UJCES Home Care HHA Application

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
List B expiration date:

MonthDayYear
Date
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
I9 Hire Date

MonthDayYear
First Worked Date

MonthDayYear
Date
Base Rate
Supplemental Wages
Overtime Rate
Send Payrate PDF to user:

YesNo
Personal Information
First Name*
Middle Name
Last Name*
Street Address:*
Apartment/Suite #:*
Hidden spacer
City:*
State:*
Zip:*
Is your mailing address the same as where you live?*

YesNo
Please Provide Your Mailing Address*

Street Address

Apartment / Suite

CityState

Zip Code
Mobile Phone Number:*
Home Phone Number:
Email Address:
example@example.com
Date of Birth:*

MonthDayYear
Social Security #:*
Gender:*
Eye Color:*
Hair Color:*
Weight:*
in pounds
Height*
What is your primary language?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengali
Do you speak any other languages?*

YesNo
What other languages do you speak?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengali
Country of Birth:*
Race:*
Emergency Contact Name:*
First/Last
Emergency Contact Address:*
Emergency Contact Phone Number:
Emergency Relationship:*
How did you hear about UJC?*
Are you currently employed?*

YesNo
Where do you work?
Have you ever work for a home care agency before?*

YesNo
Have you ever been dismissed or suspended by a home care agency before?*

YesNo
Have you ever worked taken care of someone in the home before?*

YesNo
Have you applied to this agency before?*

YesNo

3 References: Non-relatives and must be known for at least a year*

	Name	Phone Number	Relationship	Time known
Reference 1
Reference 2
Reference 3

Availability
Are you currently working as an HHA?
What shift(s) can you accept?*

Hourly (12 hours)Live-in/Sleep-in
Which days of the week can you work - hourly?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Which days of the week can you work - live in?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
HM - Days Mapped
W4 & I9
Marital Status*

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
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?*
Have you had a final finding of patient abuse?*
If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
Were you ever fingerprinted before at another Home Care Agency?

YesNo
When did you have the fingerprints done?

MonthDayYear
Education

Education*

	Name	Location	Years Spent	Did you graduate	Subjects Studied
Grammar School
High School
College
Trade, Business School, Other

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

YesNo
Last Date of Employment

MonthDayYear
Date
List below your previous employer(s), starting with the last one.
Name Of First Employer*
Employer Address*
Supervisor Name*
Supervisor Phone*
Position*
Salary*
Reason for Leaving *
Start Date*
End Date*
Do you have another Former Employer to add?*

YesNo
Name Of Second Employer*
Employer Address*
Supervisor Name*
Supervisor Phone*
Position*
Salary*
Reason for Leaving *
Start Date*
End Date*
Do you have a third Former Employer to add?*

YesNo
Name Of Third Employer*
Employer Address*
Supervisor Name*
Supervisor Phone*
Position*
Salary*
Reason for Leaving *
Start Date*
End Date*
Health Questionnaire
Hep B Vaccine - Please select from one of the following:*

I am requesting to receive the Hepatitis B VaccineRefuse the Hepatitis B vaccine and hold the agency harmlessProvide written proof of my immunity (I will supply documentation)Provide written proof of previous vaccination (I will supply documentation)Provide written proof of medical contraindication (I will supply documentation)
Influenza (flu) Vaccine*
As part of your application process, you are required to take a Pre-Employment Medical Examination. This exam is FREE to you. As part of this exam, you will have to take a TB-Tuberculosis Screening Skin Test.

Some of you have either recently taken this TB Skin Test or will tell us that yon always test positive for TB. Either way, we will need to see proof of this test. Be advised that the New York State Department of Health (DOH) will not allow us to hire you as a Home Attendant without this proof.
I have read the above conditions*
Tuberculosis (TB) Screening Skin Test:*

I have recently taken the TB skin Test and I have a positive resultI have recently taken the TB skin Test and I have a negative resultI always test positive for TB, plese do not give me the test, I have proof to show youI have not had a recent TB test, I do not have a history of TB positive results. Please give me a Skin Test.
Benefits & Compensation
Would you like to enroll in direct deposit?*

YesNo
Bank Name*
Bank Account Number*
Quizzes
HIPAA TRAINING EXAMINATION
PH is:*

A. protected health informationB. personal health insuranceC. prioritized health informationD. none of the above
HIPAA is:*

A. is a law which extends traditional protections of private medical information to cover data stored and transmitted electronicallyB. important because it reminds us of the importance to Peep patient information confidentialC. requires all employees working in the health care field to be trained in protecting PHID. all of the above
HIPAA is important to home care workers because:*

A. it reminds workers to be careful of what they do with PHIB. medical privacy is a patient right •C. there are penalties for not complyingD. all of the above
Training in HIPAA for home care workers:*

A. is required by the federal governmentB. must be done every yearC. is only important for the office staffD. all of the above
You may discuss PHI freely with:*

1. your personnel specialist2. your UJC nurse3. the program director4. the UJC secretary5. the patient’s doctor6. any of the patient’s relatives7. another UJC home attendant
1. Technical safeguards protect your laptop as well as your agency’s computer systems.*

A.TrueB. False
2. A password is an example of a physical safeguard.*

A.TrueB. False
3. Logging into your computer system with your password is anexample of a physical safeguard, it could prevent someone fromtampering with your system.*

A.TrueB. False
4. It’s ok under HIPAA to have an unattended machine available to the public which receives EPHL*

A.TrueB. False
5. It’s bad practice under HIPAA to- back up data at the end of theworkday. I only need one place to have the date available. Naturaldisasters and theft of the computer systems never happen anyway.*

A.TrueB. False
SEXUAL HARASSMENT AT WORK
1. What is sexual harassment?*

A. A form of sex discriminationB. Unwelcome conduct sexual in natureC. Personally offensive languageD. All of the above
2. Sexual harassment includes interfering with an individual’s work performance because of intimidation and/or a hostile or offensive work environment.*

A.TrueB. False
3. Examples of sexual harassment*

A. Abusive languageB. PropositionsC. IntimidationsD. All of the above
4. Harassing behaviors*

A. TouchesB. Look/LeersC. BraggingD. All of the above
5. Who can be a target of sexual harassment?*

A. MalesB. FemalesC. TransgenderD. All of the above
6. Retaliation against a worker is tolerated under sexual harassment rules.*

A.TrueB. False
7. It is everyone’s responsibility to report sexual harassment.*

A.TrueB. False
8. All complaints should be investigated.*

A.TrueB. False
9. You can be held liable for engaging in sexual harassment and participating in an act to be discriminatory practice or attempting to do so.*

A.TrueB. False
By clicking the submit button, I agree to terms & conditions.*

I Agree
Signature
Applicant Signature *

Clear

	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?

HHA/PCA Application for Employment

For Office Use Only

Personal Information

Availability

W4 & I9

Education

Employment History

Health Questionnaire

Benefits & Compensation

Quizzes

HIPAA TRAINING EXAMINATION

SEXUAL HARASSMENT AT WORK

Signature

Government Assistance

New York Urban Youth Jobs Program

Employee Status & Referrals