Welcome Care Application & Orientation

Welcome Care
Licensed Home Care Agency

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
Street Address:
Apartment/Suite #:
If no apartment enter "N/A"
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
Country of Birth:
Race:
How did you hear about Welcome Care Inc.?
What is your primary language?
Do you speak any other languages?
What other languages do you speak?
Emergency Contact Name 1:
First/Last
Phone Number:
Relationship:
Emergency Contact Name 2:
First/Last
Phone Number:
Relationship:
Work Availability and Preferences
Position applying for:
Date available to start:

MonthDayYear
2 digit month, 2 digit day, 4 digit year

Work Availability:

Rows	End Time	Start Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Have you ever worked for this employer before? Are you a re-hire?
HM worked with us before
Last Date of Employment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for leaving:
Desired work hours:

Answer the following:

Rows	Yes	No
Will work with children?
Will work with pets?
Will work with smokers?
Will work with AIDS Cases?
Will work Live-In Cases?
Will work alternate W/E cases?
Experience with Kosher kitchen?
Experience with Hoyer Lift?
Will work weekends?
Will work only mornings?
Will work only nights?
Will work only afternoons?
Will work only light duty?

Do you have a car?
HM Speaks english
Legal and Background Check
Are you a U.S. Citizen?
HM - US 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
HM - right to live and work in US
**Sorry, we cannot accept your application at this time. Please start your application over again**
Education
Select ALL levels of education you have:
High School Name:
High School Address:
Did you graduate?
Degree Type:
Major:
Date Started:
Date Ended:
College Name:
College Address:
Did you graduate?
Degree Type:
Major:
Date Started:
Date Ended:
Technical School Name:
Technical School Address:
Did you graduate?
Degree Type:
Major:
Date Started:
Date Ended:
Other School Name:
Other School Address:
Did you graduate?
Degree Type:
Major:
Date Started:
Date Ended:
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
Children OVER age 17?
Work History
List below your previous employer(s), starting with the last one.
Name Of First Employer
Position
Phone Number
Address
Type of work performed:
Reason for Leaving
Start Date
End Date
Do you have another Former Employer to add?
Name Of Second Employer
Position
Phone Number
Address
Type of work performed
Reason for Leaving
Start Date
End Date
Do you have a third Former Employer to add?
Name Of Third Employer
Position
Phone Number
Address
Type of work performed
Reason for Leaving
Start Date
End Date
Health Benefits Enrollment
I would like to:
Reason for declining coverage:

Other
Carrier Name and Member ID:
Carrier Name and Member ID:
Health Questionnaire
Hep B Vaccine - Please select from one of the following:
Date Vaccine Received:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Have you received the Influenza (flu) Vaccine?
Influenza (flu) Vaccine Declination:

Flu Shot/Vaccine Questionnaire:

Rows	Yes	No
Have you ever had an allergic reaction to flu vaccine?
Are you allergic to eggs or egg products?
Do you have a history of Guillain- Barre Syndrome? (Illness associated with the swine flu in 1976 characterized By fever, nerve damage, and muscle weakness)
Are you allergic to thimerosal (a mercury - based preservative)?
Are you allergic to latex?
Do you feel ill today, or do you have a fever?

Health Assessment

In the past two years have you been treated for any of the following:

Rows	Yes	No	If yes, When
Tuberculosis
Heart Disease
High Blood Pressure
Diabetes
Visual Impairment
Visual Impairment (corrected by glasses)
Hearing Impairment
Epilepsy or Seizure Disorder
Drug/Alcohol Abuse or Addiction
Psychiatric or Behavioral Disorder
Chickenpox (Varicella)

Are you pregnant?
How many weeks?
TB Questionnaire
Have you ever had a test for Tuberculosis?
PPD/Mantoux Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Result:
Chest X-Ray Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Result:
Dates of treatment:
Treatment Type:
Do you currently have any of the below symptoms?
- Weakness
- Unexplained weight loss
- Loss of appetite
- Long-term fever less than 101
- Chills & sweats at night
- Shortness of breath
- Persistent cough
- Coughing up blood
- Flu-like symptoms
- Chest pain

If you have been exposed to TB please include any treatment type you may have received:
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?
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 had a final finding of patient abuse?
Have you been arrested or convicted of a crime before?
HM Convicted of a crime
If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
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:
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
New York Urban Youth Jobs Program
If you are 16 or 17 years old your parent or guardian must sign and submit the application for you. If you have little or no access to a computer, mail the completed and signed application to Harriman State Office CampusBuilding 12, Room 412 Albany, NY 12240 or fax it to (518) 485-1359. We do not accept applications submitted for you by a business or tax consultant. If you have questions or need help, please call (877) 226-5724 or email info@youthworks.ny.gov.
I currently live in the town or city limits of the following target area:

