HHA - Prime Assisted Home Care

HHA/PCA 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
{nycId} ID Number
{nycId} ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
State Benefit 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
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Base Rate
Supplemental Wages
Overtime Rate
Office Signature
Personal Information
First Name
Middle Name
Last Name
Street Address:
Apartment/Suite #:
Hidden spacer
City:
State:
Zip:
County:
Mobile Phone Number:
Home Phone Number:
Email Address:
example@example.com
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender:
Social Security #:
Height:
Weight: Pounds
Eye Color:
Hair Color:
Country of Birth:
Race:
Emergency Contact Full Name:
Emergency Contact Mobile Phone Number:
Emergency Contact Home Phone Number:
Emergency Contact Email:
example@example.com
Relationship:
What is {emergencyname}'s relationship?
Do you have another emergency contact?
Emergency Full Name:
Mobile Phone Number:
Home Phone Number:
Relationship:
What is {emergencyFull2}'s relationship?
What is your primary language?
Do you speak any other languages?
What other languages do you speak?
How did you hear about us?
Other - Please specify:
Friend's Name:
Referral-Employee Name:
How would you like to be notified?
Do you have a Valid Driver’s License?
Current marital status:
Education and Training
Do you have experience working with computer?
Did you graduate High School?
High School Name:
City and State:
Did you attend college?
College Name:
College City/State:
Major Course of Study:
Degree/Diploma Certification:
Did you graduate?
Number of Years completed:
HM - Name of School:
HM - City and State
Do you have a HHA Certificate?
Name of School/Program:
Date Completed:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Do you have a PCA Certificate?
Name of School/Program:
Date Completed:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Are you currently employed of any of the following:
Your Veteran and/or Disability Status:
Preferences & Shift Availability

Choose Days and Times

Rows	AM	PM	Availability
SATURDAY
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY

Shift Preference
Which location(s) can you work in?
Do you work with pets?
Are you able to work with smokers?
Do you have kosher experience?
Work Experience and Professional References
Employer Name:
Employer Address:
Supervisor's Name:
Phone:
Position:

Other
Start Date:

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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Do you have another employer to add?
Employer Name:
Employer Address:
Supervisor's Name:
Phone:
Position:

Other
Start Date:

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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Have you ever worked with us before?

Additional References:

Rows	Name	Phone Number	Relationship
Reference 1
Reference 2

Benefits & Compensation
Select which benefits plan interested in:
Please review the Benefits Guide:
Please review the Flex Card:
* I hereby acknowledge the offer of medical insurance coverage, providing Minimum Essential Coverage (MEC), Behavioral Health Benefits, Telehealth, and Dental / Vision Discounts through Doctegrity. I understand by waiving medical coverage, by checking the box and completing the section below, I will not have an opportunity to enroll into benefits until my employer’s next open enrollment period or due to a qualifying event. I understand waiving coverage will result in my funds going to the Flex Card instead.
Reason for waiving coverage:

Other
HM - Reason for waiving coverage:
How would like to get paid?
Please provide HR with a copy of a voided check and select a backup payment method.
Is your mailing address the same as where you live?
Please Provide Your Mailing Address

