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  • Trainee Application for Employment

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    • For Office Use Only

    • ID Type - Select ALL that Apply
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    • Send Payrate PDF to user:
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    • Personal Information

    • Preferred method of communication:*
    • Gender:*
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    • What is your primary language?*
    • Do you speak any other languages?*
    • What other languages do you speak?*
    • Do you have a driver's license?*
    • Do you have a car available?*
    • Will you take public transportation?*

    • Availability

    • Select ALL available work assignments:*
    • Rows
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    • Select ALL days available to work:*

    • Interview

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    • {firstName}, Please complete the application below

    • Education & Employment History

    • Highest level of education*
    • Skill level (select ALL that apply):*
    • Do you have any professional licenses or certifications?*

    • List below your previous employer(s), starting with the last one.

    • Do you have another Former Employer to add?

    • W4 & I9

    • Tax Marital Status*
    • Are you a resident of New York State?*
    • Are you a resident of New York City?*
    • Are you a resident of Yonkers?*

    • Legal and Background Check

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    • HM Citizenship Status

    • **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?*
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    • Heart to Heart Home Care Agency/Training Program is required to submit certain information on each aide/trainee to be included in the HCR. This information includes name (current and previously used), date of birth, current home address, gender, information on the training program and employment information.

      Heart to Heart Home Care Training Program must verify and document the trainee’s identify by examining an unexpired, approved document containing the trainee’s photograph. If the trainee fails to provide one of the specific documents, the training program must deny
      participation in the program.

         Heart to Heart Home Care Agency/Training Program also must obtain consent to utilize the last four (4) digits of the trainee/aide’s social security in the HCR process or identify three (3) security questions to be utilized in place of the last four (4) digits. Please indicate which option you prefer:

          I give consent to Heart to Heart Home Care Agency/Training Program to utilize the last four (4) digits of my social security number in the HCR process. 
        Utilize three (security questions from the HCR)
      *   Utilize the following three (3) security questions for the HCR process:
      1. Mother’s Maiden Name:      
      2. City of Birth:          
      3. Mother’s First Name:      

    • 1. Mother’s Maiden Name:   *   
      2. City of Birth:   *       
      3. Mother’s First Name:   *   

    • Benefits & Compensation

    • Do you have Bank information to sign up for direct deposit?*
    • Account Type*

    • Health Questionnaire

    • Hep B Vaccine - Please select from one of the following:
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    • Have you received or will receive the Influenza (flu) Vaccine?
    • Influenza (flu) Vaccine Declination:

    • 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?*
    • 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?*
    • 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?*
    • 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?*
    • Have you been arrested or convicted of a crime before?*
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    • Type of Felony:*
    • Were you referred to this employer by:*
    • Urban Youth Section 

    • New York Urban Youth Jobs Program

    • 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
    • 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

         *         

    • 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:*
    • 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:*
    • show signature 

    • Signature

    • Clear
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    • I have been given this notice in my primary language
    • Clear
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    • Pay Rate 
    • W4 
    • IT 2104 
    • Are you a resident of New York City? - Mapped 2104*
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    • Are you a resident of Yonkers? - Mapped 2104*
    • Marital Status IT 2104 Mapped
    • I9 
    • ID Type 2
    • ID Type 3
    • ID Type 4 state ID
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    • 8850 
    • Are you a member of a family that received SNAP (Food Stamps Benefits)?
    • 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 unemployed for a combined total of 6 months before you were hired?
    • Are you under age 40? - 8850
    • Important Calculations 
    • Urban Youth Hidden Mapped Fields 
    • Age Range 16-17 Yes/No
    • Age Range 18-24 Yes/No
    • CHRC 
    • Crime Mapping DOH CHRC
    • Crime Mapping DOH CHRC - New
    • Patient Abuse Mapping DOH CHRC
    • Patient Abuse DOH CHRC - New
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    • ACA Benefit Form 
    • Declining coverage ACA, mapping
    • Hidden Mapped Fields 
    • 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?*
    • Do you currently have any of the below symptoms?*
      • 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?
    • Rows
    • Were you ever fingerprinted before at another Home Care Agency?*
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    • I wish to deposit:*
    • Do you have another bank to add?*
    • Account Type*
    • I wish to deposit:*
    • waiver 
    • Clear

    • 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?*
    • 7. When working with persons who are disabled, the general goal of care is to:*
    • 8. Which of the following is the most appropriate practice to promote good skin care in the elderly?*
    • 9. In giving foot care to a patient who has diabetes, the Home Health Aide/PCA may take which of these actions?*
    • 10. When assisting a patient to walk with his walker, you should:*
    • 11. A patient who has been on bed rest is to get up in a chair. The Home Health Aide helps the patient to sit on the edge of the bed. The patient says "I am dizzy". What should the Aide do?*
    • 12. Which of these statements describes good body mechanics?*
    • 13. Milk is a good source of calcium. Which of these foods is also high in calcium?*
    • 14. When patients do not have enough fluids, they may develop which of these problems?*
    • 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:*
    • HM Pass/Fail
    • I allow TC Services USA to submit this application on my behalf
      • 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


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    • Are you entitled to compensation for a service-connected disability?*
    • Were you discharged from active duty within the last year?*
    • 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?*

    • References

    • Do you have another Reference?
    • Do you have a third Former Employer to add?
    • HM - legally authorized to work
    • Have you been terminated from a position in the last 10 years?*

    • Medical Benefits

    • Select from the following:*
    • 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:*
    • Should be Empty: