This form is an acknowledgement and disclosure form. It is used to identify outside employment and help prevent scheduling conflicts or overlapping service hours. It is not a disciplinary warning.

I understand and acknowledge the following:
1. I must accurately disclose outside employment and work schedules that may conflict with my Heart to Home schedule.
2. I may not provide care, clock in, document, submit time, or be paid for services for two clients/participants at the same time.
3. This applies whether the clients are with Heart to Home, another agency, or two different agencies, and whether or not the clients live in the same home.
4. I must not accept or work a shift that overlaps with another client's scheduled service hours unless the arrangement has been specifically reviewed and authorized in writing by the appropriate payer/program and Heart to Home.
5. If my outside-employment schedule changes or creates a possible conflict, I must notify Heart to Home before working the conflicting hours.
6. All clock-in/clock-out times and service documentation must reflect the actual time I personally provided authorized services.

By signing below, I confirm that the information I provided on this form is complete and accurate. I understand Heart to Home's requirement prohibiting overlapping service hours and agree to notify the agency of outside-employment schedule changes that could create a conflict.