Street Address

Apartment / Suite

CityState

Zip Code
Street
Apartment
City
State
ZIP
Bank Name:
Bank City/State:
Routing/Transit #:
Account #:
Type of Account
I wish to deposit:
Enter the specific dollar amount:
Do you have another bank to add?
Bank Name:
Bank City/State:
HM - Bank Info:
Routing/Transit #:
Account #:
Type of Account
I wish to deposit:
Enter the specific dollar amount:
W4
Tax Marital Status:
Total number of children UNDER age 17
Other Dependents
4(a) Other income (not from jobs):
If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here
4(b) Use the W4 Deductions Worksheet if you expect to claim deductions other than the standard deduction and want to reduce your withholding:
4(c) Extra withholding:
Enter any additional tax you want withheld each pay period
Are you a U.S. Citizen?
Please note: When you have completed your application, please provide to HR your Permanent Resident Card (front & back), Employment Authorization Card (front & back) or any other ID type you may have (front & back).
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**
Are you a resident of New York City?
Are you a resident of Yonkers?
Legal & Background Checks
Have you ever been convicted of healthcare fraud?
Have you ever been assessed and paid any civil monetary penalties in connection with offenses related to the provision of health care?
Are you listed by a Federal agency as excluded, debarred or otherwise ineligible toparticipate in federally funded health care programs?
Have you been convicted of a crime?
Have you had a final finding of patient abuse?
Please explain:
Health Questionnaire
Influenza (Flu) Vaccine:
- I have received information on teh importance of the Flu vaccincation
- I understand that I must wear a surgical mask while caring for patients during the flu season
- I have received a supply of surgical masks's from the agency
I understand that failure to comply with these requirements will put me and the patient I care for at risk, and that my employment with Agency is conditional on meeting the above requirements.
Hep B Vaccine - Please select from one of the following:
I have been provided with information on the Hepatitis B Vaccine and have been evaluated by an agency health professional. I have had the opportunity to ask questions about the benefits and risks of the Hepatitis B Vaccination. I also understand that there is no guarantee that I will be come immune and that there is a possibility that I will experience an adverse side effect from the yeast products
Did you ever have a positive TB Test?
When did you test positive?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Have you been treated with Tuberculosis medication?
Duration of treatment:
years, months, etc
Medication(s) used:
years, months, etc
Have you ever received a BCG (Tuberculosis Vaccination)?
Have you ever been exposed to an isolated case of TB this year?
Have you had a TB x-ray?
When did you have the TB x-ray?

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

Please indicate any illness or symptoms experienced by you in the past or currently:

Rows	No	Yes
Chronic cough
Cough with sputum
Color in sputum
Persistent night sweats
Chronic fatigue
Involuntary weight loss
Any serious illness

If you have any of the above symptoms you must see your physician.
Are you under any medical treatment for any condition at this time?
What type of treatment?
Have you received the COVID-19 vaccination?
HM - Have you received the COVID-19 vaccination?
The COVID-19 vaccine aims to protect not just me, but also my patients, colleagues, our families, and the broader community from the disease and its severe complications, including death. If I contract COVID-19, I can be contagious for several days before showing symptoms, endangering those around me and my patients. Even if I display mild or no symptoms, contracting the virus means I can still transmit it to patients, potentially causing them severe illness or death.

It's estimated that nearly 1 in 5 American adults who have contracted COVID-19 suffer from "Long COVID", enduring symptoms that can persist for months or even years, impacting their quality of life. If I get infected withCOVID-19, I risk serious, life-threatening consequences for myself and the patients I come into contact with, including vulnerable community members.

