Manilla APP

Valid Picture ID (Front Side) IF PASSPORT TOP PAGE*

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Valid Picture ID (Back Side) IF PASSPORT BOTTOM PAGE*

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I94 (If Applicable)

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I94 Front Side(If Applicable)

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Green card Holder

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Green card Holder Back Side

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Licensure (RN/LPN/OT/PT) can be looked up on NARS

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CPR Certificate

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Car Registration (Drivers)

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TB TEST

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Physical

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Resume

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Employment History

Please begin with your most recent or current place of emloyment
Can be left blank if resume is provided
Licenses and Certifications
Criminal History- By my signature below, Iacknowledge/consent to a criminal check on my name. Have you ever beenconvicted of violating any law? (Please omit minor traffic violations.)
Criminal History
If yes, please list conviction(s),date(s), and location(s) blanks .The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. I attest that the above referenced information is true and accurate to the best of my knowledge. I further give the agency permission to call any of my cited previous employers or reference candidate for information regarding my character, employment history or work ethics.
Signature Date

Pre-Hire Interview
Date

MonthDayYear
Date
Name

First NameLast Name
Position applying for blanks .
AGENCY POLICY: we cannot hire individuals with convictions listed as unemployable by the state. Would anything be likely to show up on their Criminal History check to prevent us from hiring?
blanks
DIRECTCARE STAFF INTERVIEW (PRE-Screening)

These series of questions are used to asses staff response, there is no right or wrong anser
What would you do if you arrive at a patient’s home and he/she refused to let you in?
Brief verbal response: blanks* .
What would you do if your patient fell and insists that you do not call for help and insists that they are ok?
Brief verbal response: blanks* .
How long do you think it is okay to hold onto paperwork for a patient?
Brief verbal response: blanks* .
How do you feel about scheduling an elderly patient’s visit at 8 pm?
Brief verbal response: blanks* .
How would you respond if the Administrator calls you in to give you a written warning for something she has discovered happened?
Brief verbal response: blanks* .
Pre-Hire Read/Write/Report Competency

Please read the paragraph below, and answer the following questions.
Mary is my patient who I see every week on Monday and Thursday. Mary's plan of care includes to assist with bathing, blood pressure, and report ALL skin changes to the nurse. One day you go to her home and find Mary eating an apple for lunch and when assisting her bathing, you see a large open cut on her leg you had not seen before.
Is there anything you need to report about Mary?blanks . Who will you report this to: blank .

Professional Reference form

Please provide a professional reference, can be any colleague or coworker you have worked along side with.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
The individual below has applied for a position with position with Pacific Hands Home Care LLC (Name) blanks .
Position employee is applying for is .

Signature* Date*
Applicants Authorization to Release information

I hearby give permission for my pervious employer to release this referral information about my position with their company and commentts regarding my work ethic and character while in their employ.

Professional Reference form

Please provide a professional reference, can be any colleague or coworker you have worked along side with.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
The individual below has applied for a position with position with Pacific Hands Home Care LLC (Name) blanks .
Position employee is applying for is .

Signature* Date*
Applicants Authorization to Release information

I hearby give permission for my pervious employer to release this referral information about my position with their company and commentts regarding my work ethic and character while in their employ.

Conflict Of Interest

POLICY:

No employee or member of the Governing Body, Advisory Committee, or other individual, committee, or entity shall derive any profit or gain directly or indirectly by reason of their association with the agency, without the prior knowledge and approval of the Governing Body. All board members and/or employees, at the discretion and specific request of the board, will be required to submit a disclosure statement annually.

If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Administrator and Governing Body.

In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the agency and a board member shall not participate in discussions unless requested by the board nor vote on such transactions. The abstention and the reason for it shall be recorded in the minutes.

Field staff in any capacity understands that all patients are patients of the Agency not personal patients of the field staff. Patients may never be serviced privately by an employee of Our Agency for the financial gain of the employee. Should an employee terminate employment with Pacific Hands Home Care, the field staff understands that the patient may not be encouraged or otherwise moved from our Agency to another agency.

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST.

I,________________________________________________, have read and am fully familiar with

the agency’s policy statement regarding conflict of interest. I am not presently involved in any

transaction, investment, or other matter in which I would profit or gain directly or indirectly as a

result of my membership on the agency’s board of Directors or its committees or my employment.

Furthermore, I agree to disclose any such interest which may occur in accordance with the

requirements of the policy and agree to abstain from any vote or action regarding the agency’s business that might result in any profit or gain directly or indirectly, for myself.
I also work for another homecare agency:   Reply Yes or No in the blank field

blanks field. IF YES, I am disclosing the name of the agency/agencies: blank .
First Name   Last Name
Signature   Date

Driving Status Statement
Are you currently licensed to drive a motor vehicle? Do you Carry Auto insurance, and have you supplied us a current copy of my license and auto insurance?

First Name Last Name
Signature Date

Thank you for your interest and application! Please keep an eye on your email for the second half of the application upon review. We appreciate your interest.
Should be Empty:

Emergency Contact information

Employment History

Criminal History- By my signature below, Iacknowledge/consent to a criminal check on my name. Have you ever beenconvicted of violating any law? (Please omit minor traffic violations.)

Pre-Hire Interview

DIRECTCARE STAFF INTERVIEW (PRE-Screening)

Pre-Hire Read/Write/Report Competency

Professional Reference form

Professional Reference form

Driving Status Statement