint Identification Records System (Justice/FBI-009) and the FBI’s Blanket Routine Uses (Justice/FBI-BRU). Routine uses include, but are not limited to, disclosures to: appropriate governmental authorities responsible for civil or criminal law enforcement, counterintelligence, national security or public safety matters to which the information may be relevant; to State and local governmental agencies and nongovernmental entities for application processing as authorized by Federal and State legislation, executive order, or regulation, including employment, security, licensing, and adoption checks; and as otherwise authorized by law, treaty, executive order, regulation, or other lawful authority. If other agencies are involved in processing this application, they may have additional routine uses.

Additional Information: The requesting agency and/or the agency conducting the application investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice.

1. Name (as shown on your income tax return):*

2. Business name/disregarded entity name, if different from above:

3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes:*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust estateLimited liability company

Require the tax classification (C=C corporation, S=S corporation, P=Partnership)

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.Other

Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)*

Please type the 'Other' option here:*

Exempt payee code (if any):

Exemption from FATCA reporting code (if any):

(Applies ta accounts maintained outside the U.S.)

5. Address (number, street and apt. or suite no.):

6. City, state, and ZIP code:

7. List account number(s) here (optional) :

Requester's name and address (optional):

Part I: Taxpayer Identification Number
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this Is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number:

OR Employer identification number

Part II: Certification
Under penalties of perjury, I certify that:

The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
I am a U.S. citizen or other U.S. person (defined below); and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign Here: Signature of U.S. Person:*

Date:*

General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

Form 1099-INT (interest earned or paid)
Form 1099-DIV (dividends, including those from stocks or mutual funds)
Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
Form 1099-S (proceeds from real estate transactions)
Form 1099-K (merchant card and third party network transactions)
Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
Form 1099-C (canceled debt)
Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

The parties to this contract, * (herein “COMPANY”) and * (herein “CONTRACTOR”) hereby agree as follows:

CONTRACTOR is a duly trained Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant, Home Health Aide, or Homemaker/Companion as required by the laws of the State of Florida.
CONTRACTOR wishes to be registered with COMPANY for the purpose of receiving referrals from individuals or organizations requesting home care servicesfrom CONTRACTOR as defined and authorized under Florida law.
COMPANY agrees to:
1. Provide CONTRACTOR access to organization’s Policy and Procedures Manual, the terms of which are hereby incorporated herein and made a part of this Agreement.
2. Maintain a record, as required by Florida law, required CONTRACTOR documentation (including but not limited to, training requirements, background screening, health screening, etc.)
3. Refer to CONTRACTOR appropriate requests for home care services when an individual or organization contacts COMPANY for home care services for which CONTRACTOR qualifies based on skill level, location, pay rate, etc. CONTRACTOR will choose whether to accept the referral or decline it. (CONTRACTOR’S desired payment rates, location, etc. shall be as stated in the attached Addendum A, which may be revised, from time to time, subject to the agreement of both parties.
4. Collect the payment for services on CONTRACTOR’s behalf and pay CONTRACTOR for services provided each week. Payments will be made for the previous week worked. Timesheets will be due every Monday to allow for checks to be drafted.
5. Maintain a record, as required by Florida law, on each patient who receives services from CONTRACTOR.
CONTRACTOR agrees to:
1. Follow COMPANY’s Policies and Procedures. CONTRACTOR specifically acknowledges being informed of Policies and Procedures delineating state requirements for among other things, recordkeeping, caregiver qualifications, documentation to be kept on file, contact numbers and emergency management plan.
2. Abide by the terms and provisions in the Nurse Registry Licensure law, Chapter 400.506, F.S. and Rule 59A-18.
3. Not solicit for home care CONTRACTOR services any client to whom CONTRACTOR is referred by COMPANY until ninety (90) days has passed since the termination of CONTRACTOR’s services to the client. In the event CONTRACTOR violates this non-solicitation clause, both parties hereby agree that CONTRACTOR shall pay the sum of five thousand dollars ($5,000) to COMPANY as liquidated damages for each violation.
4. Execute a Business Associate Contract if required under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
5. When services are to be terminated the client shall be notified of the date of termination and the reason for termination, and these shall be documented in the client's record.
6. Payment for services will be negotiated with client on a case by case basis and will be accepted by CONTRACTOR as per Addendum B to this Agreement.
INDEPENDENT CONTRACTOR RELATIONSHIP. Both COMPANY and CONTRACTOR understand and agree that CONTRACTOR is an independent contractor and is solely responsible for CONTRACTOR’s federal tax obligations, including any required payments for self-employment estimated taxes; and any required or desired insurance coverages. COMPANY does not provide fringe benefits to independent contractors. COMPANY shall issue CONTRACTOR an IRS form 1099 each calendar year.
CIVIL RIGHTS REQUIREMENTS. Both parties agree to comply with federal and state civil rights requirements and not unlawfully discriminate because of race, color, religion, sex, national origin, age, handicap, or marital status.
TERM. This initial term of this Agreement is for one year from the effective date written below and this Agreement shall automatically renew for successive one-year terms, until terminated by either party. Either party may terminate this Agreement by giving the other party thirty (30) days written notice of intent to terminate. Both parties specifically agree that any outstanding ninety-day period for non-solicitation, described in section 4 above, shall survive termination date of this Agreement and remain in full force and effect until the ninety-day period(s) has expired.
TERMINATION FOR CAUSE. This Agreement may be terminated immediately upon material breach of any term of this Agreement by either of the parties.
NOTICES. Any written notice required or permitted to be given hereunder shall be to the addresses listed below and delivered by: (i) registered or certified mail, return receipt requested, postage prepaid; or (ii) nationally recognized overnight courier service. All such notices shall be effective upon receipt.

