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  • HHA/PCA Application for Employment

  • For Office Use Only

  • Citizenship Status
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  • ID Type - Select ALL that Apply
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  • Clear
  • By clicking the submit button, I agree to:*

  • By completing this application, you are applying to both Swift Home Care and Ultimate Care – two trusted home care agencies working together to offer you greater access to opportunities.

    One Application = Two Agencies
    Your application will be reviewed by both Swift Home Care and Ultimate Care, giving you access to job opportunities across both agencies.

    Double the Exposure = More Cases
    Being a part of both agencies means you’ll have a higher chance of getting matched with open cases that fit your location and availability.

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    • Personal Information

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    • What is your primary language?*
    • Do you speak any other languages?*
    • What other languages do you speak?*
    • Have you worked with us before?*
    • Rows

    • Availability

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    • Rows
    • Are you available to work on a live-in case?*
    • Which days of the week do you prefer to work a live-in case?*
    • Can you work with a patient who has a pet?*
    • Can you work with a patient who smokes?*
    • Can you work with a male patient?*
    • Transportation:
    • Prior Patient Experience:

    • Consumer Information

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    • Do you live with the consumer?

    • Work Experience

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    • May we contact the provided supervisor as a reference?*
    • Do you have another employer to add?*
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    • May we contact the provided supervisor as a reference?

    • W4 & I9

    • Tax Marital Status*
    • Are you a resident of New York City?*
    • Are you a resident of Yonkers?*
    • Current Marital Status*
    • Are you a U.S. Citizen?
    • Are you authorized to work in the U.S.?

    • **Sorry, we cannot accept your application at this time. Please start your application over again**

    • Legal & Background Checks

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

    • Health Questionnaire

    • Influenza (Flu) Vaccine*
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    • What are the reason(s) of declining the flu vacation?*
    • Do you have any of the below symptoms?*
      • Weakness
      • Fatigue
      • Lack of Appetite
      • Weight Loss
      • Night Sweats
      • Flu Like Symptoms
      • Chest Pain
      • Shortness of Breath
      • Blood Soak Sputum
      • Persistent Cough
      • Color of Sputum - Clear
      • Color of Sputum - Yellow
      • Low Grade Fever
    • Rows
    • Have you ever had a test for Tuberculosis?*
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    • Have you ever been exposed to anyone exhibiting the above signs or symptoms , or someone who has had active tuberculsis?*

    • Direct Deposit

    • Type of account:
    • What amount would you like to be deposited into this amount?
    • Do you have another account to add?*
    • Type of account:
    • What amount would you like to be deposited into this amount?

    • Benefits Enrollment

    • Medical Insurance
    • Additional benefit enrollments (select all that apply):

    • 401k Enrollment

    • Purpose of filing:*

    • I authorize the deduction of a PERCENTAGE of*   of my compensation for the Pre-Tax contribution portion of my account, subject to the requirements and limitations of the Plan. 

    • 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?*
    • 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 because you reached the maximum allowable?*
    • 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?*
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    • 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 Veteran Affairs?*
    • Are you a Veteran of the US Armed Forces?*
    • Are you a member of a family that receive SNAP (Food Stamp Benefits)?*
    • Are you entitled to compensation for a service-connected disability?*
    • 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.*
    • Were you convicted of a Felony during the year before you were hired?*
    • Type of Felony:*
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    • Clear
    • Application - Pages 1-2 
    • Clear
    • Gender - HM
    • Have you been convicted of a crime? - HM*
    • Pay Rate 
    • If Language is English PayRate
    • W4 
    • Marital Status - W4
    • IT 2104 
    • Are you a resident of New York City? - Mapped 2104*
    • Are you a resident of Yonkers? - Mapped 2104*
    • I9 
    • ID Type 2
    • ID Type 3
    • ID Type 4 state ID
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    • 8850 
    • HM Under age 40
    • A Vocational Rehab Agency approved by the state? 8850
    • The Dept. of Veteran Affairs? 8850
    • Important Calculations 
    • Urban Youth Hidden Mapped Fields 
    • Age Range 16-17 Yes/No
    • Age Range 18-24 Yes/No
    • Clear
    • CHRC 
    • Crime Mapping DOH CHRC
    • Patient Abuse Mapping DOH CHRC
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    • Hidden Mapped Fields 
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    • Insurance Benefits 

    • Benefits & Compensation

    • It can take up to two weeks for direct deposit payments. Please provide HR with a copy of a voided check and select a backup payment method.*
    • Is your mailing address the same as where you live?
    • I wish to pick up my check from:

    • Quizzes and Training

    • HHA CANDIDATE COMPETENCY TEST #1

    • 1. Sometimes a client may share religious beliefs and opinions which the home health aide does not agree with. What is the correct approach in dealing with such a situation?*
    • 2. Which should the Home Health Aide do first if her patient is having trouble in breathing is?*
    • 3. A home health aide works in the home of their client Mrs. Thompson, who is terminally ill. One day a neighbor asks the health aide if Mrs. Thompson is very ill. How should the health aide response?*
    • 4. A client accuses a home health aide of taking ten dollars without permission. The aide has not taken the money but the client refuses to believe her. What should the health aide do?*
    • 5. When a client complains of pain, what should the health aide do first?*
    • 6. What is the primary reason for covering your mouth and nose when coughing or sneezing?*
    • 7. Signs of infection should be reported to a supervisor. Which of the following are not signs of infection?*
    • 8. Which of the following may be an early warning sign of cancer?*
    • 9. Good sources of protein are:*
    • 10. Why is it important that a client have good mouth care?*
    • 11. A nonsterile dressing is one that is:*
    • 12. Which of the following are true about canes, walkers and crutches?*
    • 13. Mr. Jones is on a low-cholesterol diet. This means that he should not eat:*
    • 14. After Mrs. Thompson dies, her husband wishes to share his feelings and emotions. The aide should:*
    • 15. The reason for covering a burn with a clean cloth before going to the hospital for treatment is to:*
    • 16. If you do not know how to do an assigned task, you should:*
    • 17. Health care workers should wash their hands:*
    • 18. Customer service satisfaction is very important because ...*
    • 19. A client who is unable to move needs to have his position changed every:*
    • 20. When you take vital signs:*
    • HM - Pass/Failed

    • 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:
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    • I am 16 or 17 years old and have the permission of my parent of guardian to submit this application:
    • 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:
    • Should be Empty: