Download New Employee 11 Pack Form

Download File

Click the button above to download and print our job application.

After you have completed the job application, feel free to scan it and upload it to Upload Completed 11 Pack Form

You may also email it back to contact@bethesdaelitecare.com

Upload Completed 11 Pack Form

Please upload your completed application below along with the supporting documentation and certifications. Be sure to sign all required pages of the application.

How did you hear about us?

Internet Search Employee Other

Phone Number

Reference Person

Upload Form

2 Forms of ID

Social Security Card

Certification of HHA/PCA

Direct Deposit Information

2 References

Proof of legality

Physical and Immunization Records

Covid Vaccine Card

Online Fill-up of New Employee 11 Pack Form

ANNUAL CONFIDENTIALITY OF INFORMATION AGREEMENT

Print Name:

Date

I acknowledge that any information contained in the client’s Clinical records is of a strict confidential nature. HIV related information is further protected from disclosure by New York State Law. In addition, a client must give written permission before any information may be released to an individual, agent, or agency outside of the company except" where specifically indicated by law, statute, or third-party agreement.

I understand that any unauthorized use of client information is in direct violation of agency policy and will result in disciplinary action. All information designated confidential that is obtained or generated as a result of any or all of the operations of the agency will be dealt in a confidential manner. All information that is gathered, maintained, or stored by the agency becomes the agency’s property and cannot be released without proper authorization from the administrator.

Altering information is prohibited by the agency and by law. Correction of any identified erroneous information must be done according to agency policy.

WHAT WE CAN DO TO MAINTAIN CONFIDENTIUALLITY OF INFORMATION

In order to protect any individual from invasion of Privacy and to protect the interest of the agency, any information gathered for client care or operations will be gathered, maintained, and stored in such a manner as to assure confidentiality. Access to information will be only on a need to know basis to perform the scope of one’s duties and responsibilities. Dissemination of information will be handled according to the agency policy.

Proven violation or breech of the confidentiality agreement may be cause for immediate termination,

I attest that I have received an In-Service training on Client Confidentiality, including HIV Confidentiality, and I understand that I am responsible for the following and maintaining this Confidentiality Policy Agreement, with all of its Guidelines, both written and verbal.

Date

Employee Name:

HIV Confidentiality Law Employee Training

I an employee or a contractor of service at BETHESDA ELITE CARE INC, have been provided with a summary of the New York State HIV Confidentiality Law.

I agree to abide with the regulations of this law.

Name:

Date

Title:

DECLINATION OF INFLUENZA VACCINATION

My employer or affiliated health facility, Bethesda Elite Care inc. has recommended that I receive the influenza vaccination to protect the patients I serve.

I acknowledge that I am aware of the following facts:

Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
Influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications, and death.
If contract influenza, I can shed the virus 24 hours before influenza symptoms appear. Me shedding the virus can spread influenza to patients in this facility.
If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.
Iunderstand that the strains of virus that cause influenza infection change almost every year and even if they don’t change, my immunity declines over time. Therefore, vaccination against influenza is recommended each year. Because I have refused the vaccination against influenza I will be required to wear surgical or procedure masks in areas where patients or residents may be present during the influenza Vaccine.
Iunderstand that I cannot get influenza from the influenza vaccine.
The consequences of refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including
- My co-workers
- My family
- My community

Despite these facts, I am choosing to decline the influenza vaccination right now for the following reasons:

I understand that I can change my mind at any time and accept the influenza vaccination, if the vaccine is still available.

I have read and fully understand the information on this declination form.

Name:

Date

Name (print):

Department:

Hepatitis B and C Vaccination

O.S.H.A regulation states that all health care professionals with occupational exposure to blood borne pathogens must be offered the Hepatitis B vaccinations. If you have been determined to be at risk to blood borne pathogens.

A. I have already received the hepatitis B vaccine.
B. I decline the hepatitis B vaccine.
C. I finterested in the hepatitis B vaccine, I may contact Bethesda Elite Care Inc.

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the hepatitis B vaccine. However, I decline hepatitis B vaccination at this time. I understand that declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupation exposure to blood or other potentially infectious materials and I want to be vaccinated with the hepatitis B vaccine, I can receive the vaccination series. I have received information on the Hepatitis B vaccine and have been evaluated by an agency health professional. I have had an opportunity to ask questions about the benefits and risks of Hepatitis B vaccination. I also understand that there is guarantee that I will become immune and that there is a possibility that I will experience an adverse side effect from the vaccine.

