RAH-EFG - Application Packet

Application

Page 2
Past Employment or Job Related Volunteer Experience
(Fill out completely, including unpaid positions; listing most recent position first. You may include any verified work performed on a volunteer basis. Do not list any volunteer organizations if participation in such an organization may reveal your race,
national origin, religion or other protected classification).
Past Employment #1
Company or Facility:
Type of Facility:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Compensation (if any):
Dates of Employment:
Reason for leaving?
Health Professionals Only:
Was this an agency or travel assignment?
Specialty Experience:
Past Employment #2
Company or Facility:
Type of Facility:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Compensation (if any):
Dates of Employment:
Reason for leaving?
Health Professionals Only:
Was this an agency or travel assignment?
Specialty Experience:
All employers including your current employer may be contacted to verify the information you provide. May we contact your current employer prior to any offer of employment?

Application

page 3
Education:
High School:
School Name - State - Zip Code
Type of Degree/Certificate
Did you graduate?
Nursing/Tech School:
School Name - State - Zip Code
Type of Degree/Certificate
Did you graduate?
College:
School Name - State - Zip Code
Type of Degree/Certificate
Did you graduate?
Post-College:
School Name - State - Zip Code
Type of Degree/Certificate
Did you graduate?
Other Training:
School Name - State - Zip Code
Type of Degree/Certificate
Did you graduate?
Licensure (Health Professionals Only)
Licenses #1
Type
State
License Number
Expiration Date

MonthDayYear
Date
Active (Yes/No)
Licenses #2
Type
State
License Number
Expiration Date

MonthDayYear
Date
Active (Yes/No)
Licenses #3
Type
State
License Number
Expiration Date

MonthDayYear
Date
Active (Yes/No)
Licenses #4
Type
State
License Number
Expiration Date

MonthDayYear
Date
Active (Yes/No)
Certifications (Health Professionals Only)
Certificate #1
Type
Expiration Date

MonthDayYear
Date
Certificate #2
Type
Expiration Date

MonthDayYear
Date
Certificate #3
Type
Expiration Date

MonthDayYear
Date

Application

Page 4
Work Experience References:
Please list references other than relatives.
Work Experience References #1
Name
Position
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Acquainted
Work Experience References #2
Name
Position
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Acquainted
Work Experience References #3
Name
Position
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Acquainted
Additional Information:
State any additional information regarding job-related skills, experience, and qualification you feel may be helpful to us in considering your application:
PLEASE READ CAREFULLY AND INITIAL:

I acknowledge that I am applying for a position with EFG Home Health, LLC, doing business as Right at Home (the “Company”). The Company is independently owned and operated under a franchise agreement with Right at Home, Inc., and is not related to Right at Home, Inc. I understand that I am applying for a job with the Company and not Right at Home, Inc. Right at Home. Inc. and the Company are not joint employers. The decision to hire me will be made solely by the Company and not Right at Home, Inc.
Initial
I agree that if I am hired by the Company, my employment with the Company is at-will. Employment at-will may be terminated with or without cause and with or without notice at any time by me or the Company. Nothing in this Application, the Company's Employee Handbook or in any document or written or statement and nothing implied from any course of conduct shall limit the Company's or my right to terminate employment at-will. No manager, supervisor, or employee of the Company has any authority to enter into an agreement for employment for any specified period of time or to make any agreement for employment other than at-will. Only the President of the Company has the authority to make any such agreement and then only in writing and signed by the President and me or my authorized representative. I further understand and agree that, except for my at-will employment status, if hired, my wages, hours, working conditions, job assignment(s), and compensation rate(s) will be subject to change by EFG Home Health, LLC.
Initial
I certify that the information contained in this application and any resume I provided or that I furnish during the application process, is true, accurate, complete, and correct to the best of my knowledge. I authorize the investigation of all the information I provided in this application and my resume, unless I have indicated otherwise. I understand that any material misrepresentation, falsification, or omission of information by me may result in the Company refusing to hire me, or if I am hired, to discipline or terminate my employment, regardless of the timing or circumstances of discovery of the false answer(s) or omission(s).
Initial
I acknowledge that due to the nature of the Company’s business, attendance and punctuality are essential requirements of every job and that poor attendance or tardiness may result in disciplinary action or termination in accordance with applicable law.
Initial
I authorize the references, prior employers, and/or sources I have listed to provide to the Company any information concerning my prior experience, including but not limited to information about my work performance, qualifications, character, demeanor or behavior without giving me prior notice.
Initial

