Touch of Love Home Care Application

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
Expiration Date List B
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
Title:
Registry #:
Base Rate
Supplemental Wages
Overtime Rate
Office Signature
Personal Information
First Name
Middle Name
Last Name
Maiden Name
Mother's Maiden Name
Alias/AKA 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
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 Name:
First/Last
Phone Number:
Relationship:
What is your primary language?
Do you speak any other languages?
What other languages do you speak?
HM - Other Languages
Do you have any requirements needed to help perform any job-related tasks?
Please explain:
Do you have a drivers license?
Driver License Number
State of driver's License
Name on Driver's License
HM - Number and state
W4 & I9
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**
Preferences & Shift Availability
Position Desired:
Which days can you work?
What hours are you available?
HM - Days available to work
Education
Did you attend high school?
High School Name:
Highest Grade Completed:
Year Graduated:
Did you attend college/university?
College / University Name:
Highest Grade Completed:
Year Graduated:
Work Experience & References
Have you ever worked for Touch of Love Home Health Care Services? Are you a re-hire?
List below your previous employer(s), starting with the last one.
Name Of First Employer
Position
Supervisor's Name and Title
Phone Number
Reason for Leaving
Address
City:
State:
Zip:
Start Date
End Date
Do you have another Former Employer to add?
Name Of Second Employer
Position
Phone Number
Supervisor's Name and Title
Address
City:
State:
Zip:
Start Date
End Date
Reason for Leaving
Do you have a third Former Employer to add?
Name Of Third Employer
Position
Address
City:
State:
Zip:
Start Date
End Date
Reason for Leaving

List Two (2) Professional References (Non-Relatives)

Rows	Name	Phone Number	Relationship
Reference 1
Reference 2

Legal & Background Checks
Have you been convicted of a crime? (other than traffic violations)
Do you have a possible conflict to disclose, such as activities from myself or family members?
Please explain the conflicts:
Have you had a final finding of patient abuse?
Please explain:
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?
State where unemployment benefits are received:
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?
Were you referred by the Department of Veterans Affairs?
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 a period or periods totaling at least 6 months during the past year.
Are you a member of a family that received SNAP benefits for at least 3 months during the last 15 months?
Name of Primary Recipient:
And City, State where benefits are received:
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
Home Health Aide Assessment Test
1. Mrs. Jones takes her dentures out to be clean every night. After brushing then where should they be store until morning?
2. Mr. Smith just had his prescription filled and mentions to you, that the pills look different than the pills he usually takes. You:
3. Mr. Mitchell has just come home from the hospital after surgery and his neighbor stops you and asks how he’s doing? You:
4. Mr. Johnson refuses to let you was her genitals. You should:
5. Mr. Morris has just started using a walker to get around. For his own safety you
6. Mrs. Kipp has been constipated for the past few days and says that she is uncomfortable. She asks you to please give her an enema. You:
7. Which of the following drinks in highest protein?
8. Mr. Fredrick wakes and complaints of being dizzy. He is sweating and his skin feels clamming. You:
9. What is considered the normal temperature of the human body?
10. Mr. Babs must be transferred from the wheelchair to the commode. You:
11. Mrs. Everest has a headache. She wants to take Tylenol. You:
12. What does TRR stand for?
13. During your shift with Mr. Miner, you notice bruises on his arms and legs. He tells you that his son got angry when he wet the bed. You:
14. Mrs. Nesmith wet the bed. You must change her sheets. The first thing you do is?
15. After you put clean sheets on Mrs. Nesmith’s bed you:
16. Its lunch time. You fix Mr. Jacob’s his favourite soup and a sandwich. There is enough for two people so you:
17. You finished your shift for the day and you are running a little late. You:
18. An example of a well-balance meal is
19. You are walking behind Mrs. Gehman when she suddenly faints. You:
20. Mrs. Jenkins has extremely dry skin. The doctor has prescribed a medicated lotion to be applied two times a day. You:
By clicking the submit button, I agree to the terms & conditions of Touch of Love Home Care Inc.
Applicant Signature

I agree that the signature will be the electronic representation of my signature for all purposes when I (or my agent) use them on documents, including legally binding documents, just the same as pen-and-paper signature.

Rows	No	Yes
Does the patient have a history of temporary or permanent residence for greater than one month in a country with a high TB rate?
Has the patient had close contact with someone who has had TB?
Has the patient had a prior diagnosis of active or latent TB?
Has the patient been treated with medication for TB or for a positive TB test?

Rows	No	Yes
Do you drink alcoholic beverages?
Do you take depressant or narcotic drugs that alter your behavior?
Do you take prescription medications?
Do you smoke?

Rows	No	Yes
DIABETES
MIGRAINE HEADACHES
KIDNEY DISEASE
FAINTING OR DIZZINESS
HEART DISEASE
WEIGHT GAIN/LOSS 15+lbs. OR MORE
HIGH BLOOD PRESSURE
CHANGE IN ENERGY LEVEL
FREQUENT/PERSISTANT COUGH
TUBERCULOSIS
BLOOD IN SPUTUM
MENTAL ILLNESS
SHORTNESS OF BREATH
EPILEPSY/CONVULSIONS
CHEST PAIN/PRESSURE
CANCER
SWELLING IN LEGS AND FEET
PAIN IN CALF WHEN WALKING
CHANGE IN BOWEL HABITS
BACK PAIN WHEN URINATING
INFECTIOUS DISEASE
INCREASED THIRST
PERSISTANT SORES/LUMPS
ARTHRITIS
NIGHT SWEATS/FEVER/CHILLS
UNEXAMPLAINED FATIGUE (3+ WEEKS)

Rows	No	Yes
Frequent headaches/migraines
Diminished vision/glaucoma
Asthma
Pain, pressure or tightness in the chest
High blood pressure
Change in energy level
Heart trouble
Diabetes
Allergies
Weakness/paralysis
Seizure disorder
Arthritis
Back problems or pain
Fainting, blackout, dizziness
Hepatitis
Neck Problems
Any recent decline in your general health?

Rows	No	Yes
Unexplained productive cough
Unexplained weight loss
Unexplained appetite loss
Unexplained fever
Night sweats
Shortness of breath
Chest pain
Increased fatigue
Have been told you have TB
Lived with anyone with TB
Have you been exposed to someone with TB?
Have you left the country in the last 6 months?

Application for Employment

For Office Use Only

Personal Information

W4 & I9

Preferences & Shift Availability

Education

Work Experience & References

Legal & Background Checks

Government Assistance

New York Urban Youth Jobs Program

Home Health Aide Assessment Test

Availability

Benefits & Compensation

Health Questionnaire