Joyful Home Care HHA/PCA 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
ID Expiration Date as text
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
Base Rate
Supplemental Wages
Overtime Rate
Send Payrate PDF to user:

YesNo
Personal Information
First Name*
Middle Name
Last Name*
Alias/AKA Name
Maiden Name
Street Address:*
Apartment/Suite #:
Hidden spacer
City:*
State:*
Zip:*
County you live in:*
Mobile Phone Number:*
Home Phone Number:
Work Phone Number:
Email Address :*
example@example.com
Gender:*

MaleFemaleOther
Gender-doh103
Preferred method of contact:*

MobileHomeWork
Date of Birth:*

MonthDayYear
Social Security #:*
Eye Color:*
Hair Color:*
Weight:*
in pounds
Height*
Current Marital Status:*

MarriedSingle
What is your primary language?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengaliAzerbaijaniCreoleFrenchTajikArmenian
Do you speak any other languages?*

YesNo
What other languages do you speak?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengaliAzerbaijaniAlbanianTajikArmenianMalayalam
Country of Birth:*
Race:*
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship:*
Time Known:*
How did you hear about Joyful Home Care?*
Availability

Daily availabiity:*

	Start Time	End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Hours (Select all):*

4 hours6 hours8 hours10 hours12 hoursLive-in (24 hours)Live in Nights
Desired boroughs available to work:*

QueensNassauSuffolk
Transportation:*

CarBusTrainOther
Available Start Date:*

MonthDayYear
References
Reference Contact Name 1:*
First/Last
Phone Number:*
Relationship:*
How long known 1:*
Address 1

Street Address

Street Address Line 2

CityState

Zip Code
Do you have another Reference?

YesNo
Reference Contact Name 2:*
First/Last
Phone Number:*
Relationship:*
Address 2

Street Address

Street Address Line 2

CityState

Zip Code
How long known 2:*
W4 & I9
Tax Marital Status*

Married Filing JointlyMarried Filing SeparatelySingleHead of Household
oldMarital Status

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
Are you a resident of New York City?*

YesNo
Are you a resident of Yonkers?*

YesNo
Total number of children UNDER age 17*
Other Dependents*
Legal and Background Check
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:
HM - legally authorized to work

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

YesNo
Last Date of Employment

MonthDayYear
Date
Have you been terminated from a position in the last 10 years?*

YesNo
Please explain:
Education & Employment History
Highest level of education*

High SchoolCollegeNeither
School Name*
Address*
Diploma/Degree Type*
Diploma/Degree Name*
Course of Major*
Year Completed*
Did you graduate?*
Do you have any professional licenses or certifications?*

YesNo
School Program
Certification Type:

HHAPCA
HM - Certificate Type
Registry Number:
List below your previous employer(s), starting with the last one.
Name Of First Employer
Position
Reason for Leaving
Start Date
End Date
Do you have another Former Employer to add?

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

YesNo
Name Of Third Employer
Position
Reason for Leaving
Start Date
End Date
Benefits & Compensation
Would you like to sign up for direct deposit?*

YesNo
Bank Name*
Bank Account Number*
Confirm Bank Account Number*
Bank Routing Number*
Account Type*

CheckingSavings
Medical Benefits
Select from the following:*

I wish to enroll in Major Medical InsuranceSupplemental BenefitsI decline to enroll in the insurance plan
I decline enrollment at this time because:*

I have insurance through another jobI have insurance through my spouse's jobI have MedicaidI have MedicareOther
If you are declining enrollment for yourself because of other healthcare coverage, you may enroll yourself prior to the next enrollment period. To do this, you must have involuntarily lost your other coverage and we must receive your enrollment application within 30 days after your other coverage ended.

Any person who knowingly and with intent to defraud any insurance company or other persons files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed $5,000 dollars and the stated value of the claim for each violation. Any material misrepresentation within this waiver may subject the group to termination.
Coverage Type:*

Employee OnlyEmployee + SpouseEmployee + Child(ren)Family
Reason to decline coverage:
Spouse Name:
Health Questionnaire
Hep B Vaccine - Please select from one of the following:*

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 understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious material and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.I have been vaccinated with Hepatitis B vaccine and will supply the agency with supporting documentation.I consent to receiving the vaccine series at no charge to me
Date Vaccine Received:*

MonthDayYear
Date
Have you received or will receive the Influenza (flu) Vaccine?*

