Castle Rock HHA Application

HHA Application for Employment
For Office Use Only
Citizenship Status
Alien Registration Number/USCIS Number:
USCIS Number:
Emp. Authorization ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
ID Type - Select ALL that Apply
{nycId} ID Number
{nycId} ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
ID Expiration Date as text
List B expiration date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State Benefit ID Number
Permanent Resident Card ID Number
Perm. Resident Card ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Employment Authorization Card ID
Foreign Passport with I-551 ID Number
Foreign Passport I-551 ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
US Passport ID Number
US Passport Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
US Passport Card ID Number
US Passport Card Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I9 Hire Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Base Rate
Supplemental Wages
Overtime Rate
Send Payrate PDF to user:
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
2 digit month, 2 digit day, 4 digit year
Social Security #:
Gender:
Eye Color:
Hair Color:
Weight:
in pounds
Height
Race:
What is your primary language?
Do you speak any other languages?
What other languages do you speak?
Country of Birth:
City of Birth:
Emergency Contact Name:
First/Last
Phone Number:
Relationship:
Do you have another Emergency Contact?
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?
Were you referred by anyone?
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:
Do you have another Reference?
Reference Contact Name 2:
First/Last
Phone Number:
Relationship:
Time Known:
W4 & I9
Tax Marital Status
oldMarital Status
Are you a resident of New York City?
Are you a resident of Yonkers?
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
**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
Have you ever worked for this Employer before? Are you a re-hire?
Last Date of Employment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
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
Do you have another Former Employer to add?
Name Of Second Employer
Position
Supervisor's Name
Phone Number
Reason for Leaving
Start Date
End Date
Do you have a third Former Employer to add?
Name Of Third Employer
Position
Supervisor's Name
Phone Number
Reason for Leaving
Start Date
End Date
Benefits
Would you like to enroll in the Castle Rock Home Care Health Plan?
I decline enrollment at this time because:
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:
Reason to decline coverage:
Spouse Name:
Availability
Please select the shifts you would like to work on:
Please select the shifts you would like to work on:

Pediatric Shifts
- Usually 5 days a week
- Usually 4-5 hours in the afternoon
- Pay $21.44
NHTD Shifts
- 12 hour cases - no live-ins
- Must take one day of the weekend
- No night cases will be given to new hires
- Pay $21.44
Cluster Shifts
- Short 1-hour cases
- Higher Pay
Benefits & Compensation
Would you like to sign up for direct deposit?
Bank Name
Bank Account Number
Bank Routing Number
Account Type
I wish to deposit:
Dollar amount
Do you have another bank to add?
Bank Name
Bank Account Number
Bank Routing Number
Account Type
I wish to deposit:
Dollar amount
Health Questionnaire
Hep B Vaccine - Please select from one of the following:
Influenza (flu) Vaccine Declination: Please check all that apply.
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.
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.
TB Questionnaire
Have you ever been tested for exposure to tuberculosis by having a TB skin test?
Date of last skin test:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result:
Has anyone in your family had TB?
Have you had any of the below symptoms during the past month?
- Weight Loss
- Shivering
- Hoarseness
- Chills
- Chest Pains
- Night Sweats
- Coughing Blood
- Weakness
- Persistent Cough
- Unexplained Weight loss
- Shortness of Breath

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?
Which countries?
Have you been vaccinated against tuberculosis with BCG vaccine?
Are you currently taking immuno-suppressive drugs?
What drugs are you taking?
Government Assistance
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?
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?
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?
Name of Primary Recipient of Cash Benefits (TANF):
And City, State where benefits are received (TANF):
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?
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.*
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.
Parent or Guardian Name:
Parent or Guardian Phone Number:
Employee Status & Referrals
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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of Release

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Type of Felony:
Please explain:
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?
Live in Collect
Signature
Please review the following documents:
By clicking the submit button, I agree to terms & conditions.
Applicant Signature
Remote Inspected
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

Availability

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