Other area
Are any of the following statements true:
- I have a high school diploma
- I have a GED (General Education Development degree)
- I have satisfactory completed a Test for Assessing Secondary Completion (TASC) exam
- I am enrolled in a Treatment Accountability for Safer Communities (TASC) program
Yes No*
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:
I am currently attending High School:
I am currently enrolled in a High School Equivalency (HSE) program:
I am 16 or 17 years old and I have my parent's or guardian's permission to submit this application:
Parent or Guardian Name:
Parent or Guardian Phone Number:
I would like the Department of Labor to contact me by:
Orientation Test
1. When the agency office is closed, such as on the weekend, holidays, or during a major storm, the agency continues to do business.
2. Home Care Workers can sign as a witness for a clients Health CareProxy.
3. In the clients Bill of Rights, the client has the right to have his/her property treated with respect and care.
4. If there is a fire in the building it is permissible (OK) to take the elevator.
5. It is acceptable to speak about the difficulties experienced with a specific client with your friends at home.
6. Confidentiality means that you cannot discuss a client in public, or in a casual conversation with neighbors.
7. Disposable gloves should be worn when cleaning up the environment where blood or body fluids spill has occurred.
8. The spread of AIDES does not occur though intercourse.
9. Have you been involved in two events that would be considered an incident:
Incident 1:
Incident 2:
Training and Competency Pre-Questionnaire
1. The primary goal of the NHTD waiver program is to assist individuals toavoid a skilled nursing facility.
2. The service Coordinator is the primary decision maker of the waiver team.
3. HIPAA and confidentiality concerns do not apply to participants in theNHTD waiver, due to the nature of the program.
4. All community resources and state plan Medicaid services are to beresearched and used before requesting NHTD waiver services.
5. In some situations, an individual can be enrolled in two differentwaiver programs at the same time.
6. All NHTD waiver participants must meet nursing home level of care.
7. What is TBI?
8. What is NHTD?
9. Which one of these are services available to participants?
10. Who is responsible for maintaining oversight and supervision at all times while servicing the participant?
11. How often should the Patient’s Right and Responsibilities be reviewed with the participant?
12. The Reginal Resource Development Specialist (RRDS) is responsible for which of the following:
13. The following waiver services may bill for services provided prior to a Notice of Decision being issued:
14. Which of the following is not a Serious Reportable Incident?
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
- Pay Rate A
- Pay Rate B
- Pay Rate C
- Pay Rate D
- Pay Rate E
- Pay Rate F
- Pay Rate G
- Pay Rate H
- Master Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- I have been given this notice in my primary language
- Hep B decline Applicant Signature
- Hep B decline date
- Hep B accept Applicant Signature
- Hep B accept date
- direct deposit Mailing Address - Mapped
  Enter a
- HM Flu decline signature
- flu decline date
- If Language is English PayRate
- If Language is Other PayRate
- 2 My primary language is - Pay rate - mapped
- 1 My primary language is -
- 1 secondary language is
- No My primary language is - Pay rate - mapped for PDF
- My primary language is - Pay rate - mapped for PDF
- Total Under 17 - W4
- Total Other Dependents - W4
  0
- Total Dependents - W4
  Under 17 + Total other deponentes
- Employer’s name and address W4
  LHCSA Home Health Holdings Inc 329 East 149th Street, 3rd Floor, Bronx, NY 10451
- Employer identification number W4 (EIN)
- Are you a resident of New York City? - Mapped 2104
- Date of Birth DOH CHRC NYS Health - Mapped
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Are you a resident of Yonkers? - Mapped 2104
- Marital Status IT 2104 Mapped
- Marital status 2 IT 2104 Mapped
- Total yonkers-mapped 2014
- Total number of allowances - NYC - mapped mber of allowances Yonkers 21- 2014
- Total number of allowances
- ID Type 2
- ID Type 3
- ID Type 4 state ID
- SSN Space Digits - I9
  Important - combines all SSN Digits
- Document Title List A2
- Citizenship/Immigration Status - I9
  Important - baed on Citizen Status
- Issuing Authority List A2
- Date I9 Authorized
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Document Number List A2
- Document Title List A
- Expiration List A2
- Issuing Authority List A
- Document Title List A3
- Document Number List A
- Issuing Authority List A3
- Expiration List A
- Document Number List A3
- Expiration List A3
- Document Title List B
- Issuing Authority List B
- Document Number list B
- Document Title List C
- Issuing Authority List C
- Document number List C
- Starting Wage - 8850
  $15.00
- 8850 Capture #2
  If this contains yes then #2 on the 8850 will be checked off
- 8850 Refered By Capture
  If this contains yes then #2 on the 8850 will be checked off
- Are you a member of a family that received SNAP (Food Stamps Benefits)?
- MH - Age Under 40 - 8850
- A Vocational Rehab Agency approved by the state? 8850
- An Employment Network under the Ticket to Work Program? 8850
- The Dept. of Veteran Affairs? 8850
- Were you referred to this employer by - none/not sure - 8850
- Position - 8850
- 8850 # 1
- 8850 # 2
- 8850 # 3-mapped
- 8850 # 4-mapped
- 8850 # 5-mapped
- 8850 #6
- 8850 #7
- Were you unemployed for a combined total of 6 months before you were hired?
- Are you under age 40? - 8850
- Start/End 3 Mapped
- Age 2 - Calculation for age range
- Age
  todays date - date of birth
- Mother's Maiden Name
- Name - First Last
- Name - First and Middle
- First name and middle initial - IT 2104-mapped
- Full Name
- Name - First and Middle Initial
- Name - First and Last 2
- Name - Middle Initial
- M.I. - ID Mapped
- Initials
- SSN Last 4 Substring
- SSN Last 4
- SSN Last 4 - attestation form
- SSN First 3 Substring
- SSN - Last 4
- SSN - First 3
- SSN - Middle 2
- SSN Middle Substring
- digit 4
- digit 5
- 6
- 7
- digit 8
- digit 9
- Initials
- Street and Apartment
- City/State/Zip
- Full Address - Street/Apt/City/State/Zip
- State - application for employment
- Age Number
  used to calculate under age 40 question
- First Name
- Last Name
- MI Initial
- Date of Birth
- SSN
- Phone Number
- urban Address - Street and Apt
- City state zip
- State
- ZIP
- Email
- Age Range 16-17 Yes/No
- Age Range 18-24 Yes/No
- Crime - No
- Crime - Yes
- Patient Abuse - Yes
- Patient Abuse - No
- Crime Mapping DOH CHRC
- Crime Mapping DOH CHRC - New
- Patient Abuse Mapping DOH CHRC
- Patient Abuse DOH CHRC - New
- Combined Height CHRC - Mapped:
- Convicted Of a Crime: CHRC - Mapped
- When: Logic Can be applied If needed
- HM CHRC Date Space
- Date Fingerprinted: Logic Can be applied If needed - ignore
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Declining coverage ACA, mapping
- First Middle Last
- Language
- Caregiver Code
- Google Form Column
- City State ZIP
- Education & Employment History
- CHRC Date Text
- HM CHRC spacing date field string NY Health
- It can take up to two weeks for direct deposit payments. Please provide HR with a copy of a voided check and select a backup payment method.
- Is your mailing address the same as where you live?
- Please Provide Your Mailing Address
  