Application

Page 5
During my employment with the Company I will treat all confidential information of the Company and its clients as strictly confidential, proprietary and belonging to the Company. I shall not use, misappropriate, disclose, communicate, reveal or convey (whether directly or indirectly, orally, in writing or otherwise, voluntarily or involuntarily) any confidential information to any person or entity, including for my own use or a third party, except for the advancement of the Company’s interests in the course of performing my employment obligations. Confidential information shall be protected for so long as such information remains confidential, except for trade secrets which shall be protected in perpetuity. My obligation to protect confidential information shall survive the termination of my employment from the Company even if such termination constitutes a wrongful termination of my employment. The Company shall be entitled to equitable and legal relief, including an injunction of damages, in the event I breach these confidentiality provisions. I understand that as a condition of my employment I may be required to sign a separate Confidentiality and Non-Disclosure Agreement. Nothing in this policy is intended to prevent my right to discuss wages, hours and working conditions with coworkers, or in any way to limit my right to engage in protected concerted activity protected by law.
Initial
I understand that if hired the Company does not guarantee a referral or placement with a client.
Initial
I agree to submit to legally permissible drug testing upon an offer of employment from the Company and prior to starting work. I agree that any offer of employment is contingent upon my receiving a negative test result.
Initial
I UNDERSTAND THAT THIS APPLICATION WILL BE ACTIVE FOR SIXTY (60) DAYS FROM THE DATE IT WAS MADE AFTER WHICH I MUST REAPPLY FOR FURTHER CONSIDERATION FOR EMPLOYMENT.
Initial
My signature below certifies that I agree to be bound by the terms and conditions stated in this application, which contains all the understandings between the Company and me concerning the topics addressed herein, and supersedes any prior inconsistent understandings between the Company and me on such issues.
First Name
Last Name
Signature
Date

MonthDayYear
Date

Job Description

Page 1
Home Health Aide and Certified Nursing Assistant
Job Summary

Provides various personal care and related paraprofessional services in accordance with an established plan of care. Provides for the personal needs and comfort of patients in their homes.

Essential Functions
1. Adheres to Agency policies and procedures.
2. Performs work under the supervision of the Nursing Supervisor.
3. Performs personal care activities contained in a written assignment by the Nursing Supervisor which includes but is not limited to, assisting the patient with activities of daily living, such as:
  - Personal hygiene (assisting to bathroom or using bed pan, bathing, care of mouth, skin, and hair)
  - Ambulation
  - Eating
  - Dressing
  - Shaving
  - Meal Preparation
4. Performs other assigned activities that are taught by a nurse for a specific patient. These include but not limited to:
  - Assisting with the change of ostomy appliances
  - Reinforcement of dressings (non-sterile)
  - Assisting with the use of devices for aid to dally living (cane, walker, wheelchair, or lift device)
  - Assisting with prescribed range of motion exercises
  - Assisting with self-administered simple urine tests for sugar acetone or albumin (Home Health Aide
  - may not interpret results)
  - Measuring and preparing special diets
  - Measuring intake and output
  - Taking vital signs (temperature, pulse, respirations and blood pressure)
  - Application of an external (condom-type) catheter
  - Assist with application of arm sling, arm splint or leg splint
5. The HHA/CNA will NOT perform any of the following:
  - Sterile dressing change
  - Irrigation of body cavities such as enemas, colostomy or wound
  - Gastric lavage or gavage
  - Catheterization
  - Administration of oral medications, eye drops or medicated skin ointments
  - Administration parenteral or IV medications
  - Application of heat by any method
  - Naso-gastric or gastrostomy tube feedings or care
  - Tracheostorny tube care
  - Suctioning of the nose, mouth, or tracheostomy
  - Nail care on a patient with diabetes or compromised circulation
  - Any personal health service that has not been included on the paraprofessional task sheet

