Bwell Home Care HHA/PCA

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

MonthDayYear
ID Type - Select ALL that Apply
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:
Personal Information
First Name
Middle Name
Last Name
Maiden Name
Alias Name
Mother's Maiden Name
Mother's First 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 #:
Country of Birth:
City of Birth:
Race:
Gender:
Eye Color:
Hair Color:
Weight:
Height:
May we send you text messages?
How did you hear from us?

Other
What is your primary language?
Do you speak any other languages?
What additional languages do you speak?
Emergency Contact Name:
First/Last
Phone Number:
Relationship
Emergency Contact Name:
First/Last
Phone Number:
Relationship
Emergency Contact Name:
First/Last
Phone Number:
Relationship
Availability
Are you able to work with patients with pets?
Are you able to work with patients who smoke?
Availability Days:
Desired work hours:

Other
Location of Preference:
W4 & I9
Tax Marital Status
HM -Tax Marital Status
Are you a resident of New York City?
Are you a resident of Yonkers?
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**
Have you been convicted of a crime other than a traffic violation?
Have you had a final finding of patient abuse?
Please provide a brief explanation of the violation
Have you ever been fingerprinted before at another Home Care Agency?
Date

MonthDayYear
Date
Education, References & Employment History

Education

Rows	Name of School	Date of Certification	Graduated
High School
College 1

Have you ever worked for this Employer before? Are you a re-hire?
List below your previous employer(s), starting with the last one.
Name Of First Employer
Address
Job Title
Supervisor Name
Phone Number
Reason for Leaving
Start Date
End Date
Do you have a second employer to add?
Name Of Second Employer
Address
include city/state/zip
Job Title
Supervisor Name
Phone Number
Reason for Leaving
Start Date
End Date
Health Questionnaire
Hep B Vaccine Program - Please select from one of the following:
COVID-19 Vaccine - Please select from one of the following:
COVID-19 Declination reason:
Influenza (Flu) Vaccine - Please select from one of the following:
Reason of declination:
Have you travelled outside of United State in the last 14 days?
Date Departed:

MonthDayYear
Date
Date Arrived at the US:

MonthDayYear
Date
Have you visited any facilities with confirmed COVID-19 cases (i.e. grocery store, bank)?
Does someone you are in close contact with have COVID-19 (household, daycare, etc.)?
Who?
Date Diagnosed:

MonthDayYear
Date
Are you close contact with someone who is sick with respiratory symptoms?
Who?
Date Symptom Began:

MonthDayYear
Date

Do you feel any of the following symptoms:

Rows	Yes	No
Fever?
Cough?
Difficulty breathing?
Muscle aches?
Fatigue?
Headaches?
Sore throat?
Runny nose?
Diarrhea?

Benefits
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?
Would you like to enroll in the Commuter Benefits Program? This is only eligible to full time employees.
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:
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?
Name of Primary Recipient of Cash Benefits (TANF):
And City, State where benefits are received:
Are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, AND the earliest 18-month period beginning after August 5, 1997, ended within 2 years 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?
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?
Unemployed Since:

MonthDayYear
Employee Status & Referrals
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?
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
Terms & Conditions:
Applicant Signature
Pay Rate
Per hour for additional wage
Per hour for supplemental wages
Single Pay Overtime Rate
Wage Parity Overtime Rate

Rows	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

Availability

W4 & I9

Education, References & Employment History

Health Questionnaire

Benefits

Government Assistance

Employee Status & Referrals

Policies

Availability

New York Urban Youth Jobs Program

Payment - Direct Deposit