Life Care Home Care HHA

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

State IDNYC 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
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:

YesNo
Personal Information
First Name*
Middle Name
Last Name*
Maiden Name
Alias/AKA
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
Country of Birth:*
City of Birth:*
Social Security #:*
Race:*
Gender*

FemaleMale
What is your primary language?*

EnglishSpanishRussianChineseUrduCreoleFrenchArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengali
Do you speak any other languages?*

YesNo
What additional languages do you speak?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengaliCreoleFrench
Please describe necessary accommodations: *
First/Last
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship*
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship*
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship*
How did you hear about Life Care?*
Availability
Days Available:

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Which city are you available to work in?

BrooklynQueensBronxManhattanStaten Island
Hours Available:

4 hours6 hours8 hours10 hoursLive-In 24 Hour Shift

Availability*

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

Will you work with children?*

YesNo
Will you work with pets?*

YesNo
Will you work with smokers?*

YesNo
Do you have experience with Kosher Kitchen?*

YesNo
Do you have experience with Hoyer Lift?*

YesNo
Will you travel?*

YesNo
Do you drive?*

YesNo
Have you applied for employment with us?*

YesNo
Have you worked within past 6 months?*

YesNo
When did you apply with us?*

MonthDayYear
Date
When will you be available to begin work?*

MonthDayYear
Date
Apart from absence for religious observance, are you available for full-time work?*

YesNo
Are you currently employed by another Licensed Home Care Agency?*

YesNo
Employment History
List below your previous employer(s), starting with the last one.
Name Of First Employer
Address
Name of Supervisor
Responsibilities
Phone Number
Please enter a valid phone number.
Reason for Leaving
Weekly Pay
Start Date
End Date
Do you have a second employer to add?

YesNo
Name Of Second Employer
Address
include city/state/zip
Name of Supervisor
Responsibilities
Phone Number
Please enter a valid phone number.
Reason for Leaving
Weekly Pay
Start Date
End Date
W4 & I9
Tax Marital Status*

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
HM -Tax Marital Status

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
Are you a resident of New York City?*

YesNo
Are you a resident of Yonkers?*

YesNo
Total number of children UNDER age 17*
Other Dependents*
Are you a U.S. Citizen?*

YesNo
Are you a lawful permanent resident?*

YesNo
Are you an alien authorized to work?*

YesNo
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?*

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

YesNo
Please provide a brief explanation of the violation
Health Questionnaire
Hep B Vaccine Program - Please select from one of the following:*

CONSENT: I wish to receive the Hepatitis vaccineAlready have the vaccine and can provide writn proof previous vaccinationProvide written proof immunityProvide written proof of medical contrdictionDECLINATION:I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I know this continues to put me at risk, but if in the future, while actively working with the Company, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive at no charge to me.
Influenza (Flu) Vaccine - Please select from one of the following:*

I will be getting the flu vaccine for the Flu season or I have already had the vaccine. I will wear a surgical mask during any time spent with any patientsI will NOT be getting the flu vaccine for the Flu season. I will wear a surgical mask during any time spent with any patients.
Reason for declining:*

Medical reasons (must have a NYS DOH 4482 filled out by a physician)Personal (non-medical) reasonsReligious reasons
My Employer, Life Care Services Inc. has recommended that I receive influenza vaccination to protect the patients I serve. I acknowledge that I am aware of the following facts:

•Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
•Influenza vaccination is recommended for me and all other healthcare workers to protect this facility's patients from influenza its complications, and death.
•If I contract influenza I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
•If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill
•I understand that the strains of virus that cause influenza infection change almost every years and, even if they don't change, my immunity declines over time. This is why vaccination against influenza is recommend each year.
•I understand that I cannot get influenza from the influenza vaccine.
•The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including patients in this healthcare facility, my coworkers, my family, my community

Despite these facts, I am choosing to decline influenza vaccination right now.
Because I refused influenza vaccination I will be required to wear surgical or procedure masks in areas where patients or residents may be present during influenza season. I understand that l can change my mind at any time and accept influenza vaccination, if vaccines is still available. I have read and fully understand the information on this declination form.
Government Assistance
Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?*

YesNoNot Sure
Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?*

YesNo
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?*

YesNoNot Sure
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?*

YesNo
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?*

YesNoNot Sure
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days?*

YesNo
Have you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit?*

YesNo
Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?*

YesNo
Unemployed Since:

MonthDayYear
Employee Status & Referrals
Are you a Veteran of the US Armed Forces?*

YesNo
Are you entitled to compensation for a service-connected disability?*

YesNo
Were you discharged from active duty within the last year?*

YesNo
Were you employed for 35 or more hours during any week in the 180-day period immediately prior to the date on which you began employment with the employer?*

YesNo
Were you convicted of a Felony during the year before you were hired?*

YesNo
Were you referred to this employer by:

A Vocational Rehab Agency approved by the state?An Employment Network under the Ticket to Work Program?The Dept. of Veteran Affairs?None of the above / Not Sure
Were you referred to an employer by a Vocational Rehabilitation Agency approved by a State? *

YesNo
To the best of your knowledge, are you able to perform all the duties required for this position without reasonable accommodation?

YesNo
Have you ever worked for this Employer before? Are you a re-hire?*

YesNo
Policies
Terms and Conditions:*

I have reviewed the above document and agree to the Terms and Conditions
Applicant Signature*

Clear
Employer's Business Organization Address

	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?

	Name & Location of School	Last Year Attended	Graduated
High School
College 1
College 2
Other

For Office Use Only

Personal Information

Availability

Employment History

W4 & I9

Health Questionnaire

Government Assistance

Employee Status & Referrals

Policies

New York Urban Youth Jobs Program

Education, References & Employment History

Benefits

Consumer/Patient Information

Payment - Direct Deposit