Terms and Conditions:

This application must be completed and all questions regarding your training and work experience answered. All information on this application is confidential, SILVER LINING HOMECARE will not contact your present employer without your consent.

The information listed in my application is complete and true. I understand that if employed, false statements on this application are cause for dismissal. I will comply with all of the agency’s rules and regulations regarding my employment. SILVER LINING HOMECARE may request information regarding my background which will include work and personal references.

SILVER LINING HOMECARE does not discriminate because of sex, age, physical handicap, race, creed or national origin. The agency is an equal opportunity employer.

I9:

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes):

W4:

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

NY State Tax IT-2104:

I certify that I am entitled to the number of withholding allowances claimed on this certificate.

NY Pay Rate:

Employee Acknowledgement: On this date, I have been notified of my pay rate, overtime rate (if eligible), allowances, supplements and designated payday. I told my employer what my primary language is.

Reference Request:

Release of Information: I hereby release from all liability the company, institution or person named above and authorize them to release all information regarding my employment with them.

Conditional Offer For Employment:

This letter serves as notice of the conditional offer for employment as a HHA or PCA. The offer is conditional based on receipt of accurate, complete and timely of the following information at this office:

Original Certificate of Training, Two work related references from your former employers, A complete pre-employment physical examination report from your physician indicating you are able to work and are free from any health impairment that is a potential risk to the patient or other employee or which may interfere with the performance of your duties including habituation or addiction to drugs and/or alcohol, Current Tuberculosis test (yearly), Lab report for rubella titer or MD documentation of receipt of vaccine, Lab report for Rubeolla titer or MD documentation of receipt of vaccine (if born on or after 1/1/57), Evidence of attendance of mandatory hours and topics of in-service if you have not worked for a NYS home care agency for the past 24 months and Evidence of ability to work in the USA.

Once this information is received and the review deems it complete and accurate you will be scheduled for the agency’s orientation and competency testing/review.

NYS Public Health Law requires that all non-licensed caregiver staff undergo a criminal background review which includes that your fingerprints be taken and sent to the FBI. During the time from taking the fingerprints and receipt of the FBI report you can work as a provisional employee of the agency. Once your criminal background study report is received and reviewed by the agency the decision for hiring will be made and if appropriate your work status will become “probationary” for the first 3 months of employment.

Employee HIPAA Training Acknowledgement:

I, acknowledge that I:

Attended training classes by my employer on:

(1) The Federal and State laws and regulations requiring the use of the confidentiality, integrity and accessibility safe guards for patient protected health information ( “ PHI “).

(2) The policies and procedures established by my employer to implement the required PHI safeguards, including but not limited to;

(3) Password management

Log- in procedures and requirements identifying and reporting security incidents; and

The application of those polices and procedures to my specific job functions

Understand the policies, procedures and otherwise maintain the confidentiality and integrity of PHI; and

Understand that my employment may be terminated for failure to adhere to these polices and procedures.

NOTICE TO APPLICANTS FOR DIRECT CARE POSITIONS :

Pursuant to Title 10, Section 400.23 of the New York Code of Rules and Regulations, the home care agency, is required to conduct a criminal background check of all applicants for employment in non-licensed positions providing direct patient care and/or supervision. Pursuant to these regulations, we are required to notify you of the following:

We will submit your fingerprints to the New York State Department of Health and request the Department to forward such information to the Attorney General of the United States. The Attorney General will then conduct a full search of records of the Federal Bureau of Investigation (FBI) to ascertain if you have any record of a criminal conviction.

The Attorney General will provide its findings to the New York State Department of Health, which will in turn forward the results to us. If the background check reveals that you have been convicted of certain enumerated crimes, your application for employment will be rejected. If you have been offered provisional employment, such employment will be terminated.

Pursuant to the regulations, you have the right to:

a. Obtain a copy of the results of the criminal background check, review the information contained and explain same;

b. Withdraw your application for employment without prejudice at any time before we make a decision on your application. In such event we will destroy your fingerprint card and any information we may have obtained in connection with the criminal background check.

c. The finger-printing and criminal background checks are conducted at no cost to you.

d. Any information we receive about you as a result of a criminal background check will be used only for determining your suitability for employment in a position involving direct patient care or supervision. Such information will be treated as confidential and will not be disclosed to anyone else except as permitted by law.

e. If your employment application is denied because of information obtained during the course of a criminal background check we will provide you with a written statement of our decision and the basis thereof.

I HAVE RECEIVED A COPY OF THIS NOTICE OF CRIMINAL BACKGROUND CHECK ON THE DATE SET FORTH BELOW.

Confidentiality Statement:

Agency records are maintained in a safe and secure area with specific access availability to ensure confidentiality. Agency records, files, documents and reports are the exclusive property of the Agency. Only authorized personnel will have access to clinical/financial/personnel records.