  Street Address
  
  Apartment / Suite
  
  CityState
  
  Zip Code
- Please briefly explain the condition for any symptoms answered yes:
- Were you ever fingerprinted before at another Home Care Agency?
- When did you have the fingerprints done?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- 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
- Insurance Company Name:
- Policy Number:
- waiver employee name
- waiverlast 4
- waiver email
- waiver date
- waiver signature
- Quiz
- 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?
- 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:
- Quiz Score Correct
- Quiz Score Percentage
- HM Pass/Fail
- Work History
- Have you worked at another home care agency in the past?
- Previous Agency Name:
- Phone Number:
- Last day of work:
- Last day of work:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- - 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.*
- Would you like to sign up for direct deposit?
- Bank Name
- Bank Account Number
- Bank Routing Number
- Account Type:
- Do you want to enroll in a transit commuter account?
- Frequency of pay:
- Dollar Amount:
- Will you be taking a train or bus to work?
- Trains near you:
- Buses near you:
- References
  
  Cannot be relatives
- Reference Contact Name 1:
  First/Last
- Phone Number:
- Reference Address 1:
- Reference Contact Name 2:
  First/Last
- Phone Number:
- Reference Address 2:
- Have you been terminated from a position in the last 10 years?
- Please explain:
- Result:
- Result:
- Should be Empty:

Rows	Yes	No
Weakness
Unexplained weight loss
Loss of appetite
Long-term fever less than 101
Chills & sweats at night
Shortness of breath
Persistent Cough
Coughing up blood
Flu-Like Symptoms
Chest Pain
Clear Color Sputum
Yellow Color Sputum

For Office Use Only

Personal Information

Work Availability and Preferences

Legal and Background Check

Education

W4 & I9

Work History

Health Benefits Enrollment

Health Questionnaire

Health Assessment

TB Questionnaire

Government Assistance

Employee Status & Referrals

New York Urban Youth Jobs Program

Orientation Test

Training and Competency Pre-Questionnaire

Signature

Education & Employment History

Quiz

Work History

References