Print Name:

Name:

Date of Hire:

STATEMENT REGARDING DRUG/ALCOHOL USE

New York State Law requires that no employee shall assume his/her duties unless he or she is free from a health impairment which is of potential risk to a patient or which may interfere with the performance of his or her duties, including the habituation or addiction to the depressant, stimulant, narcotics, alcohol, or other drugs or substances which may alter the employee’s behaviors.

Are you presently using any illegal drugs (that is marijuana, cocaine, etc.)?

yes Or No

Do you drink excessively (three or more alcoholic beverages per day)?

yes Or No

If yes, explain

Are you free from health impairment, including the habituation or addiction to such substances as depressant, stimulants, narcotics, alcohol or other drugs?

Yes Or No

Name:

Date of Hire:

It is a LEGAL & REGULATORY REQUIREMENT that these forms be a Permanent part of your department file! PLEASE CPMPLETE EACH SECTION, ALONG WITH A SIGNATURE AND DATE!

DRUG-FREE WORKPLACE EMPLOYEE ACKNOWLEDGEMENT

Please PRINT Name Legibly

(Last) (First) (MI)	Date of Hire
Employee #	Job Title	Department	Location

I understand that, as a provider of health care, Bethesda Elite Care Inc. Permanente recognizes that chemical dependency is a chronic disease that can have tragic consequences for individuals, families, and the workplace.

As a condition of employment, all employees are expected to abide by the organization’s policy which prohibits the use and/or abuse of drugs, including alcohol, in the workplace.

By my signature below, I acknowledge, understand, accept, and agree to comply with this policy. I also understand that failure to comply with these policies may result in disciplinary action up to and including termination.

DRUG-FREE WORKPLACE ATTESTATION

I have received a copy of Bethesda Elite Care Inc. Policy of Alcohol and Drugs.
I have read, understood, and familiarized myself with this policy, and understand that Kaiser Permanente is committed to providing a drug-free workplace.
I understand that it is my responsibility to comply with this policy, and that this policy applies to me.
I agree to abide by the terms of the policy, as a condition of employment.
I understand that violations of this policy will subject me to disciplinary action, up to and including discharge.
If I have any questions about this policy, I will seek clarification from my Compliance Coordinator or Nursing Dept.
I understand that, in acknowledgement that chemical dependency is a chronic disease and that rehabilitative treatment is available, Bethesda Elite Care supports the use of such treatment, and will provide it when conditions and circumstances warrant.
I understand that, if I am experiencing alcohol or drug dependency, I am urged by the organization to make use of Bethesda Elite Care Inc. confidential Employee Assistance Program, and/or such disability plans, rehabilitation programs, and health coverage plans are appropriate.

Employee Name:

Date:

ANNUAL TUBERCULOSIS SCREENING QUESTIONNAIRE

Name:

Social Security Number:

1. Do you have any of the following?

Symptoms	Yes	No	Comments
Weakness
Fatigue
Lack of Appetite
Excessive Weight Loss
Low Grade Fever
Night Sweats
Flu-Like Symptoms
Chest Pain
Shortness of Breath
Persistent Cough
Blood Streaked Sputum
Clear, Yellow, or Dark Sputum

2. Have you had a tuberculin test?

Yes No

PPD Test

Date:

Result:

Chest X-Ray

Date:

Result:

3. Have you been exposed to anyone with the above signs or symptoms or who has had Tuberculosis?

Yes No

If I should notice any of the above signs or symptoms, I will immediately notify my physician and the supervisor of Bethesda Elite Care, Inc.

Employee Name:

Date

R.N. Name:

Date

ANNUAL SELF-HEALTH ASSESSMENT FORM

In order to comply with New York State Department of Health Regulation 766 "an annual, or more frequent necessary, health status assessment is required to assure that all personnel are free from any health impairment that is of potential risk to the patient, family, or employees, or that may interfere with the performance of duties. The assessment shall be of sufficient scope that no person shall assume his/her duties unless he/she is free from a health impairment which is of potential risk to patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol, or other dogs or substances which may alter the individuals behavior."

The purpose of the Annual Self-Health Assessment is to ensure both your safety and our consumers safety while performing the essential functions of your job. It is critical that you inform Bethesda Elite Care Inc. of any changes in your health status that could endanger you or the consumer(s) you are working with.

