Life Care Home Care HHA

HHA/PCA Application for Employment

Citizenship Status

Alien Registration Number/USCIS Number:

USCIS Number:

Emp. Authorization ID Expiration Date

ID Type - Select ALL that Apply

NYC ID Field for mapping

{nyState} ID Number

{nyState} ID Expiration Date

State Benefit ID Number

Permanent Resident Card ID Number

Perm. Resident Card ID Expiration Date

Employment Authorization Card ID

Foreign Passport with I-551 ID Number

Foreign Passport I-551 ID Expiration Date

US Passport ID Number

US Passport Expiration Date

US Passport Card ID Number

US Passport Card Expiration Date

Hire Date

Base Rate

Overtime Rate

Supplemental Wages

Send Payrate PDF to user:

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:

Country of Birth:

City of Birth:

Social Security #:

Race:

Gender

What is your primary language?

Do you speak any other languages?

What additional languages do you speak?

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?

Days Available:

Which city are you available to work in?

Hours Available:

Availability

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

Will you work with children?

Will you work with pets?

Will you work with smokers?

Do you have experience with Kosher Kitchen?

Do you have experience with Hoyer Lift?

Will you travel?

Do you drive?

Have you applied for employment with us?

Have you worked within past 6 months?

When did you apply with us?

Date

When will you be available to begin work?

Date

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

Are you currently employed by another Licensed Home Care Agency?

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.Format: (000) 000-0000.

Reason for Leaving

Weekly Pay

Start Date

End Date

Do you have a second employer to add?

Name Of Second Employer

Address

include city/state/zip

Name of Supervisor

Responsibilities

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reason for Leaving

Weekly Pay

Start Date

End Date

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

Medical Insurance Selection:

Reason for declining Major Medical Insurance:

Would you like to:

Account Type

Bank Name

Routing Number

Account Number

Hep B Vaccine Program - Please select from one of the following:

DECLINATION: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:

Reason for declining:

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.

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:

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 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?

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?

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

Terms and Conditions:

Applicant Signature

Employer's Business Organization Address

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?

Rows	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

Benefits

Payment - Direct Deposit

Health Questionnaire

Government Assistance

Employee Status & Referrals

Policies

New York Urban Youth Jobs Program

Education, References & Employment History

Benefits

Consumer/Patient Information