DECLINATION STATEMENT
:Understanding the above facts, I voluntarily choose to decline the COVID-19 vaccine at this time. However, I recognize my right to change my decision and opt for vaccination in the future.
I understand
By clicking the submit button, I agree to terms & conditions.
Applicant Signature
- Master Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Wage Parity Date
- HM - Mailed check Applicant Signature
- HM - Mailed check - date
- Number of Dependents
  Under 17 + Total other deponentes
- Marital Status - Page 2
- height calculation
- Gender - HM
- Patients Name - Mapped
- Primary Language
- Secondary Language
- If Language is English spanish russian PayRate
- If Language is English Spanish or Russian Creole
- 1 language is not english - Pay rate - mapped
- 2 My primary language is - Pay rate - mapped
- Total Under 17 - W4
- Total Other Dependents - W4
- Total Dependents - W4
  Under 17 + Total other deponentes
- 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
- Date of Birth DOH CHRC NYS Health - Mapped
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature of Parent or Legal Guardian (if subject individual is under 18 years of age)
- ID Type 2
- ID Type 3
- ID Type 4 state ID
- SSN Space Digits - I9
  Important - combines all SSN Digits
- 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
- Employer identification number (EIN) - 8850
- Starting Wage - 8850
  $15.00
- 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
- Are you a member of a family that received SNAP (Food Stamps Benefits)?
- MH - Age Under 40 - 8850
- A Vocational Rehab Agency approved by the state? 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?
- Start/End 3 Mapped
- Age 2 - Calculation for age range
- Age
  todays date - date of birth
- Mother's Maiden Name
- Name - First and Middle
- First name and middle initial mapped
- 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 4
- digit 5
- 6
- 7
- digit 8
- digit 9
- Street and Apartment
- Full Address - Street/Apt/City/State/Zip
- Age Number
  used to calculate under age 40 question
- State - application for employment
- M.I. - ID Mapped
- First Name
- Last Name
- Last Name
- Last Name
- Last Name
- Full Name
- Middle Initial
- Date of Birth
- SSN
- Phone Number
- Address - Street and Apt
- Address -City State ZIP
- City
- State
- ZIP
- Email
- Age Range 16-17 Yes/No
- Age Range 18-24 Yes/No
- underage Signature - HM
- CHRC Date Text
- HM CHRC spacing date field string NY Health
- 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
- 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
- Education & Employment History
- List below your previous employer(s), starting with the last one.
- Name Of First Employer
- Position
- Reason for Leaving
- Start Date
- End Date
- Do you have another Former Employer to add?
- Name Of Second Employer
- Position
- 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
- Name Master
  do not delete! used on all pages
- Covid Name Master
  do not delete! used on all pages
- Covid First Name
  do not delete! used on all pages
- Covid Last Name
  do not delete! used on all pages
- CovidDate
  do not delete! used on all pages
- Covid Signature
- Full Name
  do not delete! used on all pages
- Caregiver Code
- City State ZIP
- Google Column
- Certificates
- 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:
- NYC ID Field for mapping
- Sender Name
- Have you been convicted of a crime? - HM
- Marital Status
- Government Assistance
- Are you a member of a family that received SNAP (Food Stamps) benefits during the past 6 months?
- Did you get SNAP for 3 out of the past 5 months but are no longer getting them?
- 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/Welfare for the last 18 months before you were hired?
- Are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired?
- Did you start receiving TANF for any 18 months after August 5, 1997 which ended within 2 years before you were hired?
- Are you no longer receiving TANF/Welfare because you reached the maximum allowable?
- Did you receive TANF/Welfare for 9 months out of the past 18 months?
- 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?
- Were you Unemployed for the past 27 weeks and you received any unemployment benefits?
- Unemployed Since:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Did you receive a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit?
- Were you referred by a Network under the Ticket to Work program?
- Were you referred by a Network under the a Vocational Rehabilitation Agency approved by a State?
- Are you a Veteran of the US Armed Forces?
- Are you entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year
- Are you a veteran entitled to compensation for a service-connected disability and you were unemployed for aperiod or periods totaling at least 6 months during the past year.
- Were you convicted of a Felony during the year before you were hired?
- Type of Felony:
- 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
- New York Urban Youth Jobs Program
- I am currently unemployed, I was unemployed prior to completing this application or I do not have enough paid work or work that is adequate with respect to my skills and training.
- I have working papers:
- Start date of most recent employment
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- I am 16 or 17 years old and have the permission of my parent of guardian to submit this application:
- Parent or Guardian First Name:
- Parent or Guardian Last Name:
- Parent or Guardian Phone Number:
- 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 would like the Department of Labor to contact me by:
- Are any of the following five statements true?
  - I have a high school diploma.
  - I have a General Education Development diploma (GED).
  - I have High School Equivalency (HSE) diploma.
  - I have satisfactorily completed a Test for Assessing Secondary Completion (TASC) exam.
  - I am enrolled in a Treatment Accountability for Safer Communities (TASC) program.
- Are any of the following true? 18-24
- I currently live in the town, or city limits, of the following target area, check one:
  
  Other
- HM - Bank Info:
- I will provide
- HM - I will date
- HM - I will not date
- I will not provide
- Consumer/Patient First Name
- Consumer/Patient Last Name
- Personal Assistant Transportation
- Are you the consumer’s / patient’s designated representative?
- Is the consumer / patient your child who is under 21 years of age?
- Are you the consumer’s / patient’s spouse?
- I understand that if I cannot attest to the 3 statements above, I CANNOT act as the Personal Assistant for this Consumer. Any attempt to do so would be considered a violation of this CDPAP agreement and an act of fraud.
- At this time, we cannot accept your application. Please contact the human resources department.
- Marital Status - W4
- Should be Empty:

HHA/PCA Application for Employment

For Office Use Only

Personal Information

Education and Training

Preferences & Shift Availability

Work Experience and Professional References

Benefits & Compensation

W4

Legal & Background Checks

Health Questionnaire

Education & Employment History

Government Assistance

New York Urban Youth Jobs Program

At this time, we cannot accept your application. Please contact the human resources department.