Name:

Date of Birth:

Address:

Telephone:

Email:

This form is required on an annual basis, one year from the date signed, every year that you are employed with Bethesda Elite Care Inc. There is no need to have a physical by a medical professional while completing this document.Please not, you are only required to complete this form and not a medical professional.

Date of last physical examination by medical professional? Please be advised, there is no need to have a physical with this assessment.

Have there been any changes in your health since the date of your last physical or annual self-health assessment that would prohibit you from performing the essential functions of your job? Yes No If yes, list the active disease or condition and describe your symptoms below, Please remember that the intent of the annual health assessment is to offer accommodations that will ensure your safety as well as the safety of the consumers we serve. Is there anything in your current health status that puts you or the consumer at risk? Yes No lf yes, please explain:

Are you addicted to or habitually use depressants, stimulants, narcotics. Alcohol, hallucinogenic, or other drugs? Yes No please explain:

I hereby certify that the above statements are true and answered to the best of my knowledge and ability. I hereby certify that I am capable of performing my job duties.

Employee Name:

Date

Reviewed by Bethesda Elite Care RN:

Date:

Please return this form to: Attn. Nursing Dept. Bethesda Elite Care Inc. at 3 Surrey Lane Manorville NY, 11949 Phone: 631-400-9020 Fax: 631-400-9021

Acknowledgement of In-Services

Orientation AMI

I have received copies of the following In-Services; Safety Orientation for Home Health Workers, Fire Safety, Infection Control in Home Healthcare, and HIPAA: Privacy in Home Healthcare and have been In-Serviced on all of the stated documents, and their procedures related to my job responsibilities. I understand that clinical and administrative supervision/support is available if I should need further clarification of my responsibilities and duties.

Print Name:

Name:

Date

Signature/Title of Agency Administrative Evaluator:

Home Health Aide - Competency Skills Checklist

Employee Name:

Date:

S-Satisfactory Initial Annual U-Unsatisfactory

GOALS:

To provide proficient and safe care to clients To Enhance Perception of care given
To Praticipate in continuing education topics

1. Do you have any of the following?

Skills	Competency Demonstrated Date/Method	Initials
1. Follow up procedures for infection control EX: Handwashing/Standard Precautions	O I T s W
2. Taking and recording temperatures, pulse, and respiration. Report changes in patients’ conditions and environment.	O I T s W
3. Bed Bath (Sponge Tub/Shower)	O I T s W
4. Shampoo, Hair Care	O I T s W
5. Nail Care / Oral Care	O I T s W
6. Skin care / Positioning	O I T s W
7. Grooming / Dressing	O I T s W
8. Meal Prep - Fluid Intake	O I T s W
9. Medication Reminders	O I T s W
10. Toileting and Elimination/Bedpan/Commode/Urinal	O I T s W
11. Normal Range of Motion	O I T s W
12. Transfer, Ambulation, Positioning, and Passive exercises/DNR	O I T s W
13. Assists clients to achieve maximum self-reliance	O I T s W
14. Understands Advance Directives	O I T s W
15. Understands basic care and functions of clients including the physical, emotional, and developmental needs of the elderly,chronically ill, and disabled.	O I T s W
16. Observes, documents, and maintains records of patient’s care and activities performed / routine and changes	O I T s W
17. Problem solving/judgement and reports changes in patient	O I T s W
18. Understands emergency procedures and safety	O I T s W
19. Demonstrates communication skills	O I T s W
20. Punctuality and appearance	O I T s W
21. Ability to accept supervision / follow directions	O I T s W

METHOD:

O — Observe	I — Interview	T — On the training	S — In-Service	W — Written

RN Name:

Date:

SAFTY ORIENTATION: For Home Helthcare Workers Quiz

Print Name:

Date

1. Slips, trips, and falls are common causes of injuries while on the job.

TRUE FALSE

2. To avoid a back injury, you should use proper techniques for lifting and transferring patients, maintain good posture, and stay physically fit.

TRUE FALSE

3. Good mechanics include: bending at waist, lifting with your back and arm muscles, use a twisting motion, lifting higher than your waist, and keeping the load/weight far away from your body.

TRUE FALSE

4. Examples of Personal Protective Equipment includes but is not limited to gloves, gowns/aprons, face shields and shoe covers.

TRUE FALSE

5. Your personal safety is not your responsibility, and there is no need to follow the basic safety rules or beware of your surroundings.

