Harbor Care HHA

Application for Employment
For Office Use Only
Citizenship Status
Alien Registration Number/USCIS Number:
USCIS Number:
Emp. Authorization ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
ID Type - Select ALL that Apply
NYC ID Field for mapping
{nyState} ID Number
{nyState} ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
State Benefit ID Number
Permanent Resident Card ID Number
Perm. Resident Card ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Employment Authorization Card ID
Foreign Passport with I-551 ID Number
Foreign Passport I-551 ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
US Passport ID Number
US Passport Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
US Passport Card ID Number
US Passport Card Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Hire Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Base Rate
Supplemental Wages
Calculated based on Base Rate
Overtime Pay Rate
Calculated based on Base Rate x 1.50
Send Payrate PDF to user:
Introductory Questions
Which office are you applying in?
Office:
First Name
Last Name
Mobile Phone Number
1. Which of the following is the best way to help an elderly person with mobility issues move around safely?
2. When assisting with bathing, what should you do to make sure the water is safe for the elderly person?
3. Which of the following is the most respectful way to communicate with an elderly person who has hearing difficulties?
4. If an elderly person needs help getting dressed, you should:
5. Why is it important to keep elderly people hydrated?
6. When providing personal care, why is it essential to keep good personal hygiene for both the caregiver and the elderly person?
7. What should you do if an elderly person refuses to take their medication?
8. Which of these activities can help an elderly person stay mentally active?
9. Why is it important to observe changes in an elderly person's mood or behavior?
10. What should you do if an elderly person falls but seems okay afterward?
Test Score
Personal Information
First Name
Middle Name
Last Name
Mobile Phone Number
Email Address:
example@example.com
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Street Address:
Apartment/Suite #:
Hidden spacer
City:
State:
Zip:
Home Phone Number:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Social Security #:
Gender:
Eye Color:
Hair Color:
Weight:
Height:
What is your primary language?
Do you speak any other languages?
What additional languages do you speak?
Country of Birth:
Race:
Emergency Contact Name:
First/Last
Phone Number:
Relationship
Do you have another Emergency Contact?
Emergency Contact Name:
First/Last
Phone Number:
Relationship
Harbor Care Office You Applied In:
How did you hear about Harbor Care?
Insert Referral's Name
First/Last
Are you a resident of New York City?
Are you a resident of Yonkers?
Availability & Skills
Where do you prefer to work?

Skills:

Rows	No	Yes
Will you work with children?
Will you work with pets?
Will you work with Smokers?
Will you work with a male patient?
Do you have experience with Kosher Kitchen?
Do you have experience with Hoyer Lift?
Will you travel?
Do you Drive?
Do you have experience with bedridden patients?
Do you have any experience with wheelchair patients?
Do you have experience with dementia patients?
Do you have experience working with individuals with mental illnesses?
Do you have experience with Halal Kitchen?

Work Availability:

Rows	Start Time	End Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Hours Availability
W4 & I9
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**
Education & Employment History
Did you graduate High School?
High School Name
School Address
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Diploma/Degree Type
High school diploma

Cancelof
Did you graduate college?
College School Name
College Address
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Diploma/Degree Type
Did you have any other education?
Other School Name
Address
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Diploma/Degree Type
Have you ever worked for this Employer before? Are you a re-hire?
When did you work with us?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Health Questionnaire
Needed? Hep B Vaccine - Please select from one of the following:
Do you currently have any off the below symptoms?
- Weakness
- Unexplained Fatigue for more than 3 weeks
- Loss or 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
- Flu Like Symptoms
- Chest Pain

