Castle Rock HHA Application

HHA Application for Employment
For Office Use Only
U.S. CitizenPermanent ResidentAuthorized to Work
Alien Registration Number/USCIS Number:
USCIS Number:
Emp. Authorization ID Expiration Date

MonthDayYear
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
YesNo
Personal Information
First Name*
Middle Name
Last Name*
Alias/AKA Name
Maiden Name
Mother's Maiden Name
Mother's First Name
Street Address:*
Apartment/Suite #:
Hidden spacer
City:*
State:*
Zip:*
County you live in:*
Mobile Phone Number:*
Mobile Phone Number2:*
Home Phone Number:
Email Address :*
example@example.com
Date of Birth:*

MonthDayYear
Social Security #:*
Gender:*
Eye Color:*
Hair Color:*
Weight:*
in pounds
Height*
Race:*
EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengaliAzerbaijaniCreoleFrenchTajikArmenian
YesNo
EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengaliAzerbaijaniAlbanianTajikArmenian
Country of Birth:*
City of Birth:*
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship:*
YesNo
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship:*
How did you hear about Castle Rock Home Care?*
Position applying for:*
Are you related to any Castle Rock Employee?*
YesNo
Name of referral:
Education
HHA Registry Number
HHA Certificate Number
HHA Training School
References
Reference Contact Name 1:*
First/Last
Phone Number:*
Relationship:*
Time Known:*
YesNo
Reference Contact Name 2:*
First/Last
Phone Number:*
Relationship:*
Time Known:*
W4 & I9
Married Filing JointlyMarried Filing SeparatelySingleHead of Household
Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
YesNo
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:
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)
Work History
YesNo
Last Date of Employment

MonthDayYear
Date
YesNo
YesNo
YesNo
YesNo
List below your previous employer(s), starting with the last one.
Name Of First Employer
Position
Supervisor's Name
Phone Number
Reason for Leaving
Start Date
End Date
YesNo
Name Of Second Employer
Position
Supervisor's Name
Phone Number
Reason for Leaving
Start Date
End Date
YesNo
Name Of Third Employer
Position
Supervisor's Name
Phone Number
Reason for Leaving
Start Date
End Date
Benefits
YesNo - I understand that if I decline medical coverage, I will be unable to enroll in benefits un l the next open enrollment period or due to a qualifying event.
I (and my dependents) have coverage under another group plan as a spouse or dependentI (and my dependents) have coverage under Medicaid, Medicare, or TRICARE/Veteran’s AdministrationI (and my dependents) have coverage through an Individual plan, or purchased coverage through state or federal ExchangeI (and my dependents) have coverage under another group plan sponsored by a second employerI (and my dependents) do not wish to participate in health care benefits at this time (I am declining
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.
Employee OnlyEmployee + SpouseEmployee + Child(ren)Family
Reason to decline coverage:
Spouse Name:
Benefits & Compensation
YesNo
Bank Name*
Bank Account Number*
Bank Routing Number*
CheckingSavings
The entire net pay amountA specific $ amountA specific %
Dollar amount*
YesNo
Bank Name*
Bank Account Number*
Bank Routing Number*
CheckingSavings
The entire net pay amountA specific $ amount
Dollar amount*
Health Questionnaire
I consent to receive the Hepatitis B VaccineRefuse the Hepatitis B Vaccine and hold the agency harmless
I don't believe this vaccine is importantI am concerned about side effectsI never get the fluI received the flu shot outside the regular flu season and don't wish to receive it againI have had reaction to flu shotsI don't like needles/Other
COVID-19 Vaccination
Declination of COVID-19 Vaccination

Castle Rock Home Care strongly encourages all employees to receive a COVID-19 vaccination, unless there is an approved exemption or exception, to safeguard themselves and the community against the spread and impact of the disease.

Acknowledgment of Risks:

I hereby confirm my understanding of the following facts:
- COVID-19 is a grave disease that has resulted in the deaths of over 1 million people in the United States alone.
- The COVID-19 vaccine aims to protect not just me, but also my colleagues, our families, and the broader community from the disease and its severe complications, including death.
- If I contract COVID-19, I can be contagious for several days before showing symptoms, endangering those around me.
- Even if I display mild or no symptoms, contracting the virus means I can still transmit it to others, potentially causing them severe illness or death.
- It's estimated that nearly 1 in 5 American adults who have contracted COVID-19 suffer from "Long COVID", enduring symptoms that can persist for months or even years, impacting their quality of life. If I get infected with COVID-19, I risk serious, life-threatening consequences for myself and those I come into contact with, including vulnerable community members.
I already have had the COVID-19 vaccineNo, I wish to decline
I have thoroughly read the information provided in this declination form.I commit to wearing a mask and adhering toother precautionary measures, including regular testing.I understand that the terms of my employment may be affected based on evolving health department regulations
TB Questionnaire
YesNo
Date of last skin test:

MonthDayYear
Date
PositiveNegative
YesNo
YesNo
- Weight Loss
- Shivering
- Hoarseness
- Chills
- Chest Pains
- Night Sweats
- Coughing Blood
- Weakness
- Persistent Cough
- Unexplained Weight loss
- Shortness of Breath

YesNo
YesNo
YesNo
Which countries?
YesNo
YesNo
What drugs are you taking?
Government Assistance
YesNoNot sure
YesNoNot Sure
Name of Primary Recipient of Food Stamps (SNAP):
And City, State where benefits were received (SNAP):
YesNoNot Sure
YesNo
YesNo
Name of Primary Recipient of Cash Benefits (TANF):
And City, State where benefits are received (TANF):
YesNoNot Sure
YesNo
YesNo
YesNo
New York Urban Youth Jobs Program
- I am over 18 and do not have a high school diploma of GED/HSE diploma.
- I am a member of a family that is receiving assistance from TANF.
- I am a member of a family that is receiving SNAP benefits (food stamps).
- I am a member of a family that is receiving SSI benefits.
- I am receiving a free of reduced-cost school lunch.
- I have served in jail or prison, or am on probation or parole.
- I am pregnant or a parent.
- I am currently or was in foster care of 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 has been within in the 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, or is homeless.
- Another risk factor not identified above
I confirm that I currently meet one or more of the youth categories listed below.*
YesNo
YesNo
Parent or Guardian Name:*
Parent or Guardian Phone Number:*
Employee Status & Referrals
YesNo
YesNo
YesNo
YesNo
Date of Conviction

MonthDayYear
Date of Release

MonthDayYear
Type of Felony:
Please explain:
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
YesNo
Live in Collect
Signature
Please review the following documents:
I Agree
Applicant Signature *

Clear
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

Rows	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 Application for Employment

For Office Use Only

Personal Information

Education

References

W4 & I9

Legal and Background Check

Work History

Benefits

Benefits & Compensation

Health Questionnaire

COVID-19 Vaccination

TB Questionnaire

Government Assistance

New York Urban Youth Jobs Program

Employee Status & Referrals

Signature

Education & Employment History

Quiz

Rows	Yes	No
Weight Loss
Shivering
Hoarseness
Chills
Chest Pains
Night Sweats
Coughing Blood
Weakness
Persistent Cough
Unexplained Weight loss
Shortness of Breath