All agency records, files, documents and Access to confidential employee/patient information files will be limited to agency personnel involved in the care and service of the patient.

Agency staff with access to computer files holds all information in strictest confidence in the processing, storage and discarding of all data. Only authorized personnel will have access to written and computer data information; Authorized personnel will be assigned passwords/access codes to computer files necessary to conduct their responsibilities;

Responsibilities of this job position has clearance for access to the following confidential information:

Patient plans of care and identifying data I have been oriented to the agency’s confidentiality policy. I understand that any Agency employees who do not honor the Confidentiality Policy are subject to termination and possible legal action. I agree to abide by the agency’s confidentiality policy.

HIV CONFIDENTIALITY:

I received training regarding confidential HIV related information and my responsibilities in regard to maintaining the confidentiality of HIV related information obtained and maintained by Silver Lining Homecare Agency. I also have been informed of and agree to follow Silver Lining Homecare Agency’s HIV Confidentiality Policies and Procedures.

I understand that in the course of my employment with Silver Lining Homecare Agency, I may obtain confidential HIV related information about Silver Lining Homecare Agency’s clients whose confidentiality is protected by law. I have been advised that employees may be authorized to have access to confidential HIV related about clients only when reasonably necessary to perform their authorized job duties and responsibilities, as described in Agency’s Need to Know Protocol.

I understand that employees who are authorized to have access to such information shall not:

(1) Examine documents or computer data containing HIV related information unless required in the course of performing authorized duties and responsibilities.

(2) remove from the agency’s office or copy such documents or computer data unless acting within the scope of assigned duties;

(3) discuss the content of such documents or computer data with any person unless that person has authorized access and a need to know the information discussed; or

(4) illegally discriminate, abuse or harass any person to whom HIV related personal health information applies.

I agree not to disclose confidential HIV related information about any client to any person without a specific, written release from the individual to whom such information pertains, unless I am specifically authorized to make the disclosure without a release in accordance with applicable law and this Agency’s HIV Confidentiality Policy and Procedures.

I acknowledge that violation of confidentiality laws and rules and this Agency’s HIV Confidentiality Policy and Procedures may lead to disciplinary action, including suspension or dismissal from employment and criminal prosecution.

ELDER MISTREATMENT AND ABUSE:

I have read and understand the material presented to me on Elder Mistreatment and Abuse.

I also understand that if I suspect that a client is being abused, that I will promptly notify SILVER LINING HOMECARE AGENCY, INC. or the DPS, or I will personally call Adult Protective Services (APS) or the Elder Abuse Hotline - after which I will notify the agency of my actions.

ELDER ABUSE HOTLINE: 1- 800.677.1116 - Toll Free Phone #.

Adult Protective Services- to report Elder Abuse etc.

Call the police or 9-1-1 immediately if someone you know is in immediate, life-threatening danger. Specially trained operators will refer you to a local agency that can help.

Staff availability: M-F from 9a – 8p EST.

You may remain anonymous if you so desire - the important action here is to make the above

department aware of your suspicions. They will do the follow-up and an investigation if it is warranted.

Agreement:

I swear that I currently meet the qualifications listed above in the New York Youth Jobs Program: Youth Certification Qualifications section.

I understand that I must provide private, personal information on this application to qualify for the program. I understand that I do not need to explain why I qualify to anyone I ask for a job, or who gives me a job, or anyone who I work with.

I agree to allow the New York State Department of Taxation and Finance to share my wage record with the New York State Department of Labor.

I believe the information submitted in this application is true, correct and complete.

I understand that the New York State Department of Labor will make sure the information submitted in this application is true and may ask me for more information or details.

I am aware that there are consequences for filing false documents or other information with the government. I agree to the statements above.

CORPORATE COMPLIANCE EDUCATION ACKNOWLEDGEMENT:

This is to certify that I have received Corporate Compliance Training and Educational Materials pertaining to the Federal False Claims Act, New York False Claims Act, Whistleblower Protection and Identifying Fraud and Abuse Law, as well as where to report these issues should they be suspected or uncovered.

Sleep and Meal Policy:

I acknowledge receipt of the Agency’s “Sleep and Meal Period Policy for Employees on Duty for 24 Hours or More,” together with the Sleep and Meal Period Exception Certification Form, and by my signature below, I hereby agree to the terms and conditions set forth in this policy. I specifically and expressly agree that I will follow this policy and will notify my coordinator any time I work a shift of 24-hour or more and: (1) I am unable to enjoy a total of at least 3 hours of Bona Fide Meal Periods; (2) I am unable to enjoy at least an 8-hour Bona Fide Sleep Period; or (3) the sleeping facilities in the patient’s home are inadequate.