As a healthcare professional, I am aware that I may have exposure to the influenza virus. I am also aware that I can either consent or decline the vaccination.
- I understand that if I choose to decline the influenza vaccine, and my job duties may cause me to infect patients or to become infected, I may be required to wear a surgical mask for the duration of my shift. Failure to wear a surgical mask during duty will result in disciplinary action, up to and including termination.
- I understand that I may change my mind at any time and accept the influenza vaccination if the vaccine is available.
- I understand that if I decline the vaccine AND refuse to wear a surgical mask, I am voluntarily resigning my position at Harbor Care.
Choose an option:
I will receive the influenza vaccine from:
I decline the influenza vaccine for the following reason:
Direct Deposit
Type of Account
How will you be depositing your paycheck?
What is the desired dollar amount?
What is the desired percentage?
Name of Bank:
Account Number:
9-Digit Routing #:
Government Assistance
Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?
Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?
Name of Primary Recipient of Food Stamps (SNAP)
And City, State where benefits were received
Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?
Did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made?
Name of Primary Recipient of Cash Benefits (TANF):
And City, State where benefits are received:
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days?
Have you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit?
Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?
What state did you receive unemployment compensation in?
New York Urban Youth Jobs Program
Do you currently meet one or more of the youth categories below?
I confirm*

• I am pregnant or a parent of a child.
• I am over 18 and do not have a high school diploma of GED/HSE diploma.
• I am a member of a family that is receiving assistance from Temporary Assistance for Needy Families (TANF).
• I am a member of a family that is receiving SNAP benefits (food stamps).
• I am a member of a family that is receiving SSI benefits.
• I am receiving a free of reduced-cost school lunch.
• I have served in jail or prison, or am on probation or parole.
• I am currently or was in foster care of the custody of the Office of Children and Family Services.
• I am a veteran.
• I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years.
• I am the daughter or son of a parent who is collecting unemployment insurance.
• I live in public housing or receive housing assistance such as a Section 8 voucher, or am homeless.
• I have another risk factor not identified above
I am currently unemployed, or I was unemployed prior to completing this application or I do not have enough paid work that it is adequate with respect to my skills and training:
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I am currently enrolled in High School:
I am currently enrolled in a High School Equivalency (HSE) program or have obtained a high school diploma:
I am 16 or 17 years old and have the permission of my parent of guardian to submit this application:
Parent or Guardian Name:
Parent or Guardian Phone Number:
I have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or I am enrolled in a TASC program.
Agreement:
I have provided my private information on this application. While I need to disclose this information to qualify for the program, I understand that do not need to explain the reasons I choose to anyone I ask for a job, who gives me a job, or who I work with. I agree to allow the New York State Department of Taxation and Finance to share my wage records with the New York State Department of Labor. 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 details. I believe this information is correct and complete. I am aware that there are consequences for filing false documents or other information with the government.

When I check this box and submit this form, I agree to the statement above
Employee Status & Referrals
Have you been convicted of a crime?
Have you had a final finding of patient abuse?
If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
Label HHA/PCA
Are you a Veteran of the US Armed Forces?
Are you entitled to compensation for a service-connected disability?
Were you discharged from active duty within the last year?
Were you convicted of a Felony during the year before you were hired?
Date of conviction:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of release:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Federal or State conviction?
Were you referred to this employer by:
Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State?
To the best of your knowledge, are you able to perform all the duties required for this position without reasonable accommodation?
Policies
Please Review:
Terms and Conditions

Disclaimer:
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Influenza Vaccination Consent or Declination From:

As a healthcare professional, I am aware that I may have exposure to the influenza virus. I am also aware that I can either consent or decline the vaccination.

I understand that if I choose to decline the influenza vaccine, and my job duties may cause me to infect patients or to become infected, I may be required to wear a surgical mask for the duration of my shift. Failure to wear a surgical mask during duty will result in disciplinary action, up to and including termination.

I understand that I may change my mind at any time and accept the influenza vaccination if the vaccine is available.

I understand that if I decline the vaccine AND refuse to wear a surgical mask, I am voluntarily resigning my position at Harbor Care.

Hepatitis B Vaccine Declination:

I understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have also been asked if I have any questions regarding this information, and if I had questions, they have been fully answered to my satisfaction. I have been offered the opportunity to be vaccinated with the Hepatitis B Vaccine at no charge to myself.

I am choosing to decline the Hepatitis B Vaccine at this time. I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, while employed by Harbor Care, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Application Affidavit:

I have applied for a position as an HHA/PCA with Harbor Care LHCSA. All the information I have submitted is true to the best of my knowledge. All certificates are valid (or copies of the originals) and all background information is correct. I authorize Harbor Care to obtain any information regarding and pertaining to my employment and health status. I understand that this may include contacting the following to obtain information to verify signatures, dates, forms, and date.