COMPANY:

CONTRACTOR:

APPLICABLE LAW. This Agreement will be governed by the laws of the State of Florida and Venue shall lie in Dade County, Florida.
RESOLVING DISPUTES. In the event a dispute shall arise between the parties to this agreement, the parties agree to participate in at least four hours of mediation in order to attempt to resolve the dispute. The parties agree to share equally in the costs of the mediation. If a dispute arises under this agreement which cannot be resolved through mediation and court action is necessary to enforce this agreement, the prevailing party shall be entitled to reasonable attorney fees, costs and expenses in addition to any other relief to which he or she may be entitled.
ENTIRE AGREEMENT. This is the entire written Agreement between the parties and any amendments shall be in writing and signed by both parties before becoming effective. If any clause is found to be unlawful all other clauses shall remain in full force and effect.

Printed Name:

Title:

Signature:

Date:

Printed Name:*

Signature:*

Date:*

ELITE CARE HOME HEALTH AGENCY, LLC shall attempt to refer to CONTRACTOR appropriate requests for home care services based on information provided by CONTRACTOR regarding skill level, area of service, requested pay rate, etc.

Requested Rates of Pay Between $* per hour to $* per hour

Limitations on service areas:

Limitations on services to be provided:

Other information (no pets/languages/etc):

Title:

Printed Name:

Signature:

Date:

Printed Name:*

Signature:*

Date:*

Prepared by the Florida Health Care Association with the assistance of the Alzheimer Resource Center of Tallahassee, Florida to meet the statutory requirement of 400.4785(1) (a) F.S.

History
Alzheimer’s disease (AD) was first discovered in 1906 by a German doctor named Alois Alzheimer. It is a disorder of the brain, causing damage to brain tissue over a period of time. The disease can linger from 2 to 25 years before death results. AD is a progressive, debilitating and eventually fatal neurological illness affecting an estimated 4-5 million Americans. It is the most common form of dementing illness.

Alzheimer’s disease is characterized clinically by early memory impairment followed by language and perceptual problems. This disease can affect anyone - it has no economic, social, racial or national barriers.