TRUE FALSE

Number of questions answered correctly:

Agency Evaluator Name:

FIRE SAFETY: In Home Healthcare Quiz

Print Name:

Date

1. You should only use Standard Precautions if you are going to be coming in contact with someone who is at high risk of infection.

TRUE FALSE

2. It is not important for a home to have a smoke detector on each level of the home, especially near the bedrooms.

TRUE FALSE

3. What you do in the first 1-3 minutes of a fire is critical to protect the lives and property.

TRUE FALSE

4. The acronym to follow in case of a fire is R-A-C-E.

TRUE FALSE

5. It is not important or your responsibility to asses a home for fire hazards, or to report any issues to the agency.

TRUE FALSE

Number of questions answered correctly:

Agency Evaluator Name:

INFECTION CONTROL: In Home Healthcare Quiz

Print Name:

Date

1. You should only use Standard Precautions if you are going to be coming in contact with someone who is at high risk of infection.

TRUE FALSE

2. Hand washing is the single most important precaution against the spread of infection.

TRUE FALSE

3. There is NO need to wash your hands after the removal of your gloves.

TRUE FALSE

4. Gloves should be worn when you are assisting a client/patient with ambulating, when you are washing their dishes and when you come in contact with any bodily fluids such as blood, urine, or stool.

TRUE FALSE

5. The majority of cold germs are spread through hand to hand contact.

TRUE FALSE

Number of questions answered correctly:

Agency Evaluator Signature:

HIPAA - Privacy in Home Healthcare Quiz

Print Name:

Date

1. The HIPAA Privacy Rule restricts the use and disclosure of patient/client data including how it is stored, who can access it, where it goes and how it is used; and it gives the patient/client rights regarding their protected health information and more control over how and when it is used and by whom.

TRUE FALSE

2. Apatient/client’s Protected Health.Information (PHI) includes but is not limited to their name and address, their social security or other identification numbers, and any of their medical diagnosis.

TRUE FALSE

3. An agency employee is allowed to discuss the patient/client that they are taking care of with the friends/family or other patients/clients.

TRUE FALSE

4. The agency is only required to provide an agency employee with the minimum amount of health information necessary for them to be able to complete their job assignment/duties.

TRUE FALSE

5. If you violate the Privacy Rule, HIPAA has established civil and criminal penalties including a $100.00 civil penalty up to a maximum of $25,000.00 per year for each standard violation, and a criminal penalty for knowingly disclosing PHI which is a penalty that may escalate to a maximum of $250,000.00 for conspicuously bad offenses.

TRUE FALSE

Number of questions answered correctly:

Agency Evaluator Signature:

Universal Precaution (Gloves)

Complete this form on each visit for all cases with HHA/PCA

HHA Initial:

Date of Visit:

PCA Initial:

Date of Visit:

A. Does the aide have sufficient supply of gloves available? Yes NO

B. Does the aide verbalize knowledge of when and how gloves are to be used? Yes NO

C. Does the aide demonstrate Proper use and disposal of gloves? Yes NO

D. Does the aide verbalize the need to wash hands after removing gloves? Yes NO

E. Does the aide verbalize when he or she is NOT to use gloves? i.e., vacuuming, cooking, etc. Yes NO

IF THE ANSWER TO ANY OF THESE QUESTIONS ABOVE IS NO, PLEASE EXPLAIN FURTHER.

Was education provided as needed?

RN Name:

Date:

Employee Orientation/AMI Program 12 Hours - 2Days

Applicants Name:

Job Title:

Office Branch:

ADMINISTRATIVE ORIENTATION: PART 1

Agency Philosophy and Mission Statement
Job Description and Responsibilities
Condition of employment, code of conduct, code ethics, and conflict of interest
Time slip completion/Automated System Review/ Payroll
Attendance and Punctuality Policy
Appearance/Dress Code/ID badge
Communication with the agency and after hours/ On-call procedures
Non-Discrimination and Sexual Ha rassment Policies
Ethical Issues/Conflict Resolution/Grievance Polk and Procedures
Annual Health and In-Service Requirements
Drug Screening Policy
Corporate Compliance