Medical Providers (M.D. lab, etc...) Previous Employers Schools and training programs Professional and/or personal references.

I further release Harbor Care LHCSA of any liability that may occur as a result of my personal negligence or as a result of any information that I wrongfully or fraudulently submitted to Harbor Care LHCSA, or in the course of applying for a position during my association with them. I understand that any information fraudulently submitted will result in my immediate termination.

As a job applicant/employee of Harbor Care LHCSA, I hereby attest to the fact that I have received no special inducements, remuneration , or promises thereof to work for this agency. I understand that I will receive a salary commensurate and also in line with what other employees of this agency are receiving for similar work and experience. All other benefits that I may be eligible for will be in accordance with policies established by Harbor Care LHCSA.

Hiring of personnel, salaries and benefits are awarded without regard to race, religion, disabilities, marital status, or sexual orientation. Harbor Care LHCSA is an equal opportunity employer. I have read the preceding statement and I understand and agree with its contents.

Direct Deposit:

Harbor Care Agency is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

Employment Verification Applicant’s Authorization Release:

Applicant’s Authorization Release: I hereby authorize the release of any information requested by Harbor Care LHCSA concerning my employment in your company. I also release the above-named employer from all liability and responsibility regarding any information provided to Harbor Care about our past association.

Professional Reference Verification Release of Information:

I hereby authorize the release of any and all information requested by Harbor Care LHCSA. I release you from all liability and/or responsibility regarding the information provided by you about our past association. I agree that this information will be held in strict confidence and that I will not have access to this information. I appreciate your prompt attention to this matter.

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.
¬¬
CHRC:

I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own (not applicable for Expedited Review submitted pursuant to CHRC Form 104).

8850 Form:

I have provided my private information on this application. While I need to disclose this information to qualify for the program, I understand that I do not need to explain the reasons I choose to anyone I ask for a job, who gives me a job, or who I work with. I agree to allow the New York State Department of Taxation and Finance to share my wage records with the New York State Department of Labor. 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 details. I believe this information is correct and complete. I am aware that there are consequences for filing false documents or other information with the government.

Acknowledgement of Non-Relation:

I hereby confirm that I will not provide personal care or home health services for a patient to whom I am related in the following capacities: Spouse, parent, son, son-in-law, daughter, or daughter-in-law. If I am ever assigned to a patient to whom I am related in any of these capacities, I will immediately notify my coordinator.