Causes
There is no one cause for Alzheimer’s disease. AD may be sporadic or passed through the genetic make-up. The disease causes gradual death of brain tissue due to biochemical problems inside individual brain cells. The symptoms are progressive, but there is great variation in the rate of change from one person to another. Although in the early stages of Alzheimer’s the victim may appear completely healthy, the damage is slowly destroying the brain cells. The hidden process damages the brain in several ways:

Patches of brain cells degenerate (neuritic plaques)
Nerve endings that transmit messages become tangled (neurofibrillary tangles)
There is a reduction in acetylcholine, an important brain chemical (neurotransmitter)
Spaces in the brain (ventricles become larger and filled with granular fluid)
The size and shape of the brain alters - the cortex appears to shrink and decay

Understandably, as the brain continues to degenerate, there is a comparable loss in mental functioning. Since the brain controls all of our bodily functions, an Alzheimer victim in the later stages will have difficulty walking, talking, swallowing and controlling bladder and bowel functions. They become quite frail and prone to infections such as pneumonia.

Dementia vs. Normal Aging
As a person grows older, he/she worries that forgetting the phone number of a best friend must mean he/she is becoming demented or getting Alzheimer’s disease. Forgetfulness due to aging or increased stress is not normal aging and is not dementia.
“Dementia” is an encompassing term for numerous forms of memory loss. There are many types of dementia such as Alzheimer’s disease, Multi-Infarct dementia or Parkinson’s disease. When a person has dementia, he/she will lose the ability to think, reason and remember and will inevitable need assistance with everyday activities such as dressing and bathing. Changes in personality, mood are also symptoms of dementia. Many dementias are treatable and reversible. Alzheimer’s disease is the most common form of untreatable, irreversible dementia.

Alzheimer’s Disease - Stages of Progression
Alzheimer’s Disease can be characterized as having early, middle, and late stages through which the patient gradually progresses, but not at a predictable rate. The range of the course of the disease is 2-25 years. NOTE: Stages very often overlap. Everyone progresses through these stages differently.

First Stage: This is a very subtle stage usually not identified by either the impaired person or the family as the beginning signs of the disease. Subtle changes in memory and language along with some confusion occur at this time. The family usually denies or excuses the performance deficiencies at this stage.

Forgetfulness/memory loss
Impaired judgment
Trouble with routines
Lessening of initiative
Disorientation of time and places
Depression
Fearfulness
Personality change
Apraxia (forgetting how to use tools and equipment)
Anomia (forgetting the right word or name of a person)

Second Stage: As Stage 1 moves onto Stage 2, there is usually a particular significant event which forces the family (and impaired person) to consider that something is really wrong. At this time, they usually go to a doctor to diagnose the problem.

Poor short-term memory
Wandering (searching for home)
Language difficulties
Increased disorientation
Social withdrawal
More spontaneity, fewer inhibitions
Agitation and restlessness, fidgeting, pacing
Developing inability to attach meaning to sensory perceptions: (taste, touch, smell, sight, hearing)
Inability to think abstractly
Severe sleep disturbances and/or sleepiness
Convulsive seizures may develop
Repetitive actions and speech
Hallucinations
Delusions

Third (Final Stage): This stage is the terminal stage and may last for months or years. The individual will eventually need total personal care. They may no longer be able to speak or recognize their closest relatives.

Little or no memory
Inability to recognize themselves in a mirror
No recognition of family or friends
Great difficulty communicating
Difficulty with coordinated movements
Becoming emaciated in spite of adequate diet
Complete loss of control of all body functions
Increased frailty
Complete dependence

COMMON PROBLEMS WITH DEMENTIA

Delusions
Suspiciousness: accusing others of stealing their belongings
People are “out to get them”
Fear that caregiver is going to abandon (results in AD person never leaving caregiver’s side)
Current living space is not “home”

Hallucinations
Seeing or hearing people who are not present

Repetitive actions or questions
They forget they asked the question
Repetitive action such as wringing a towel

Wandering
Pacing
Sundowning: trying to get “home”
Generally feeling uncomfortable or restless
Increased agitation at night

Losing thing/Hiding things
Simply do not remember where items are
Might hide things so that people don’t “steal” them

Inappropriate sexual behavior
Person with AD loses social graces and is only doing what feels good

Agnosia: inability to recognize common people or objects
A wife of forty years will become a stranger to the person with AD, he might even think she is the hired help
Might not recognize a spatula or the purpose of the spatula and/or cannot verbalize the name or purpose of the object

Apraxia: loss of ability to perform purposeful motor movements
Cannot tie a shoe or manipulate buttons on a shirt

Catastrophic reactions
(Causes) AD person often becomes excessively upset and can experience rapidly changing moods. The person becomes overwhelmed due to factors such as too much noise, too many people around, unfamiliar environment, routine change, being asked to many questions, being approached from behind.

