Four Seasons HHA

For Office Use Only
Citizenship Status

U.S. CitizenPermanent ResidentAuthorized to Work
Alien Registration Number/USCIS Number:
USCIS Number:
Emp. Authorization ID Expiration Date

MonthDayYear
ID Type - Select ALL that Apply

State IDNYC IDState Driver LicenseState Learner PermitState Benefit CardPermanent Resident CardEmployment AuthorizationUS PassportUS Passport CardForeign Passport with I-551None, I do not have any of this information
NYC ID Field for mapping
{nyState} ID Number
{nyState} ID Expiration Date

MonthDayYear
State Benefit ID Number
Permanent Resident Card ID Number
Perm. Resident Card ID Expiration Date

MonthDayYear
Employment Authorization Card ID
Foreign Passport with I-551 ID Number
Foreign Passport I-551 ID Expiration Date

MonthDayYear
US Passport ID Number
US Passport Expiration Date

MonthDayYear
US Passport Card ID Number
US Passport Card Expiration Date

MonthDayYear
Hire Date

MonthDayYear
Base Rate
Overtime Rate
Supplemental Wages
Send Payrate PDF to user:

YesNo
Personal Information
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:*

MonthDayYear
Social Security #:*
Social Security #:
Country of Birth:*
Race:*
Gender:*
Eye Color:*
Hair Color:*
Weight:*
Height:*
What is your primary language?*

EnglishSpanishRussianChineseUrduCreoleFrenchArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengali
Do you speak any other languages?*

YesNo
What additional languages do you speak?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengaliCreoleFrench
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship*
Do you drive?*
Driver's License Number:*
Expiration Date:*

MonthDayYear
Are you a resident of New York City?*

YesNo
Are you a resident of Yonkers?*

YesNo
Where did you hear about Four Seasons Home Care?*
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?*
W4 & I9
Tax Marital Status*

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
HM -Tax Marital Status

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
Total number of children UNDER age 17*
Other Dependents*
Are you a U.S. Citizen?*
Are you a lawful permanent resident?*

YesNo
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?*

YesNo
Have you had a final finding of patient abuse?*

YesNo
Please provide a brief explanation of the violation
Education, References & Employment History
Have you ever been fired or asked to resign?*

YesNo
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

Add Another Reference
Professional Reference Name #3:
include city/state/zip
Title #3:*
Professional Reference Phone Number #3:

Education

	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?*

YesNo
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?

YesNo
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?

YesNo
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?

YesNo
Can we conduct a Criminal Background Check on you?

YesNo
Health Questionnaire
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.*

I accept the ACA complaince medical coverage offered by Four Seasons Home CareDecline the medical coverage
Hep B Vaccine Program - Please select from one of the following:*

I do NOT wish to be given the Hepatitis B Vaccine at this time. I am aware that I may request to be provided the vaccine at a later date during my employment with the agencyI have already received the Hepatitis B Vaccine Series.I am requesting to receive the Hepatitis B Vaccine
Influenza (Flue) Vaccine - Please select from one of the following:*

I have received my flu vaccination ·and have provided the office with the proper documentation.I acknowledge that I have read this document in its entirety and fully understand it. Despite these facts, I have 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.
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?*

	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?*

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

YesNo
Policies
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.*

By clicking the submit button, I agree to the terms & conditions.
Applicant Signature*

Clear

	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, References & Employment History

Health Questionnaire

Policies

Availability

New York Urban Youth Jobs Program

Payment - Direct Deposit

Government Assistance

Employee Status & Referrals