SMS Messaging Terms:
By opting in to receive text messages from Harbor Care, you certify that you
are the owner or authorized user of the mobile phone number you provide and
that you are at least 18 years old or have appropriate consent. You understand
and agree that Harbor Care may send text messages to your number related to
your inquiry, care services, scheduling, or other important updates.
Message frequency may vary. Standard message and data rates may apply.
You may opt out at any time by replying STOP to any text message. Reply HELP
for help or contact us at info@harborcareny.com or 718-743-2432.
I agree to receive text updates, regarding care services, scheduling, marketing, or other important updates from Harbor Care at the number above. Msg & data rates may apply. Reply STOP to cancel. Reply HELP for help.
prefilledRecruiterCode
prefilledEvent
Applicant Signature
- Referred By:
- Certificates Display
- Which one of our offices are you closest to?
- Live in Collect
- Live in Collect 2
- Hidden/Mapped - Are there any types of patients you refuse to work with?
- Are you willing to do Live In Work? - Mapped
- Are you willing to work short hours? - Mapped
- Do you have a high school diploma?
- Do you have a college degree?
- College Degree or Major:
- Certifications Mapped
- Start/End Mapped1
- Start/End Mapped 2
- Language Application - Mapped
- Job 1 Date Range
- Job 2 Date Range
- Job 3 Date Range
- Direct Deposit - Mapped
- direct deposit Mailing Address - Mapped
  Enter a
- If Language is English PayRate
- If primary language is not english
- My primary language is - Pay rate - mapped
- 2 My primary language is - Pay rate - mapped
- Yes My primary language is - Pay rate - mapped PDF
- No My primary language is - Pay rate - mapped PDF
- Preparer’s Name and Title: - Pay Rate - Mapped
- Marital Status - W4
- Total Under 17 - W4
- Total Other Dependents - W4
- Total Dependents - W4
  Under 17 + Total other deponentes
- Employer’s name and address W4
  QUALITY HEALTH CARE 3512 QUENTIN ROAD BROOKYN, NY 11234
- Employer identification number W4 (EIN)
- Are you a resident of New York City? - Mapped 2104
- Are you a resident of Yonkers? - Mapped 2104
- Marital Status IT 2104 Mapped
- Marital status 2 IT 2104 Mapped
- Total number of allowances Yonkers 2104-mapped 2014
- Total number of allowances - NYC - mapped - 2014
- Total number of allowances
- Signature of Parent or Legal Guardian (if subject individual is under 18 years of age)
- EMPLOYER:
- ATTN:
- PHONE:
- FAX:
- RE:
- ID Type 2
- ID Type 3
- SSN Space Digits - I9
  Important - combines all SSN Digits
- New SSN Space Digits - I9
  Important - combines all SSN Digits
- First Name of Employer or Authorized Representative
- Title of Employer or Authorized Representative
- Last Name of Employer or Authorized Representative
- Employer's Business or Organization Name
- Employer's Business or Organization Address (Street Number and Name)
- City or Town
- sTATE
- ZIP
- Citizenship/Immigration Status - I9
  Important - baed on Citizen Status
- Date I9 Authorized
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Document Title List A
- Issuing Authority List A
- Document Number List A
- Expiration List A
- Document Title List A2
- Issuing Authority List A2
- Document Number List A2
- Expiration List A2
- Document Title List A3
- Issuing Authority List A3
- Document Number List A3
- Expiration List A3
- Document Title List B
- Issuing Authority List B
- Document Number list B
- Document Title List C
- Issuing Authority List C
- Document number List C
- First Name - I9
- Last Name - I9
- Middle Initial - I9
- Hire Date - I9
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Employer identification number (EIN) - 8850
- Default Company Name - 8850
- Starting Wage - 8850
  $17.00
- 8850 Capture #2
  If this contains yes then #2 on the 8850 will be checked off
- 8850 Refered By Capture
  If this contains yes then #2 on the 8850 will be checked off
- County
  If this contains yes then #2 on the 8850 will be checked off
- Are you a member of a family that received SNAP (Food Stamps Benefits)?
- MH - Age Under 40 - 8850
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- A Vocational Rehab Agency approved by the state? 8850
- An Employment Network under the Ticket to Work Program? 8850
- The Dept. of Veteran Affairs? 8850
- Were you referred to this employer by - none/not sure - 8850
- Position - 8850
- 8850 # 1
- 8850 # 2
- 8850 # 3-mapped
- 8850 # 4-mapped
- 8850 # 5-mapped
- 8850 #6
- 8850 #7
- Were you unemployed for a combined total of 6 months before you were hired?
- Are you under age 40? - 8850
- Start/End 3 Mapped
- TB Number1
- Number2
- Number3
- Number4
- Age 2 - Calculation for age range
- Age
  todays date - date of birth
- SSN First Three
- SSN Middle 2
- Mother's Maiden Name
- Name - First Last
- Name - First and Middle
- First name and middle initial - IT 2104-mapped
- Name - First and Middle Initial
- Name - First and Last 2
- Name - Middle Initial