(Reactions) AD person may become angry, agitated, weepy, stubborn or physically violent. It is best to attempt to avoid catastrophic reactions rather than dwell on how to handle them.

HANDLING DISTURBING BEHAVIORS
One of the most difficult challenges for caregivers is how to handle some of the disturbing behaviors that Alzheimer’s can cause. Symptoms such as delusion, hallucinations, angry outbursts, suspiciousness, failure to recognize familiar people and places are often the most upsetting behaviors for families. The following points may help in responding to disturbing symptoms.

First, try to understand if there is a precipitating factor causing the behavior. Were there household changes, too much noise or activity, was the daily routine upset? Time of day can also affect behavior (Sundowning). Being aware of these factors can help to better plan activities or anticipate problems.

Keep tasks, directions and routine simple without being condescending
Always give the person plenty of time to respond
Attempt to remain calm and remind yourself that the behavior is due to the disease
Avoid arguing
Write down the answers to frequently asked questions, then remind them to look at the message
Reduce environmental noise: television, radio, too many people talking
Use distraction when unacceptable behavior starts: bring them into a different room, start talking about childhood or another favorite topic, show them magazines, ask them to help you do something like dusting or sweeping
Do not overreact or scold for problem behavior: redirect or distract
Be reassuring with touch, eye contact and tone of voice
Find the familiar: old pipe, favorite chair, family pictures
Avoid denying hallucinations: try non-committal comments like, “You spoke with your mother, I miss my mother too”
Be sure to inform physician of hallucinations, no matter how tame
Restless behavior or pacing is usually unavoidable, however you can make the environment safe by installing locks that are above reach, remove unnecessary obstacles, make sure the person is wearing some kind of identification

Job Title/Position: Nurse
Reports To: Administrator

The Nurse is responsible for the overall direction of home care services. Nurse establishes, implements and evaluates goals and objectives for home care services that meet and promote the standards of quality and contribute to the total organization and philosophy.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES

Coordinates and oversees all direct and indirect client services provided bycaregivers.
Provides help in assessment, planning, implementation and evaluation of client and family/caregiver care to all caregivers as indicated.
Assists the Administrator in the preparation and administration of the organization's budget.
Interprets operational indicators to detect census changes and increases or decreases in volume, which could impact staffing levels, revenues or expenses.
Nurse assists Administrator in hiring, evaluation and termination of organizationpersonnel.
Oversees the maintenance of client records, statistics, reports and records for purposesof evaluation and reporting of organization activities.
Assures proper maintenance of client records in compliance with local, state and federal laws.
Develops, implements and evaluates the orientation program for new organization personnel. Responsible for orientation of new organization personnel, either directly or by delegating to another staff member.
Assists in the development of organization goals. Develops, recommends, and administers Organization policies and procedures.
Assures compliance with all local, state and federal laws regarding licensure and certification of organization personnel.
In the absence of the Administrator, the Nurse will become the acting Administrator and will be vested with authority to act in behalf of the Administrator.
Other duties as assigned by the Administrator.

POSITION QUALIFICATIONS

Registered nurse with current licensure to practice professional nursing in theState.
Experience in a home care preferred.
Demonstrated ability to supervise and direct professional administrativepersonnel.
Ability to market and deal tactfully with customers and the community.
Must be a licensed driver with an automobile that is insured in accordance with state and/or Organization requirements and is in good working order.
Knowledge of business management and governmental regulations.
Has excellent observation, verbal and written communication skills. Will be required to communicate with clients and client’s family members when necessary.
Will be required to be stationary for long periods of time and work at a computer and/or on the phone.
May occasionally have to lift patients/clients if necessary.