Job Description

Page 2
1. The HHA/CNA performs light housekeeping tasks which will facilitate the patient's self-care at home. These tasks include, but are not limited to:
  - Vacuuming
  - Dusting
  - Sweeping or mopping floors
  - doing dishes
  - laundry
  - cleaning bathrooms
2. The HHA/CNA will NOT:
  - Perform heavy duty household cleaning such as washing walls, waxing floors, washing windows, etc.
  - Household repairs or maintenance
  - Yard care or maintenance
3. The HHA/CNA is responsible for documentation of service provided, using the Client Care Record.
4. The HHA/CNA should not contact the physician directly, but rather refer all questions or reports of patient's condition changes immediately to the Nursing Supervisor.
5. In-Service Training:
  - Home Health Aides will receive at least twelve hours of in-service training per year (or as many as required by State law) as documented in the In-Service Log which is monitored by the Nursing Supervisor. The in-service training may be performed while the Home Health Aide is providing care to patients.
6. Working Conditions/Environment:
  - Primarily works a certain number of hours or shifts in patients' place of residence, travel required. Shift times and days vary with patient needs.
  - The Agency cannot promise to provide you with a certain number of visits or hours of employment in any given week. We cannot guarantee work close to your home or on a convenient public
7. Education, Experience, Knowledge, Skills, Abilities, and Availability:
  - High school graduate of G.E.D. certificate preferred.
  - Six months of experience as a Home Health Aide in health care (in homes or facilities) and successful completion of a State Approved Nurse Aide or Home Health Aide course.
  - The Home Health Aide shall have successfully completed a Competency Evaluation that meets the State licensing law for home health agencies.
  - Must have a sympathetic attitude toward the care of the sick, and ability to deal effectively with the demands of the job.
  - Current CPR Certificate is required.
  - Meets the requirements for employees providing direct patient care.
  - Read, write, speak, and understand English as needed for the job.
  - Have valid driver's license and use of an insured automobile for work or access to adequate transportation preferred
First Name
Last Name
Signature
Date

MonthDayYear
Date

Reference Check
Candidate Authorization

I authorize Right at Home or any designated officer, employee, agent, or representative of Right at Home to confer with the above-named references. I understand that Right at Home may ask questions about my educational background, work experience, achievements, prefinance, attendance, and reason for separation from former employment, among other topics.

I understand that any information provided by my references is to be used solely for the purpose of determining my acceptability for employment with Right at Home.

I release all of the above-named references from any claim for damages, including, but not limited to, claims for defamation, inte1ference with contract, and negligence, which may arise or result from any reference information provided by a reference pursuant to this authorization.
Reference #1:
Company Name
Contact
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference #2:
Company Name
Contact
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference #3:
Company Name
Contact
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Signature
Date

MonthDayYear
Date

Attestation Acknowledgement
READ FIRST:

Click on the link below to review our ATTESTATION OF COMPLIANCE.

CLICK HERE
First Name
Last Name
Under penalty of perjury, I {firstName} {lastName}, hereby swear or affirm that I meet the requirements for qualifying for employment in regard 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.
Signature
Title
Date

MonthDayYear
Date

Inquiry Release
In conjunction with my application for new or continuing employment (including contract and/or volunteer services) with you, I understand that you intend to hire Selection Management Systems, Inc. (“SMS”) to obtain Consumer Reports and/or Investigative Consumer Reports (Reports) about me as defined in the federal Fair Credit Reporting Act (“FCRA”). These Reports may include information concerning my academic background, character, credentials, credit capacity, credit standing, credit-worthiness, general reputation, mode of living, personal characteristics, reasons for work termination, work experience, work habits and/or work performance. You may also seek information concerning my civil litigation history, criminal record, educational background, employment history, motor vehicle record, and/or worker’s compensation history.

I understand that you may rely on the information contained in these Reports in determining whether to extend an offer of employment to me or maintain my employment with you. I also understand that you may run Reports about me at least once every two years. If you contemplate making an adverse employmentrelated decision that will affect me based, in whole or in part, upon a Report obtained from SMS, I will receive a copy of the Report and a written summary of my Consumer Rights under the FCRA before you finalize that decision.