CLINICAL ORIENTATION: PART Il

OSHA/ Infection Control/Standard Precautions/PPE
HIPAA/Confidentiality/HIV Confidentiality
Influenza (FLU) Vaccine Policy and Procedure
Hepatitis Bandc
Safety in the home (employee and client)
Emergency Preparedness Plan/Fire Safety
Client’s Bill of Rights and Responsibilities
Client Plan of Care
Advance Directives/Death in home/DNR (if patient is DNR, HHA must call Bethesda Elite Care Not 911)
If patient does not have DNR, must call 911, then call Bethesda Elite Care
Reporting Occurrences, Incidents, and changes in the patient’s conditions
Reporting potential abuse/Neglect of a Client
Proper body mechanics
Hospice Policies and Procedures Reviewed
O2 being used in home
Fire Safety

Acknowledgement of In-Service

I have received a Bethesda Elite Care Paraprofessional Handbook and have been oriented on Bethesda Elite Care Inc. policies and procedures related to mu jab responsibilities. I agree to follow all guidelines, both written and verbal. Failure to follow the above can result in immediate termination. I understand that clinical and administrative supervision/support is available if I should need further clarification of my duties.

I have been oriented to all of the above/Applicant’s Name:

Date:

Name/Title of Agency Administrative Presenter:

Name/Title of Agency Clinical Presenter:

Direct Deposit Enrollment/Change Form

Company Name:

Client Number:

Employee/Worker Name:

Employee/Worker Number:

EMPLOYEE/WORKER: Retaina copy of this form for your records. Return the Original to your employer.

EMPLOYERS: Return this form to your local Paychex office. For clients using on-line services, please retain a copy of this document for your records.

COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS — PLEASE PRINT IN BLACK/BLUE INK ONLY
Type of Account	Bank Account Number*	Financial Institution ("Bank") Name	I wish to deposit (check one):
Checking Savings			% of Net Specific Dollar Amount $00 Remainder of Net Pay
Checking Savings			% of Net Specific Dollar Amount $00 Remainder of Net Pay
One of the following is required to process this enrollment (check one): Voided check with name imprinted (no starter checks) Deposit slip (only accepted if the verbiage “ACH R/T” appears before the routing number) Bank letter or specification sheet (the Signature of your local bank representative MUST be included) Other Bank Documentation — If this box is checked the employer must sign this confirmation: I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed by Paychex, Inc. Employer Name Date: "Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account.

COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS — PLEASE PRINT IN BLACK/BLUE INK ONLY
Bank Account Number*	Financial Institution ("Bank") Name	Change My Deposit Amount To:
		From % to % of Net From $.00 To $.00 Remainder of Net Pay
		From % to % of Net From $.00 To $.00 Remainder of Net Pay

EMPLOYEEMWORKER CONFIRMATION STATEMENT
*PLEASE SIGN IN BLACK/BLUE INK ONLY* I authorize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct deposit transactions I authorize comply with all applicable law. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer to make direct deposits into the named account. Employee/Worker Name Date:

EMPLOYEEMWORKER CONFIRMATION STATEMENT

PLEASE SIGN IN BLACK/BLUE INK ONLY

I authorize my employer to deposit my wages/salary into the bank accounts specified above. I agree that direct deposit transactions I authorize comply with all applicable law. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer to make direct deposits into the named account.

Employee/Worker Name

Date:

Note: Digital or Electronic Signatures are not acceptable.

From W-4

Department of the Treasury
Internal Revenue Service

Employee's Withholding Certificate

Complete Form W-4 so that your employer can withhold the correct federal income tax from pay.
Give Form W-4 to your employer.
Your Withholding is subject to review by the IRS

OMB No. 1545-0074

2020

Step 1: Enter Personal Information

(a) First Name and Middle initial:

Last Name:

(b) Social security number:

Address:

City or town, state, and ZIP code

(C)

Single or Married filing separately

Married filing jointly (or Qualifying widow(er)

Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Does Your name match the name on your social security card? If not, to ensure you get credit for your earning, contact SSA at 800-772-1213 or go to www.ssa.gov.

Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5.
See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse Multiple Jobs also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

(a) Use the estimator at www..irs. gov/W4App for most accurate withholding for this step (and Steps 3-4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding;

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3~4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 $

Multiply the number of other dependentsby$500 . . . . $

Add the amounts above andenterthetotalhere . . .........

Step 4 (optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect(optional): this year that won't have withholding, enter the amount of other income here. This may Other include interest, dividends, andretiement income . . . . .

4(a)

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and entertheresulthere

4(b)

(c) Extra withholding. Enter any additional tax you want withheld each pay period.

4(c)

Step 5: Sign Here

Under penalties of perjury, | deciare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Employee's signature (This form is not valid unless you sign it.)