Signature:

Date:

Job Title/Position: Licensed Practical Nurse
Reports To: RN

The Licensed Practical Nurse is responsible for providing direct patient care under the supervision of a registered nurse. Responsibilities include following the plan of care, providing treatments, and working collaboratively with the members of the team to help meet positive patient care outcomes.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES

Provides direct patient care as defined in State’s Name Nurse PracticeAct.
Implements plan of care initiated by the registered nurse.
Provides accurate and timely documentation consistent with the plan of care.
Assesses and provides patient and family/caregiver education and information pertinent to diagnosis and plan of care.
Participates in coordination of home health services, appropriately reporting the identified needs for other disciplines to the registered nurse and/or ClinicalSupervisor.
Uses equipment and supplies effectively and efficiently.
Participates in personal and professional growth and development.
Performs other duties as assigned by the registered nurse.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description.

POSITION QUALIFICATIONS

Graduate of an accredited practical nurse or vocational nursing program.
One year experience in hospital or home care setting is preferred.
Currently licensed as a licensed practical nurse or licensed vocational nurse in the state.
Complies with accepted professional standards and practice. Job Title/Position: Licensed Practical/Vocational Nurse
Demonstrates good verbal and written communication, and organization skills.
Must be a licensed driver with an automobile that is insured in accordance with state and organization requirements and is in good working order.
Possesses and maintains current CPR certification.
Prolonged or considerable walking or standing. Able to lift, position, or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching.

Signature:

Date:

Job Title/Position: Certified Nurse Assistant
Reports To: RN

The nurse assistant is a paraprofessional member of the home care team who works under the supervision of a registered nurse or therapist and performs various services for a client as necessary to meet the client’s personal needs, to promote the client’s comfort, and a safe environment. The nurse assistant is responsible for observing clients and reporting/documenting these observations and the services provided.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES
Responsibilities of the nurse assistant include, but are not limited to, the following:

Provident personal care including:
1. Baths B. Back rubs
2. Oral hygiene
3. Shampoos
4. Changing bed linen
5. Assisting the client with dressing and undressing
6. Skin care to prevent breakdown
7. Assisting the client with toileting activities
8. Keeping client’s living area clean and orderly
Planning and preparing nutritious meals.
Assisting in feeding the client, if necessary.
Taking and recording oral, rectal and axillary temperatures, pulse, respiration and blood pressure when ordered (with appropriate completed/demonstrated skillscompetency).
Assisting in ambulation and exercise according to the plan of care.
Performing range of motion and other simple procedures as an extensional therapy service as ordered (with appropriate completed/demonstrated skills competency).
Assisting client in the self-administration of medication.
Doing client’s laundry, as appropriate.
Meeting safety needs of clients and using equipment safely and properly (foot stools, side rails, etc.).
Reporting on client’s condition and significant changes to the assigned supervisorynurse.
Adhering to the Organization's documentation and care procedures and standardsof personal and professional conduct.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description.

POSITION QUALIFICATIONS

Experience in home care preferred.
Completed recognized nurse assistant training program desired.
At least eighteen years of age and is a high school graduate or equivalent.
Ability to read and follow written instructions and document care given.
Displays initiative and able to work with minimal direct supervision.
Empathy for the needs of the ill, frail, and impaired.
Demonstrates tact, patience, and good personal hygiene.
Licensed driver with automobile that is insured in accordance with theOrganization requirements and is in good working order.
Possesses and maintains current CPR certification.
Has excellent observation, verbal and written communication skills. Will be required to communicate with RN, clients and client’s family members when necessary.
May occasionally have to lift patients/clients if necessary.

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Job Title/Position: Home Health Aide
Reports To: RN

The home health aide is a paraprofessional member of the home care team who works under the supervision of a registered nurse and performs various personal care services as necessary to meet the client’s needs. The home health aide is responsible for observing clients, reporting these observations and documenting observations and care performed.