I have read the above disclosure and I hereby authorize you, SMS or its authorized agents to obtain the above-referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above-referenced knowledge or information they have concerning me. This authorization shall remain on file and be valid for the duration of my employment with you. It shall serve as an ongoing authorization for you to obtain Reports about me from SMS. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from any Report shall be brought only in the state or federal court in Hamilton County, Ohio and shall be governed by, and construed in accordance with, the laws of the State of Ohio.
First Name
Last Name
SSSN #
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PREVIOUS OR MAIDEN NAME (if applicable):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DRIVER’S LICENSE NUMBER:
STATE ISSUED:
Email
example@example.com
List of states and counties of residence, other than above, for the previous seven (7) years:
COUNTY
STATE (Abbreviation)
COUNTY
STATE (Abbreviation)
COUNTY
STATE (Abbreviation)
Date of Birth:

MonthDayYear
FOR IDENTIFICATION PURPOSES ONLY:
Signature
Date

MonthDayYear
Date
(My prospective employer understands that age is a protected characteristic and that any age-related information requested will not be used as the basis for any employment decision.)
COMPLIANCE REVIEW – OFFICE USE ONLY
Customer Number
Location/Store Number
Staff Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Position Applied For
Information Requested
Combined Report
Individual Reports
Criminal Convictions
#1 County & State
#2 County & State
Other
Date Submitted

MonthDayYear
Date

Privacy Policy
READ FIRST:

Click on the link below to review our PRIVACY POLICY.

CLICK HERE
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.
First Name
Last Name
Signature
Date

MonthDayYear
Date

Consumer Reports
In connection with my application for employment (including contract for service) with EFG Home Health, LLC (hereinafter Right at Home) I understand that investigative inquiries may be obtained on myself by a consumer reporting agency, and that any such report will be used solely for employment-related purposes. I understand that the nature and scope of this investigation will include a number of sources including, but not limited to, consumer credit, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, general reputation, personal characteristics, mode of living, and work habits. Information relating to my performance and experience, along with reasons for termination of past employment from previous employers, may also be obtained. Further, I understand that Right at Home will be requesting information from various Federal, State, County and other agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil, education, and other experiences. A consumer report containing injury and illness records and medical information may be obtained only after a tentative offer of employment has been made.

I understand that if Right at Home hires me, it may request a consumer report or an investigative consumer report about me for employmentrelated purposes during the course of my employment. I further understand that the scope of this investigation will be the same as the scope of a pre-employment investigation, and that the nature of such an investigation will be my continuing suitability for employment, or whether I possess the minimum qualifications necessary for promotion or transfer to another position. I understand that my consent will apply throughout my employment, unless I revoke or cancel my consent by sending a signed letter or statement to Right at Home at any time, stating that I revoke my consent and no longer allow Right at Home to obtain consumer or investigative consumer reports about me.

If I am applying for employment in the State of California or if I am a resident of California at the time of applying for employment, a summary of the provisions of California Civil Code section 1786.22 is also being provided to me with this form. This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company.

I authorize without reservation any party or agency contacted by this employer to furnish the above-mentioned information. I hereby consent to your obtaining the above information from Accurate Background, Inc. (and/or any of their licensed agents) located at 6 Orchard, Suite 200, Lake Forest, CA 92630, (800) 784-3911 or First Advantage Enterprise Screening Corporation located at 100 Carillion Parkway, St. Petersburg, FL 33716, (866) 400-FADV. I understand that to aid in the proper identification of my file or records the following personal identifiers, as well as other information, is necessary. I also agree that a fax or photocopy of this authorization with my signature will be treated with the same legal authority as the original.
First Name
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN #
Drivers License Number
Drivers License State
The following is for identification purposes only to perform the background check:
Race
Gender
Date of Birth

MonthDayYear
Date
Other or Former Names:
Professional License:
Sate
Type
Number
The following are the locations (cities/states) where I have lived and worked in the last 7 years:
Dates
City & State
Dates
City & State
Dates
City & State
Signature
Date

MonthDayYear
Date
Prospective Employer

Employment Application

HHA Competency Evaluation

HHA Competency Evaluation

HHA Competency Evaluation

HHA Competency Evaluation

Application

Application

Application

Application

Job Description

Job Description

Reference Check

Attestation Acknowledgement

Inquiry Release

Privacy Policy

Consumer Reports

Direct Deposit