Four Seasons HHA

Citizenship Status

Alien Registration Number/USCIS Number:

USCIS Number:

Emp. Authorization ID Expiration Date

ID Type - Select ALL that Apply

NYC ID Field for mapping

{nyState} ID Number

{nyState} ID Expiration Date

State Benefit ID Number

Permanent Resident Card ID Number

Perm. Resident Card ID Expiration Date

Employment Authorization Card ID

Foreign Passport with I-551 ID Number

Foreign Passport I-551 ID Expiration Date

US Passport ID Number

US Passport Expiration Date

US Passport Card ID Number

US Passport Card Expiration Date

Hire Date

Base Rate

Overtime Rate

Supplemental Wages

Send Payrate PDF to user:

First Name

Middle Name

Last Name

Alias Name

Maiden Name

Street Address:

Apartment/Suite #:

Hidden spacer

City:

State:

Zip:

Mobile Phone Number:

Home Phone Number:

Email Address:

example@example.com

Date of Birth:

Social Security #:

Country of Birth:

Race:

Gender:

Eye Color:

Hair Color:

Weight:

Height:

What is your primary language?

Do you speak any other languages?

What additional languages do you speak?

Emergency Contact Name:

First/Last

Phone Number:

Relationship

Do you drive?

Driver's License Number:

Expiration Date:

Are you a resident of New York City?

Are you a resident of Yonkers?

Where did you hear about Four Seasons Home Care?

HHA Training School Name:

Patient Name:

Four Seasons Employee Name:

Job Fair Name:

NYS Department of Health requires Four Seasons to use an Electronic Visit Verification (EVV) system. Do you own a Smartphone?

Tax Marital Status

HM -Tax Marital Status

Total number of children UNDER age 17

Other Dependents

Are you a U.S. Citizen?

Are you a lawful permanent resident?

Are you an alien authorized to work?

If not, give Visa # and expiration:

**Sorry, we cannot accept your application at this time. Please start your application over again**

Have you been convicted of a crime other than a traffic violation?

Have you had a final finding of patient abuse?

Please provide a brief explanation of the violation

Have you ever been fired or asked to resign?

Professional Reference Name #1:

Title #1:

Professional Reference Phone Number #1:

Professional Reference Name #2:

Title #2:

Professional Reference Phone Number #2:

Reference Checkbox 1

Professional Reference Name #3:

include city/state/zip

Title #3:

Professional Reference Phone Number #3:

Education

Rows	Name & Location of School	Last Year Attended	Graduated
High School
College 1
College 2
Other

Have you ever worked for this Employer before? Are you a re-hire?

List below your previous employer(s), starting with the last one.

Name Of First Employer

Address

Position

Responsibilities

Reason for Leaving

Start Date

End Date

Do you have a second employer to add?

Name Of Second Employer

Address

include city/state/zip

Position

Responsibilities

Reason for Leaving

Start Date

End Date

Do you have a third employer to add?

Name Of Third Employer

Position

Supervisor's Name

Address

include city/state/zip

Phone Number

Reason for Leaving

Start Date

End Date

Salary

May we contact your former employer(s) for references?

Can we conduct a Criminal Background Check on you?

I acknowledge that I have been offered coverage through Four Seasons Home care and understand that by declining the health insurance that i will not be able to enroll again until open enrollment.

Hep B Vaccine Program - Please select from one of the following:

Influenza (Flue) Vaccine - Please select from one of the following:

I have been advised that I should receive the Influenza vaccine to protect myself and the patients I serve. I have read the Center for Disease Control and Prevention's (CDC) Vaccine information statementexplaining the vaccine and the isease 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, families, and others.
• If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or nonexistent.
• I understand that the strains of the virus that can cause influenza infection change almost every year and even if they don't, my immunity declines over time. Therefore, 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 agency, coworkers, my family and my community.
• Because I have refused vaccination against influenza, I will be required to wear surgical or procedure masks in areas where patients may be present during influenza season.

I acknowledge that I have read this document in its entirety and fully understand it. Despite these facts, Ihave decided to decline the influenza vaccine by my signature below. I realize that I may re-address this issue at any time and accept vaccination in the future. Proof of vaccination will be required by the office to
ensure compliance.

Have you experienced any of the following symptoms in the past year?

Rows	Yes	No
A productive cough for more than 3 weeks
Hemoptysis (coughing up blood)
Unexplained weight loss
Fever, chills, or nigh sweats for no known reason
Persistent shortness of breath
Unexplained fatigue
Chest pain

Have you had contact with anyone with active tuberculosis disease in the past year?

Do you have a medical condition, or are you taking medications, which suppress your immune system?

I attest that all information provided in this employment application is true and accurate to the best of my knowledge. Furthermore, I understand that the employer is not responsible for any incorrect information entered incorrectly by me that may affect my pay, benefits, or other employment-related matters. I agree to assume full responsibility for the accuracy of the information provided and to hold the employer harmless for any consequences arising from any errors or omissions in my application.

Applicant Signature

Rows	No	Yes
Weakness
Unexplained Fatigue for more than 3 weeks
Lack of Appetite
Unexplained Weight Loss
Low Grade Fever
Unexplained Fever, Chills, or Drenching Night Sweats
Persistent Shortness of Breath
Persistent cough for more than 3 weeks
Blood streaked sputum
Clear, Yellow, or Dark Sputum
Coughing Up Blood
Chest Pain
Have you ever been diagnosed with active TB disease?
Have you been treated with medication for TB or for a positive TB test?
Have you ever been diagnosed with latent TB infection or had a positive skin test or a positive blood test for TB?
Have you ever lived in a country with a high TB rate?
Is your immune system compromised due to a virus or medication?
Have you recently had close contact with someone who has had TB disease?

For Office Use Only

Personal Information

W4 & I9

Education & Employment History

Health Questionnaire

Policies

Availability

New York Urban Youth Jobs Program

Payment - Direct Deposit

Government Assistance

Employee Status & Referrals