YesNo, I wish to decline
Influenza (flu) Vaccine Declination:*

I can't afford the vaccineI am allergic to eggs or other medical contraindicationOther: I don't want another shot
Government Assistance
Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?*

YesNo
Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?*

YesNo
Name of Primary Recipient of Food Stamps (SNAP):
And City, State where benefits were received (SNAP):
Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?*

YesNo
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?*

YesNo
Are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired?*

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

YesNo
Name of Primary Recipient of Cash Benefits (TANF):
And City, State where benefits are received (TANF):
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days?*

YesNo
Have you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit?*

YesNo
Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?*

YesNo
What sate did you receive unemployment compensation?
Are you a Veteran of the US Armed Forces?*

YesNo
Are you a member of a family that received SNAP benefits for at least 3 months during the 15 months?*

YesNo
Are you a veteran unemployed for a combined period of at least 4 weeks during the year before you were hired?*

YesNo
Name of Primary Recipient of Benefits:
And City, State where benefits are received:
Have you been arrested or convicted of a crime before?*

YesNo
Date of Conviction*

MonthDayYear
Date of Release*

MonthDayYear
Type of Felony:*

FederalState
Please explain:
Were you referred to this employer by:*

A Vocational Rehab Agency approved by the state?An Employment Network under the Ticket to Work Program?The Dept. of Veteran Affairs?None of the above / Not Sure
To the best of your knowledge, are you able to perform all duties required for this position with or without a reasonable accommodation?*

YesNo
Live in Collect
New York Urban Youth Jobs Program
New York Youth Jobs Program: Youth Certification Qualifications:

To participate in the New York Youth Jobs Program:
- You must be 16 to 24 years old, and
- You must live in one of the target areas of New York State listed in item nine on page one, and You must be unemployed, and
- At least one of the following statements must apply to you:
  
  I am over 18 years of age and do not have a high school diploma or a General Educational
  
  Development (GED) or High School Equivalency (HSE) diploma.I am a member of a family that is receiving:
  
  Assistance from Temporary Assistance for Needy Families (TANF).
  
  Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps).
  
  Social Security Income (SSI) benefits.
  
  I am receiving a free or reduced-cost school lunch.
  
  I was referred to this program by a rehabilitation agency approved by the state, or anemployment network under the Ticket to Work Program.
  
  I have served time in jail or prison or I am on probation or parole.
  
  I am pregnant or a parent.
  
  I am homeless.
  
  I am currently or was in foster care or the custody of the Office of Children and Family Services.
  
  I am a veteran.
  
  I am the daughter or son of a parent who is currently in jail or prison, or was in jail or prison withinthe past two years.
  
  I am the daughter or son of a parent who is collecting unemployment insurance.
  
  I live in public housing or receive housing assistance such as a Section 8 voucher.
  
  I have another risk factor not identified above
If you believe that you are ineligible based on the program criteria, please select N/A below

N/A
I currently live in the town or city limits of the following target area:*

AlbanyNew RochelleUticaBrookhavenNew York City (5 Boroughs)White PlainsBuffaloRochesterYonkersHempsteadSchenectadyMount VernonSyracuseOther
Are any of the following statements true:
- I am currently unemployed
- I was unemployed prior to completing this application
- I do not have enough paid work
- The work I have does not make sure of my skills and training
Yes No*
I have working papers:*

YesNo
I am currently attending High School:*

YesNo
I am currently enrolled in a High School Equivalency (HSE) program:*

YesNo
I am 16 or 17 years old and I have my parent's or guardian's permission to submit this application:*

YesNo
Parent or Guardian Name:*
Parent or Guardian Phone Number:*
I have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or I am enrolled in a TASC program.*

YesNo
I would like the Department of Labor to contact me by:*

PhoneEmail
Signature
Please review the following documents:
By clicking the submit button, I agree to terms & conditions.*

I Agree
Applicant Signature *

Clear
Remote Inspected

Yes
Remote Inspected Date
Remote Inspected By First Name
Remote Inspected By Last Name
Remote Inspected By First Name
Remote Inspected By Last Name:
Remote Inspected Date:
PayRate NYC Amount
PayRate NYC #2
PayRate NYC #3
PayRate NYC a#1
PayRate NYC a#2
PayRate NYC a#3
Supplement Number #2
Supplement Number #1
PayRate #7

	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

References

W4 & I9

Legal and Background Check

Education & Employment History

Benefits & Compensation

Medical Benefits

Health Questionnaire

Government Assistance

New York Urban Youth Jobs Program

Signature

Quiz