Fair Program:

By signing below, you confirm that You have read and understand the terms and conditions of the FAIR Program, which require You to submit all Claims to binding arbitration on an individual basis.

Human Rights Law:

Silver Lining Homecare Agency has provided me with written notice of my rights under the Human Rights Law, by signing below I acknowledge the receipt of the Sexual Harassment Policy and “STOP SEXUAL HARASSMENT ACT FACTSHEET” .

Photo Identification:

As an employee of SILVER LINING HOMECARE AGENCY INC., I acknowledge receipt of the agency issued photo identification card. As required by regulation and agency policy, I agree to wear the ID when working.

The identification card is the property of SILVER LINING HOME CARE AGENCY INC. and will be returned to the agency upon termination of employment.

Paid Time Off Policy:

Purpose: To provide home health aides, personal care aides, and personal assistants (“Aides”) who work for Silver Lining (the “Company”) with paid time off that will meet the requirements of New York State and New York City Paid Sick Leave Law and the Wage Parity Law (collectively, the “Laws”).

Coverage: All Aides will be covered by this policy.

Effective Date: September 30, 2020. This policy replaces the previous Paid Time Off policy.

Accrual Rates: Accrual of PTO will begin with the first worked shift/hours of work. Aides will accrue one (1) hour of paid time off (“PTO”) for every 15 hours worked. Unless otherwise prohibited by law, PTO pursuant to this policy will accrue for every hour worked, until the Aide reaches 56 hours of accrual during a calendar year. Once 56 hours of PTO have been accrued, Aides will accrue PTO only during the first 40 hours of work each week. Thus, in such a case, no accrual of PTO will be done for work time exceeding 40 hours.

Any PTO accrued by an Aide who had been employed and working for the Company prior to September 30, 2020 (“Existing Aide”) may be used through December 31, 2020. Effective September 30, 2020, Existing Aides will accrue PTO in accordance with this policy. Existing Aides who have accrued and unused PTO as of 11:59 p.m. on December 31, 2020 will have their PTO hours “carried over” to 2021. Earned and unused PTO by such Aides will not be paid out upon the year’s end; instead it will carry over and be available to the Aide for use in the following calendar year.

Aides who are hired on September 30, 2020 or thereafter (“New Aide”) will begin to accrue PTO under this policy upon hire. New Aides may use accrued PTO upon accrual; there will be no waiting period to use PTO.

The above accrual rates will not apply for hours that are private pay nonwage parity hours. For such hours of work, the Aide will accrue at least 1 hour of PTO for every 30 hours worked, for a total and maximum of 56 hours per year. The remainder of this policy including, but not limited to the provisions regarding the scope of use of accrued paid time hours, carry-over, and rights upon termination will apply to paid time off that is earned during private pay nonwage parity hours.

In accordance with the Laws, the hourly rate of PTO accruals will be stated on Aides’ paystubs.

Definitions:

The following terms will have the defined meaning under this policy:

“Year” means the calendar year.

“PTO” means paid time off that is granted to the Aide. The PTO under this policy may be used for any reason permitted by the Westchester County Paid Sick Leave Law, New York City Safe and Sick Leave, Domestic Worker Bill of Rights, and New York State Paid Sick Leave Law.

“Family Member” includes an Aide’s child, grandchild, current or former spouse, current or former domestic partner, parent, sibling, or grandparent, a child or parent of an Aide’s spouse or domestic partner, any other individual related by blood to the Aide, and any other individual whose close association with the Aide is the equivalent of a family relationship.

“Parent” means a biological, foster, step or adoptive parent or a legal guardian of an Aide or a person who stood in loco parents when the Aide was a minor child.

“Child” means a biological, adopted or foster child, a legal ward, or a child of an Aide standing in loco parentis.

Permitted Uses of PTO: Time accrued under this policy may be used for vacation, travel, and leisure time. In addition, PTO accrued under this policy may be used for:

The Aide’s own mental or physical illness, injury, or health condition, need for medical diagnosis, care, or treatment of a mental or physical illness, injury, or health condition, or need for preventive medical care (“Sick Time”).

Care of a family member who needs medical diagnosis, care, or treatment of a mental or physical illness, injury, or health condition or needs preventive medical care (also, “Sick Time”).

Closure of the Aide’s place of business by order of a public official due to a public health emergency or such Aide’s need to care for a child whose school or childcare provider has been closed by order of a public official due to a public health emergency.

