HHA - Prime Assisted Home Care

HHA/PCA Application for Employment
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

NYC IDState 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
{nycId} ID Number
{nycId} ID Expiration Date

MonthDayYear
State Benefit 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
Start Date

MonthDayYear
Base Rate
Supplemental Wages
Overtime Rate
Office Signature

Clear
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
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?*

YesNo
Emergency Full Name:*
Mobile Phone Number:*
Home Phone Number:
Relationship:*
What is {emergencyFull2}'s relationship?
What is your primary language?*

EnglishSpanishRussianBengaliCantoneseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishKoreanMandarinCreoleChinese
Do you speak any other languages?*

YesNo
What other languages do you speak?*

EnglishSpanishRussianBengaliCantoneseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishCreoleMandarinChinese
How did you hear about us?*
Other - Please specify:*
Friend's Name:*
Referral-Employee Name:*
How would you like to be notified?*

Mobile/TextVoice messageEmail
Do you have a Valid Driver’s License?*

YesNo
Current marital status:*

SingleMarriedDivorcedWidowed
Education and Training
Do you have experience working with computer?*

YesNo
Did you graduate High School?*

YesNo
High School Name:
City and State:
Did you attend college?

YesNo
College Name:
College City/State:
Major Course of Study:
Degree/Diploma Certification:
Did you graduate?

YesNo
Number of Years completed:
HM - Name of School:
HM - City and State
Do you have a HHA Certificate?*

YesNo
Name of School/Program:
Date Completed:

MonthDayYear
Do you have a PCA Certificate?*

YesNo
Name of School/Program:
Date Completed:

MonthDayYear
Are you currently employed of any of the following:*

Licensed Home Care AgencyCertified Home Health AgencyOther OrganizationNone of the above
Your Veteran and/or Disability Status:

Vietnam Era VeteranSpecial Disabled VeteranOther Eligible VeteranDisabled IndividualN/A
Preferences & Shift Availability

Choose Days and Times *

	AM	PM	Availability
SATURDAY
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY

Shift Preference*

4 hour8 hour12 hourLive-in
Which location(s) can you work in?*

BrooklynBronxManhattanQueensStaten IslandNassauSuffolk
Do you work with pets?*

YesNo
Are you able to work with smokers?*

YesNo
Do you have kosher experience?*

YesNo
Work Experience and Professional References
Employer Name:
Employer Address:
Supervisor's Name:
Phone:
Position:

PCAHHAOther
Start Date:

MonthDayYear
End Date:

MonthDayYear
Do you have another employer to add?

YesNo
Employer Name:
Employer Address:
Supervisor's Name:
Phone:
Position:

PCAHHAOther
Start Date:

MonthDayYear
End Date:

MonthDayYear
Have you ever worked with us before?*

YesNo

Additional References:

	Name	Phone Number	Relationship
Reference 1
Reference 2

Benefits & Compensation
Select which benefits plan interested in:*

Medical Benefits (Click to learn more)Flex Card (decline medical benefits) (Click to learn more)
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:*

I am already enrolled in a health planOther
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.*

Mailed CheckOffice Pick up
Is your mailing address the same as where you live?*

YesNo
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*

CheckingSavings
I wish to deposit:*

The entire net amountA certain dollar ($) amount
Enter the specific dollar amount:
Do you have another bank to add?*

YesNo
Bank Name:*
Bank City/State:*
HM - Bank Info:
Routing/Transit #:*
Account #:*
Type of Account*

CheckingSavings
I wish to deposit:*

The entire net amountA certain dollar ($) amount
Enter the specific dollar amount:
W4
Tax Marital Status*

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
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?*

YesNo
Are you a resident of Yonkers?*

YesNo
Legal & Background Checks
Have you ever been convicted of healthcare fraud?*

YesNo
Have you ever been assessed and paid any civil monetary penalties in connection with offenses related to the provision of health care?*

YesNo
Are you listed by a Federal agency as excluded, debarred or otherwise ineligible toparticipate in federally funded health care programs?*

YesNo
Have you been convicted of a crime?*

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

YesNo
Please explain:*
Health Questionnaire
Influenza (Flu) Vaccine:*

I want to receive the flu vaccineI have declined the Flu Vaccine for the current seasonI already have the vaccine for this season
- 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.*

I understand
Hep B Vaccine - 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 agency.I WOULD like to request the Hepatitis B VaccineI have already received the Hepatitis B Vaccine Series
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*

I am NOT allergic to yeast or yeast products.I am NOT currently immune suppressed, neither by disease nor medication
Did you ever have a positive TB Test?*

NoYes
When did you test positive?*

MonthDayYear
Have you been treated with Tuberculosis medication?*

NoYes
Duration of treatment:*
years, months, etc
Medication(s) used:*
years, months, etc
Have you ever received a BCG (Tuberculosis Vaccination)?*

NoYes
Have you ever been exposed to an isolated case of TB this year?*

NoYes
Have you had a TB x-ray?*

NoYes
When did you have the TB x-ray?*

MonthDayYear

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

	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?

YesNo
What type of treatment?
Have you received the COVID-19 vaccination?*

YesNo
* I hereby confirm my understanding of the following facts: COVID-19 is a grave disease that has resulted in the deaths of over 1 million people in theUnited States alone.

The COVID-19 vaccine aims to protect not just me, but also my patients, colleagues, our families, and the broadercommunity from the disease and its severe complications, including death. If I contract COVID-19, I can becontagious 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, potentiallycausing 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.
By clicking the submit button, I agree to terms & conditions.*

I Agree
Applicant Signature*

Clear

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.