Nursing Personnel HHA/PCA Application [NEW]

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

MonthDayYear
State 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
State ID Number
State ID Expiration Date

MonthDayYear
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
Date of Hire:

MonthDayYear
Starting Date:

MonthDayYear
Title:
Salary:
HR Representative First Name
HR Representative Last Name
HR Representative Signature

Clear
HHA/PCA Application for Employment
Personal Information
First Name*
Middle Initial
Last Name*
Maiden Name
Mother's Maiden Name
Other Names Used (Alias)
Street Address:*
Apartment/Suite #:
City:*
State:*
Zip:*
County:*
Mobile Phone Number:*
Secondary Phone Number:
Email Address:*
example@example.com
Date of Birth:*

MonthDayYear
Country of Birth:*
Race:*
Gender:*
Social Security #:*
Eye Color*
Hair Color*
Height*
Weight*
YesNo
Enter the last date of employment:*

MonthDayYear
EnglishSpanishRussianMandarinUrduArabicCantoneseHebrewCreoleUzbekChineseOther
YesNo
EnglishSpanishRussianChineseUrduArabicYiddishHebrewCreoleUzbekOther
HHAPCARN
Emergency Contact Name*
Phone Number:*
Relationship*
Address
YesNo
Referral Name:*
Phone Number:*
ParentsSpouseSiblingFamilyFriendOther
How did you hear about us?
W4 & I9
SingleMarried filing separatelyMarried but Filing JointlyHead of Household
YesNo
YesNo
Total number of children UNDER age 17*
Total number of children OVER age 17*
YesNo
YesNo
YesNo
Are you an alien authorized to work?
**Sorry, we cannot accept your application at this time. Please start your application over again**
Legal & Background Checks
YesNo
YesNo
If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)*
At this time, we cannot process your application.
References
Reference Full Name:
Reference Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Employment History
List below your previous employer(s), starting with the last one.
Company Name
Position
Supervisor's Name
Phone
Address
Reason for Leaving
Start Date
End Date
YesNo
Name of Company
Position
Phone
Address
Reason for Leaving
Start Date
End Date
YesNo
Name Of Third Employer
Position
Phone
Address
Reason for Leaving
Start Date
End Date
Pay - Direct Deposit
YesNo
Bank Name:*
Account Number:*
Routing Number:*
CheckingSaving
Deposit the entire payA certain % of payA certain $ amount of pay
Enter the % to deposit:
Enter the $ amount to deposit:
YesNo
Bank Name:*
Account Number:*
Routing Number:*
CheckingSaving
Deposit the entire payA certain % of payA certain $ amount of pay
Enter the % to deposit:
Enter the $ amount to deposit:
Health Questionnaire
I DECLINE the Hepatitis B vaccineI ACCEPT the Hepatitis B vaccineI am immune and can provide test resultsContraindicated - Can provide a valid medical opinion
Influenza / Flu:

I have been advised that I should receive the influenza vaccine to protect myself and the patients I serve. I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have had the opportunity to discuss the statement and have my questions answered by a healthcare provider. I am aware of the following facts:
- Influenza is a serious respiratory disease that kills thousands in the United States each year.
- Influenza vaccination is recommended for me and all other healthcare personnel to protect this facility’s patients from influenza, its complications, and death.
- If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
- If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or non-existent.
- I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t, my immunity declines over time. This is why vaccination against influenza is recommended each year.
- I understand that I cannot get influenza from the influenza vaccine.
- The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including all patients in this healthcare facility, coworkers, my family and my community.
- If I choose not to get vaccinated against influenza, I will be required to wear surgical or procedure masks in areas where patients or residents may be present during the influenza season.
I wish to receive the vaccineI have decided to decline the influenza vaccine by my signature below. I realize that I may readdress this issue at any time and obtain vaccination in the future
YesNo
1. Chronic Cough lasting more than 3 weeks
2. Coughing up blood
3.Unexplained Weight Loss
4. Fever, chills or night sweats for no known reason
5. Persistent Shortness of Breath
6. Unexplained fatigue
7. Chest Pains
No Symptoms

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Please explain:*
New York Urban Youth Jobs Program
YesNo
Parent or Guardian Name:
Parent or Guardian Phone Number:
YesNo
a. I am currently unemployed.
b. I was unemployed prior to completing this application.
c. I do not have enough paid work.
d. The work I have does not make use of my skills and training.

Yes No
Are any of the following 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.

Yes No
YesNo
Government Assistance
YesNo
And City, State where benefits were received
Veteran Details
YesNo
YesNo
Name of primary recipient:
And City, State where benefits were received
YesNo
YesNo
YesNo
YesNo
SNAP (Food Stamps)
YesNo
YesNo
Name of Primary Recipient of Food Stamps (SNAP)
And City, State where benefits were received
TANF (Cash Benefits)
YesNo
Name of Primary Recipient of Cash Benefits (TANF):
And City, State where benefits are received:
YesNo
Vocational Rehab
YesNo
YesNo
Date of Conviction:

MonthDayYear
Date of Release:

MonthDayYear
FederalState
YesNo
YesNo
YesNo
Employee Status & Referrals
Policies
Yes
I Agree
Applicant Signature*

Clear
NoYes

Rows	Name of School	Course or Major	Graduated?	Date of Completion
High School
College/University
Aide Training Program

For Office Use Only

HHA/PCA Application for Employment

Personal Information

W4 & I9

Legal & Background Checks

References

Employment History

Pay - Direct Deposit

Health Questionnaire

New York Urban Youth Jobs Program

Government Assistance

Veteran Details

SNAP (Food Stamps)

TANF (Cash Benefits)

Vocational Rehab

Employee Status & Referrals

Policies

Benefits & Compensation

General Questions

Benefits

Rows	Yes	No
1. Chronic Cough lasting more than 3 weeks
2. Coughing up blood
3.Unexplained Weight Loss
4. Fever, chills or night sweats for no known reason
5. Persistent Shortness of Breath
6. Unexplained fatigue
7. Chest Pains