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

{nycId} ID Number

{nycId} ID Expiration Date

State Benefit 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

Start Date

Title:

Registry #:

Base Rate

Supplemental Wages

Overtime Rate

Office Signature

First Name

Middle Name

Last Name

Street Address:

Apartment/Unit #:

Hidden spacer

City:

State:

Zip:

ARLA Application Ticket Options

Other

Maiden Name

Mother’s Maiden Name:

Mobile Phone Number:

Home Phone Number:

Email Address:

example@example.com

Date of Birth:

Gender:

Social Security #:

Height:

Weight: Pounds

Eye Color:

Hair Color:

Country of Birth:

Race:

Emergency Contact Name:

First/Last

Phone Number:

Relationship:

Emergency Street Address:

City:

State:

Zip:

What is your primary language?

Do you speak any other languages?

What other languages do you speak?

How did you hear about us?

Have you worked with us before?

Start Date of Availability:

Date

Select ALL days/times available to work:

Rows	AM	PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Are you able to work every other weekend a month or every Saturday or every Sunday

How many hours daily are you available for?

Which city are you available to work in? (select at least 2 options)

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 bed bound patient?

Can you work with a male patient?

Do you have experience with patients who use a hoyer lift?

Do you have experience with patients who uses a wheelchair?

Do you have experience with patients who uses a walker?

Other experience:

Consumer Name:

First/Last

Phone Number:

Date of Birth

Date

Do you live with the consumer?

Relationship:

Company Name:

Phone Number:

Address:

Supervisor Name:

Job Title:

Responsibilities:

Employed Start Date:

Employed End Date:

Reason for leaving:

May we contact the provided supervisor as a reference?

Do you have another employer to add?

Company Name:

Phone Number:

Responsibilities:

Address:

Supervisor Name:

Job Title:

Employed Start Date:

Employed End Date:

Reason for leaving:

May we contact the provided supervisor as a reference?

Tax Marital Status

Total number of children UNDER age 17

Other Dependents

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**

Do you give Ultimate Home Care permission to conduct a Criminal Background check?

Have you been convicted of a crime?

Have you had a final finding of patient abuse?

Please explain:

Influenza (Flu) Vaccine

Where were you vaccinated?

Date Vaccinated:

What are the reason(s) of declining the flu vacation?

Other reasons for declining you wish to discuss

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

Do you have any of the below symptoms?

DIABETES
MIGRAINE HEADACHES
KIDNEY DISEASE
FAINTING OR DIZZINESS
HEART DISEASE
WEIGHT GAIN/LOSS 15+lbs. OR MORE
HIGH BLOOD PRESSURE
CHANGE IN ENERGY LEVEL
FREQUENT/PERSISTANT COUGH
TUBERCULOSIS
BLOOD IN SPUTUM
MENTAL ILLNESS
NIGHT SWEATS/FEVER/CHILLS

SHORTNESS OF BREATH
EPILEPSY/CONVULSIONS
CHEST PAIN/PRESSURE
CANCER
SWELLING IN LEGS AND FEET
PAIN IN CALF WHEN WALKING
CHANGE IN BOWEL HABITS
BACK PAIN WHEN URINATING
INFECTIOUS DISEASE
INCREASED THIRST
PERSISTANT SORES/LUMPS
ARTHRITIS
UNEXPLAINED FATIGUE (3+ WEEKS)

Please indicate any illness or symptoms experienced by you in the past or currently:

Rows	No	Yes
DIABETES
MIGRAINE HEADACHES
KIDNEY DISEASE
FAINTING OR DIZZINESS
HEART DISEASE
WEIGHT GAIN/LOSS 15+lbs. OR MORE
HIGH BLOOD PRESSURE
CHANGE IN ENERGY LEVEL
FREQUENT/PERSISTANT COUGH
TUBERCULOSIS
BLOOD IN SPUTUM
MENTAL ILLNESS
SHORTNESS OF BREATH
EPILEPSY/CONVULSIONS
CHEST PAIN/PRESSURE
CANCER
SWELLING IN LEGS AND FEET
PAIN IN CALF WHEN WALKING
CHANGE IN BOWEL HABITS
BACK PAIN WHEN URINATING
INFECTIOUS DISEASE
INCREASED THIRST
PERSISTANT SORES/LUMPS
ARTHRITIS
NIGHT SWEATS/FEVER/CHILLS
UNEXAMPLAINED FATIGUE (3+ WEEKS)
BACK PAIN

TUBERCULOSIS (TB) SCREEN

Rows	No	Yes
Does the patient have a history of temporary or permanent residence for greater than one month in a country with a high TB rate?
Has the patient had close contact with someone who has had TB?
Has the patient had a prior diagnosis of active or latent TB?
Has the patient been treated with medication for TB or for a positive TB test?

Do you drink alcoholic beverages?

How frequent do you drink alcohol?

Do you smoke?

How much do you smoke every day?

Do you take depressant or narcotic drugs that alter your behavior?

What type of drugs do you take that alter your behavior?

Name of your Physician:

Physician Phone #:

Name of Bank:

Bank Address:

Bank Telephone:

Account Number:

Routing Number:

Type of account:

What amount would you like to be deposited into this amount?

A certain %

How much dollars would you like to contribute to this account?

HM - Dollar amount

Do you have another account to add?

Name of Bank:

Bank Address:

Bank Telephone:

Account Number:

Routing Number:

Type of account:

What amount would you like to be deposited into this amount?

A certain %

How much dollars would you like to contribute to this account?

HM - Dollar amount

Medical Insurance

Additional benefit enrollments (select all that apply):

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?

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/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?

Are you no longer receiving TANF/Welfare because you reached the maximum allowable?

Did you receive TANF/Welfare for 9 months out of the past 18 months?

Name of Primary Recipient of Cash Benefits (TANF):

And City, State where benefits are received:

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?

Unemployed Since:

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?

Are you a Veteran of the US Armed Forces?

Are you entitled to compensation for a service-connected disability and you 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:

Date of Conviction:

Date of Release:

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:

Start date of most recent employment

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

Parent or Guardian First Name:

Parent or Guardian Last Name:

Parent or Guardian Phone Number:

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:

HHA/PCA Application for Employment

For Office Use Only

Personal Information

Availability

Consumer Information

Work Experience

W4 & I9

Legal & Background Checks

Health Questionnaire

Direct Deposit

Benefits Enrollment

Government Assistance

New York Urban Youth Jobs Program

Quizzes and Training

HHA CANDIDATE COMPETENCY TEST #1

Benefits & Compensation