-
-
- Citizenship Status
-
-
- Emp. Authorization ID Expiration Date
- ID Type - Select ALL that Apply
-
- {nycId} ID Expiration Date
-
- List B expiration date:
-
-
- Perm. Resident Card ID Expiration Date
-
-
- Foreign Passport I-551 ID Expiration Date
-
- US Passport Expiration Date
-
- US Passport Card Expiration Date
- I9 Hire Date
-
-
-
- Send Payrate PDF to user:
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Date of Birth:*
-
-
-
-
-
-
-
-
- What is your primary language?*
- Do you speak any other languages?*
- What other languages do you speak?*
-
-
-
-
-
- Do you have another Emergency Contact?
-
-
-
-
-
-
- Were you referred by anyone?*
-
-
-
-
-
-
-
-
-
-
- Do you have another Reference?
-
-
-
-
-
- Tax Marital Status*
- oldMarital Status
- Are you a resident of New York City?*
- Are you a resident of Yonkers?*
-
-
-
-
-
-
-
- HM - legally authorized to work
-
-
-
-
-
- Have you ever worked for this Employer before? Are you a re-hire?*
- Last Date of Employment
- Have you been terminated from a position in the last 10 years?*
- Are you currently employed by another Licensed Home Care Agency?*
- Are you currently employed by an other Organization or Privately?*
- HM - Not employed
-
-
-
-
-
-
-
-
- Do you have another Former Employer to add?
-
-
-
-
-
-
-
- Do you have a third Former Employer to add?
-
-
-
-
-
-
-
-
- Would you like to enroll in the Castle Rock Home Care Health Plan?
- I decline enrollment at this time because:
-
- Coverage Type:
-
-
-
- Would you like to sign up for direct deposit?*
-
-
-
- Account Type*
- I wish to deposit:*
-
- Do you have another bank to add?*
-
-
-
- Account Type*
- I wish to deposit:*
-
-
- Hep B Vaccine - Please select from one of the following:*
- Influenza (flu) Vaccine Declination: Please check all that apply.
-
-
- Select the following:*
- Understanding the above facts, I voluntarily choose to decline the COVID-19 vaccine at this time. However, I recognize my right to change my decision and opt for vaccination in the future.*
-
- Have you ever been tested for exposure to tuberculosis by having a TB skin test?*
- Date of last skin test:
- Result:*
- Has anyone in your family had TB?*
- Have you had any of the below symptoms during the past month?*
-
-
- Have you been around anyone who have or is suspected of having active TB or anyone with the above symptoms?*
- Have you been in contact with anyone who lives in a shelter, prison, drug user or HIV/AIDS infected?*
- Have you recently traveled to a foreign country?*
-
- Have you been vaccinated against tuberculosis with BCG vaccine?*
- Are you currently taking immuno-suppressive drugs?*
-
-
- 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?*
-
-
- Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?*
- 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?*
- 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 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?*
-
-
- I am currently working:*
- I have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or I am enrolled in a TASC program.*
-
-
-
- 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?*
- Have you been arrested or convicted of a crime before?*
- Date of Conviction
- Date of Release
-
-
- Were you referred to this employer by:*
- To the best of your knowledge, are you able to perform all duties required for this position with or without a reasonable accommodation?*
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- 1. Which of the following is important in communication with people?*
- 2. The patient tells you he has not moved his bowels in three days. What should you do?*
- 3. Mrs. Rand, who has diabetes and takes insulin regularly, tells the Home Health Aide that she feels very nervous and jittery. What should the Aide do immediately?*
- 4. During a visit, you need to wash your hands after removing gloves:*
- 5. In what situation should gloves be used?*
- 6. A neighbor has asked you some questions about the patient you are presently taking careof: "Mrs. Collier is dying, isn't she?" How will you answer her?*
- 7. When working with persons who are disabled, the general goal of care is to:*
- 8. Which of the following is the most appropriate practice to promote good skin care in the elderly?*
- 9. In giving foot care to a patient who has diabetes, the Home Health Aide/PCA may take which of these actions?*
- 10. When assisting a patient to walk with his walker, you should:*
- 11. A patient who has been on bed rest is to get up in a chair. The Home Health Aide helps the patient to sit on the edge of the bed. The patient says "I am dizzy". What should the Aide do?*
- 12. Which of these statements describes good body mechanics?*
- 13. Milk is a good source of calcium. Which of these foods is also high in calcium?*
- 14. When patients do not have enough fluids, they may develop which of these problems?*
- 15. Patients on low salt diets are usually allowed to have which of these foods?*
- 16. Transmission of bloodborne pathogens in workplace is most likely to occur due to:*
- 17. Bloodborne pathogens are disease-causing microorganisms that are present in:*
- 18. Patient complains of falling three times in the past two days. Which of the steps should you take?*
- 19. Mrs Seever has Alzheimer’s disease. Her caregiver reports that Mrs. Seever has been trying to leave the home at all hours. What should you do?*
- 20. Part of your duties as a Home Health Aide/PCA is to ensure a safe home environment, this includes:*
- 21. In case of fire in the home what is the best procedure to follow?*
- 22. Patient suddenly complains of intense, squeezing pain in the chest that goes down the arm. The patient is sweating profusely. What should Home health aide/PCA do?*
- 23. You are watching your client transfer from bed to chair when he suddenly becomes weak and begins to fall. You should:*
- 24. A person with TB disease may exhibit any of the following symptoms except:*
- 25. Tuberculosis is:*
-
-
- HM Pass/Fail
- Should be Empty: