HHA/PCA Application for Employment

Citizenship Status

Alien Registration Number/USCIS Number:

USCIS Number:

Emp. Authorization ID Expiration Date

ID Type - Select ALL that Apply

{nycId} ID Number

{nycId} ID Expiration Date

ID Expiration Date as text

List B expiration date:

Date

State Benefit ID Number

Permanent Resident Card ID Number

Perm. Resident Card ID Expiration Date

Employment Authorization Card ID

Foreign Passport with I-551 ID Number

Foreign Passport I-551 ID Expiration Date

US Passport ID Number

US Passport Expiration Date

US Passport Card ID Number

US Passport Card Expiration Date

I9 Hire Date

Base Rate

Supplemental Wages

Overtime Rate

Send Payrate PDF to user:

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:

Email Address :

example@example.com

Gender:

Gender-doh103

Date of Birth:

Social Security #:

Eye Color:

Hair Color:

Weight:

in pounds

Height

Position applying for:

HM TItle

What is your primary language?

Do you speak any other languages?

What other languages do you speak?

Country of Birth:

Race:

Emergency Contact Name:

First/Last

Phone Number:

Relationship:

How did you hear about GR Home Care?

Date available to work:

Daily availability:

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

Hours (Select all):

Are you able to do live-in work?

Reference Contact Name 1:

First/Last

Phone Number:

Relationship:

Address 1

Street Address

Street Address Line 2

CityState

Zip Code

Do you have another Reference?

Reference Contact Name 2:

First/Last

Phone Number:

Relationship:

Address 2

Street Address

Street Address Line 2

CityState

Zip Code

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

Are you a U.S. Citizen?

Are you a lawful permanent resident?

Are you an alien authorized to work?

Give Visa # and expiration:

**Sorry, we cannot accept your application at this time. Please start your application over again**

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

Last Date of Employment

Date

Have you been convicted of a crime?

What type of crime(s) did you commit?

Rows	Select	Date
Any Class A felony defined in the Penal Law (no time limitation)
Any Class B or C felony defined in the Penal Law occurring within 10 years preceding the date of the criminal record check.
Any Class D or E Felony listed on Article 120 (Assault):
Article 130 (Sexual Offense):
Article 155 (Larceny):
Article 160 (Robbery):
Article 178 (Diversion of Prescription Medications):
Article 220 (Bribery):
Any crime defined in sections 260.32 or 260.34 (Endangering the welfare of a vulnerable elderly person:
Any comparable offense in any other jurisdiction:
Charged with a crime identified above but not yet convicted or acquitted of the crime.
Other: Specify

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 been bonded?

Please explain:

Have you ever refused a bond?

Please explain:

Have you been fingerprinted before?

When were you fingerprinted:

Other collect

Specify the other type of criminal offense:

Did you graduate high school?

School Name

Address

Diploma/Degree Name

Did you graduate?

Date of completion:

MM/YY

Do you have any professional licenses or certifications?

School Program

Certification Type:

HM - Certificate Type

Registry Number:

List below your previous employer(s), starting with the most current.

Name Of First Employer

Address

Phone Number

Position

Supervisor's Name

Salary

Start Date

End Date

Reason for Leaving

Do you have another Former Employer to add?

Name Of Second Employer

Address

Phone Number

Position

Supervisor's Name

Salary

Start Date

End Date

Reason for Leaving

Would you like to sign up for direct deposit?

Account Type

Bank Name

Bank City

Bank State

Bank Account Number

Bank Routing Number

I wish to deposit:

$ Amount deposited:

Bank Name

Bank City

Bank State

Bank Savings Account Number

I wish to deposit:

$ Amount deposited:

Hep B Vaccine - Please select from one of the following:

Confirm the following:

Have you received or will receive the Influenza (flu) Vaccine this season?

Influenza (flu) Vaccine Declination:

HM Reason for decline flu

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?

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

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?

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?

What sate did you receive unemployment compensation?

Are you a Veteran of the US Armed Forces?

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

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

Name of Primary Recipient of Benefits:

And City, State where benefits are received:

Have you been arrested or convicted of a crime before?

Date of Conviction

Date of Release

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

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

I currently live in the town or city limits of the following target area:

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 have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or I am enrolled in a TASC program.

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

1. Physical and mental health, not how old a person is, determine aging.

2. Many elderly people experience pressure from living on limited incomes.

3. Older people want the people around them to make decisions for them.

4. An elderly man or woman can learn new roles around the house.

5 .Most elderly people live with their children.

6. Alzheimer’s disease causes temporary mental changes

7. Poor nutrition can cause temporary mental changes.

8-11. Select ALL problems that should be reported to the supervisor.

8-11 collection

12. Which of the following is true about the skin of older people? They have

13. Your client, Mr. Jones, accidentally wets himself. Your best response would be:

14. Your usually active and alert client, Mrs. London, is very quiet one day. She forgets to turn the gas off under the kettle on the stove and forgets where she put some bills. You would:

15. Mrs. London tells you that one of her children is going to have an operation. You would:

16. Older people need to be protected from infection because this system does not work as well as it used to.

17. Some activities may be limited because this system is less elastic in old age.

18. The older person must be protected from falls because this system is more brittle with old age.

19. The older person cannot take in as much air as before because this system is weaker.

20. The older person should eat a diet high in fiber because this system is slowed down.

Quiz Score collect

Quiz Score Percentage

You have failed the test. You cannot submit the application until you past the test.

Please review the following documents:

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/PCA Application for Employment

For Office Use Only

Personal Information

Availability

References

W4 & I9

Legal and Background Check

Education & Employment History

Benefits & Compensation

Health Questionnaire

Government Assistance

New York Urban Youth Jobs Program

Quiz

Signature

Quiz

Medical Benefits