- SSN Last 4 Substring
- SSN Last 4
- SSN First 3 Substring
- SSN - Last 4
- SSN - First 3
- SSN - Middle 2
- SSN Middle Substring
- Digit 1
- Digit 2
- Digit 3
- digit 4
- Digit 4
- digit 5
- Digit 5
- Recruiter
- 6
- Digit6
- 7
- Digit 7
- digit 8
- Digit 8
- digit 9
- Digit 9
- Digit 3
- Street and Apartment
- City State ZIP
- Full Address - Street/Apt/City/State/Zip
- State - application for employment
- M.I. - ID Mapped
- First Name
- Last Name
- Date of Birth
- SSN
- Phone Number
- Address - Street and Apt
- Address -City State ZIP
- Email
- Age Range 16-17 Yes/No
- Age Range 18-24 Yes/No
- Age Range 24 Under Yes/No
- When I check this box and submit this form, I agree to the statement above.
- Crime - No
- Crime - Yes
- Patient Abuse - Yes
- Patient Abuse - No
- Crime Mapping DOH CHRC
- Patient Abuse Mapping DOH CHRC
- Combined Height CHRC - Mapped:
- Convicted Of a Crime: CHRC - Mapped
- When: Logic Can be applied If needed
- Date Fingerprinted: Logic Can be applied If needed - ignore
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Declining coverage ACA, mapping
- Employer 1
- Employer 2
- Employer 3
- Employment Name 1
- Employment Name 2
- Employment Name 3
- Position 1
- Position 2
- Position 3
- Reason 1
- Reason 2
- Reason 3
- Date start/end 1
- Date start/end 2 _old
- Date start/end 3-old
- Employment Start Date
- Have you ever applied to this company before? If so, when?
- Name of Employer or Authorized Representative
- Are dependent health insurance benefits available for this employee? 2104
- Master Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Master Date Text
- When I check this box and submit this form, I agree to the statement above
- Unemployed Since:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- ID Type 4 state ID
- Caregiver Code
- mWhat languages do you speak?
- Full Name
- Google Form Column
- Emergency Contact 1
- Emergency Contact 2
- Availability
- Are you currently working as an HHA?
- Are you currently working as an HH? - Mapped
- What shift(s) can you accept?
- Can you work a short hour shift? (for example 9am - 1pm)
- Which days of the week can you work - hourly?
- Which days of the week can you work - live in?
- Are there any types of patients you refuse to work with?
- If you are employed as a full time employee (30 hours per week) would you like to enroll in our health benefits plan at an Affordable Level?
- You are declining coverage, because I have coverage from:
- Insurance Name
- Policy Number:
- Insurance Name:
- Policy Number:
- Insurance Name:
- Policy Number:
- Insurance Name:
- Policy Number:
- Another source of coverage (please specify):
- Insurance Name:
- Policy Number:
- Do you wish to enroll in the Commuter Benefits program?
- Number
- old - dropdown Weight:
- old - Height: Feet
- old - Height: Inches
- Old - Have you been convicted of a crime?
- Old - Have you had a final finding of patient abuse?
- reply to email
- Date1
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Date
- CHRC Date Mapped
- List below your previous employer(s), starting with the last one.
- Name Of First Employer
- Position
- Phone
- Supervisor
- Address
- City / State / ZIP
- Responsibilities
- Reason for Leaving
- Start Date
- End Date
- May we contact your previous supervisor for a reference?
- Do you have another Former Employer to add?
- Name Of Second Employer
- Position
- Phone
- Supervisor
- Street Address
- City / State / ZIP
- Reason for Leaving
- Start Date
- End Date
- Do you have a third Former Employer to add?
- Name Of Third Employer
- Position
- Reason for Leaving
- Start Date
- End Date
- Have you ever tested for Tuberculosis (TB)?
- What was the date of the Tuberculosis (TB) test?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- What as the result of the test?
- Have you ever had a Chest X-Ray done for Tuberculosis?
- What was the date of the chest x-rays for Tuberculosis?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Do you have a history of a temporary or permanent residence in a country with a high Tuberculosis Rate for at least 1 month?
- Do you have immunosuppression, current or planned?
- Have you ever been treated for Tuberculosis?
- When were you treated for TB?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Have you recently or in the past had close contact with someone who had an active tuberculosis infection?
- When were you in close contact with some who had TB?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Age Number
  used to calculate under age 40 question
- Should be Empty:

Rows	No	Yes
Weakness
Unexplained Fatigue for more than 3 weeks
Loss or 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
Flu Like Symptoms
Chest Pain

Application for Employment

For Office Use Only

Introductory Questions

Personal Information

Availability & Skills

W4 & I9

Education & Employment History

Health Questionnaire

Direct Deposit

Government Assistance

New York Urban Youth Jobs Program

Employee Status & Referrals

Policies

Availability