The home health aide will be assigned in a manner that promotes quality, continuity and safety of a client’s care.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES
Responsibilities of the home health aide include, but are not limited to, the following:

Providing personal care including:
1. Baths
2. Back rubs
3. Oral hygiene
4. Shampoos
5. Changing bed linen
6. Assisting clients with dressing and undressing
7. Skin care to prevent breakdown
8. Assisting the client with toileting activities
9. Keeping client’s living area clean and orderly, as appropriate
Planning and preparing nutritious meals.
Assisting in feeding the client, if necessary.
Taking and recording oral, rectal and axillary temperatures, pulse, respiration and blood pressure when ordered (with appropriate completed/demonstrated skillscompetency). Job Title/Position: Home Health Aide
Assisting in ambulation and exercise according to the plan of care.
Performing range of motion and other simple procedures as an extensional therapyservice as ordered (with appropriate completed/demonstrated skills competency).
Assisting client in the self-administration of medication.
Doing client’s laundry, as appropriate.
Meeting safety needs of clients and using equipment safely and properly (foot stools, side rails, etc.).
Reporting on client’s condition and significant changes to the assigned nurse.
Adhering to the Organization's documentation and care procedures and standardsof personal and professional conduct.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description.

POSITION QUALIFICATIONS

Meets the training requirements in accordance with State and Federal laws.
At least 18 years of age.
Ability to read and follow written instructions and document care given.
Self-directing with the ability to work with little direct supervision.
Empathy for the needs of the ill, injured, frail and the impaired.
Possess and maintains current CPR certification.
Demonstrates tact, patience and good personal hygiene.
Licensed driver with automobile that is insured in accordance with Organization requirements and is in good working order.
Has excellent observation, verbal and written communication skills. Will be required to communicate with RN, clients and client’s family members when necessary.
May occasionally have to lift patients/clients if necessary.

{Note: Effective August 14, 1990, a person who has successfully completed a state established or other training program that meets the requirements of CFR 484.36(a) and a competency evaluation program, or state licensure program that meets the requirements of CFR 484.36(b), or a competency evaluation program or state licensure program that meets the requirements of S 484.36(b).}

JOB LIMITATIONS
The home health aide will not function in any manner viewed as the practice of nursing according to the State's Nurse Practice Act. Specifically, the home health aide will not administer medications, take physician's orders or perform procedures requiring the training, knowledge and skill of a nurse, such as sterile techniques.

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Job Title/Position: Companion
Reports To: RN

The Companion provides companionship to those individuals requiring socialization and/or minimum guidance to assure a protected environment and performs home management services within the client’s home.

ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Other duties may be assigned:

Provides companionship by reading, conversation, and listening.
Does household chores that include housekeeping, cooking, shopping assistance, laundry, and other routine household tasks.
Assists patient/client in completing necessary phone calls, letter writing, etc.
Maintains a safe home environment for the client.
Accompanies patient/client on walks, community trips, doctor’s office, bank, etc.
Reminds client to take self-administered medications.
Informs staffing coordinator of any changes in assignment.
Provides emotional support and promotes a sense of well-being.

This job description is not intended to be all-inclusive. The employee will be expected to perform other reasonable related duties as assigned by management.

POSITION QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE
High school diploma or general education degree (GED) or equivalent preferred. Training in the topics related to human development and interpersonal relationships, nutrition, shopping, food storage, use of equipment and supplies, planning and organizing of household tasks and principals of cleanliness and safety.

LANGUAGE SKILLS
Ability to communicate effectively with patient/client, family members, clinical management, and staff. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.

REASONING ABILITY
Ability to apply common sense understanding to carry out simple instructions. Ability to deal with simple problems in the home setting.

OTHER SKILLS AND ABILITIES
Communication skills, light housekeeping skills, cooking, cleaning, and shopping. Good physical and mental health. Caring attitude, tact, patience, and good personal hygiene.

PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Patient home setting, exposure to infectious diseases, automobile.

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Date:

We do not discriminate on the basis of age over 40, race, sex, color, religion, national origin, disability, or any other applicable status protected by state and local law. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

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