An absence due to any of the following reasons when the Aide or the Aide’s family member has been the victim of a family offense matter, sexual offense, stalking, or human trafficking (“Safe Time”):

to obtain services from a domestic violence shelter, rape crisis center, or other shelter or services program for relief from a family offense matter, sexual offense, stalking or human to trafficking; participate in safety planning, temporarily or permanently relocate, or take other actions to increase the safety of the Aide or Aide’s family members from future family offense matters, sexual offenses, stalking or human trafficking;

to meet with a civil attorney or other social service provider to obtain information and advice on, and prepare for or participate in any criminal or civil proceeding, including but not limited to, matters related to a family offense matter, sexual offense, stalking, human trafficking, custody, visitation, matrimonial issues, orders of protection, immigration, housing, discrimination in employment, housing or consumer credit;

to file a complaint or domestic incident report with law enforcement;

to meet with a district attorney’s office;

to enroll children in a new school; or

to take other actions necessary to maintain, improve, or restore the physical, psychologic, or economic health or safety of the Aide or the Aide’s family member or to protect those who associate or work with the Aide.

Increments of Leave: PTO accrued and used under this policy may be used in increments of 30 minutes or higher.

Notice of Leave Related to PTO: Aides must give as much notice as practical under the circumstances for use of PTO. Where PTO will be used as vacation time, Aides must submit a request in writing at least two weeks in advance of the first day off from work.

Where PTO will be used as Safe Time or Sick Time, Aides must provide no less than 7 calendar days’ notice for foreseeable or pre-scheduled absence. However, where it is not feasible to give advance notice, the Aide must notify his or her coordinator as soon as practicable in the circumstances that the Aide will be absent. Failure to give proper notice, where notice is possible, may result in denial of the leave or disciplinary action. Texting a supervisor regarding an absence is not acceptable. The Company reserves the right to request documentation regarding leave related to Safe Time or Sick Time, where permitted by Law.

Confidentiality Related to Safe and Sick PTO: The Company will not require the disclosure of details relating to an Aide's or his or her family member's medical condition or require the disclosure of details relating to an Aide's or his or her family member's status as a victim of family offenses, sexual offenses, stalking, or human trafficking as a condition of providing Sick Time or Safe Time.

Health information about an Aide or an Aide's family member, and information concerning an Aide's or his or her family member's status or perceived status as a victim of family offenses, sexual offenses, stalking or human trafficking obtained solely for the purposes of utilizing leave under this policy will be treated as confidential and will not be disclosed except by the affected Aide, with the written permission of the affected Aide or as required by law.

Carry-Over and Forfeiture of Earned and Unused PTO: Accrued and unused PTO will not be paid out at the end of the Year. Instead, all accrued and unused PTO will carry over from one Year to the next. There is no limit on the annual usage of earned PTO; any PTO that has been earned and accumulated by an Aide may be used in totality in any given calendar year. The Company, however, will not advance any PTO to Aides who have not earned or who have exhausted all their accumulated PTO.

Accrued and unused PTO will not be paid out upon termination of employment, regardless of the reasons for said termination. Therefore, Aides are strongly encouraged to use up their PTO benefit while employed.

Anti-Retaliation: No Aide will be subjected to any adverse employment action as a result of requesting or utilizing PTO as Safe Time or Sick Time. The Company will not utilize an Aide’s usage of Safe Time or Sick Time as a motivating factor in any adverse employment action.

Discipline: Failure to adhere to the terms of this policy may result in discipline, including termination. Each case of suspected violations will be investigated by the Company. Aides, where appropriate, will be given an opportunity to provide a statement related to their adherence to this policy. The Company will make a determination on the proper course of action with respect to each Aide, based on the totality of circumstances.

Relationship to Other Leaves: Aides on a leave of absence pursuant to federal, state, or local law may be required to use any accrued PTO for such absences. PTO will not accrue for any Aide who is on an unpaid leave of absence.

Questions: If you have any concerns or questions about this policy, please contact our HR Department at 718-717-8337

By signing below, I confirm that I have received this PTO policy, that I understand the PTO policy, and that I will comply with its terms as a condition of my initial or continued employment with the Company.

Medical Coverage Waiver Form:

I was offered the Health insurance plan offered by my employer.

I understand that I must pay $94.25/week for this coverage which is within 9.50% of my income. Although it is affordable, I choose not to enroll.

I am declining coverage for the following reason:

__ I am covered with Medicaid or another Govt Program

__ I have coverage through my spouse

__ I have coverage through another employer

Influenza Vaccination Policy for Direct Care Positions:

I have been advised that I should receive the influenza vaccine to protect myself and the patients I serve. I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have had the opportunity to discuss the statement and have my questions answered by a healthcare provider. I am aware of the following facts:

Influenza is a serious respiratory disease that kills thousands in the United States each year.

Influenza vaccination is recommended for me and all other healthcare personnel 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, I can spread severe illness to others even when my symptoms are mild or non-existent.

I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t, 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, coworkers, my family and my community.

If I choose not to get vaccinated against influenza, I will be required to wear surgical or procedure masks in areas where patients or residents may be present during the influenza season.

I acknowledge that I have read this document in its entirety and fully understand it.