Date:

Employers Only

Employer’s name and address

First date of employment:

Employer identification number (EIN)

2 Forms of ID

Social Security Card

Certification of HHA/PCA

Direct Deposit Information

2 References

Proof of legality

Physical and Immunization Records

Covid Vaccine Card

For Privacy Act and Paperwork Reduction Act Notice, see page 3

Download Employment Form

Download File

Click the button above to download and print our job application.

After you have completed the job application, feel free to scan it and upload it to Upload Completed Employment Application

You may also email it back to contact@bethesdaelitecare.com

Upload Completed Employment Application

Please upload your completed application below along with the supporting documentation and certifications. Be sure to sign all required pages of the application.

How did you hear about us?

Internet Search Employee Other

Phone Number

Reference Person

Upload Form

2 Forms of ID

Social Security Card

Certification of HHA/PCA

Direct Deposit Information

2 References

Proof of legality

Physical and Immunization Records

Covid Vaccine Card

BETHESDA ELITE CARE, INC. EMPLOYMENT APPLICATION

FOR OFFICE USE ONLY:-

Please Print clearly. This application must be completed and all questions regarding your training and word experience answered. All information on the application is confidential. BETHESDA ELITE CARE, INC. will not contact your present employer without your consent.

Your Email Address:

Name:

Other Name:

Social Security#:

Current Address:

(Apt. #)

City:

State:

Zip Code:

Length of time at this address:

Previous Address:

(Apt. #)

City:

State:

Zip Code:

Length of time at this address:

Home Phone:

Cell Phone:

Other Phone:

Education/SCHOOLS ATTENDED		NAME OF SCHOOL AND ADDRESS	DID YOU GRATUATE	COURSE OF MAJOR	DIPLOMA OR DEGREE	YEAR COMPLETED
HIGH SCHOOL
COLLEGE
GRADUATE SCHOOL
BUSINESS SCHOOL
TRAINING PROGRAM
WORK HISTORY
Name, Address and Phone # of Current/Former Employers	From: Mo/Yr	To: Mo/Yr	Job Title	Supervisor's Name	Salary	Reason for leaving




ADDITIONAL REFERENCES:
NAME		ADDRESS / PHONE#			RELATIONSHIP

AVAILABILITY
APPLYING FOR Full Time Part Time	HOURS AVAIL.	M	T	W	T	F	S	S
APPLYING FOR Full Time Part Time	HOURS AVAIL.
IF PART TIME DAYS EVENINGS	FROM
TOTAL HOURS AVAILABLE PER WEEK:	TO
WILL YOU WORK OVERTIME IF REQUIRED? Yes No IF NO, PLEASE EXPLAIN
POSITION DESIRED			SALARY DESIRED			DATE YOU CAN START

Have you ever been bonded? Yes No If Yes, by whom
Have you ever been refused bond? Yes No If Yes, by whom
Have you ever been convicted of a crime? Yes No If Yes, by whom
Professional Licenses: Profession: Lic. No: Exp. Date: Verification:
Professional Licenses: Have you ever been sanctioned by Medicare/Medicaid Yes No
Para-Professional certification: HHA PCA School/Training Program: Verification:
Para-Professional certification: HHA PCA School/Training Program: Verification:
The information listed in my application is complete and true. I understand that if employed false statements on this application are cause of dismissal. I will comply with all of the agensy's rule and regulation regarding my employement. BETHESDE ELITE CARE, INC. My request information regarding my background which will include work and personal reference.
Applicant's Signature	Today's Date
BETHESDE ELITE CARE. does not discriminate because of sex, age, physical handicap, race, creed or national origion. The agency is an equal opportunity employer.

Title:	Starting Salary:
IF HIRED: COMPLETE THE FOLLOWINGS
Date of Orientation:	Date of Hire:	Starting Date:

REFERRAL SOURCE

Walk-in

Goverment Employement Egency

Private Employement Egency

Employee

Relative

School

Advertisement-Source

Other

Name of person who referred you if applicable

For Administrative Use Only

From the EEC job classifications listed belove, which one best describes the position filler?
Position(s) applied for: Available Not Available
Position(s) applied for:
Hired Available No
Position hired for:	Date of hire:
Officials and Managers	Sale Workers	Operatives (semi-skilled)
Professionals	Office and Clearical Workers	Laborers (unkilled)
Technicians	Craft Workers	Service Workers
Notes
Completed by		Date
I certify that the information given by me is true and correct and without any omission. I understand and agree that any false statement or intentional omission on this application or any subsequently furnished from constitutes cause for discharge at any time during my employment by Bethesda. I authorize Bethesda Elite to investigate all statements made in this application. I further authorize Bethesda Elite to make any investigation of my credit, criminal and driving records in connection with this application and anytime thereafter in connection with my employment. I authorize the references listed in this application, to provide Bethesda Elite will all information conceming my previous employment and any other pertinent information about me that they may have. I understand that all information obtained during pre-employment screening is held by Bethesda Elite in confidence and will not be released to a third Party unless Bethesda Elite is required by law or is specifically authorized to do so by me. I further understand that if I am hired, I will not have an employment contract and that my employment and compensation can be changed or terminated with or without notice or cause at any time by Bethesda Elite or by me. Signature:

Employment Eligibility Verification

Department of homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9

OMB No. 1615-0047

Expires 10/31/2022

START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTIDISCRIMINATION NOTICE: itis illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an ‘employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestaion (Employee must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)		First Name (Given Name)	Middle Initial	Other Last Names Used (If any)
Address (Street Number and Name)	Apt. Number	City or Town	State	Zip Code
Date of Birth (mm/dd/yyyy)	U.S. Social Security Number	Employee's E-mail Address		Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the Unites State
2. A noncitizen national of the Unites State
3. A lowful permenant resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in expiration date field. (See instructions) Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance:	QR Code - Section 1 Do Not Write in This Space

Signature of Employee

Today's Date

Prepare and/or Translator Certification (check one):

I did not use a preparer or translator

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Field below must be completed and signed when preparers and/or translators assist and and employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator		Today's Date (mm/dd/yyyy)
Last Name (Family Name)		First Name (Given Name)
Address (Street Number and Name)	City or Town	State	ZIP Code

Section 2. Employer or Authorized Representive Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A QR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Employee Info from Section 1	Last Name (Family Name)	First Name (Given Name)	M.I.	Citizenship/Immigration Status

List A
Identity and Employment Authorization

List B
Identity

AND

List C
Employment Authorization

Document Title	Document Title Document Title
Issuing Authority	Issuing Authority Issuing Authority
Document Number	Document Number Document Number
Expiration Date (if any) (mm/dd/yyyy)	Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy)
Document Title	Additional Information QR Code - Section 2 & 3 Do Not Write in This Section
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document (s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy):

(See instructions for exemptions)

Signature of Employer or Authorized Representive		Today's Date (mm/dd/yyyy)	Title of Employer or Authorized Representive
Last Name of Employer or Authorized Representive (Family Name)		First Name of Employer or Authorized Representive (Given Name)	Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)	City or Town	State	ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representive.)
A. New Name (if applicable)		B. Date of Rehire (if applicable)
Last Name (Family Name)	First Name (Given Name)	Middle Initial	Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
Document Title	Document Number	Expiration Date (if any) (mm/dd/yyyy)

I attest under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representive

Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representive

LISTS OF ACCEPTABLE DOCUMNETS

All documents must be UNEXPIRED

Employees may represent one section from List A

or a combination of one section from List B and one section from List C.

LIST A

Documents that Estabhish

Both Identity and

Employment Autorization

LIST B

Documents that Estabhish

Identity

LIST C

Documents that Estabhish

Employment Autorization

1. U.S. Passport or U.S. Passport Card	1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a Photograph or information such as name, date of birth, gender, height, eye color, and address	1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
2. Permanent Resident Card or Alien Registration Receipt Card (Form 1-551)	2. ID card issued by federal, state or local government agencies or entities, Provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address	2. Certification of report of birth issued by the department of state (Forms DS-1350, FS-545, FS-240)
3. Foreign passport that contains a temporary I-551 stamp or temporary 1-551 printed notation on a machine-readable immigrant visa	3. School ID card with a photograph	3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Employment Authorization Document that contains a photograph (Form 1-766)	4. Voter's registration card	4. Native American tribal document
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form 1-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the Proposed employment is not in conflict with any restrictions or limitations identified on the form.	5. U.S. Military card or draft record	5. U.S. Citizen ID Card (Form \|-197)
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94 indicating Nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI	6. Military dependents ID card	6. Identification Card for Use of Resident Citizen in the United States (Form 1-179)
	7. U.S. Coast Guard Merchant Mariner Card	7. Employment authorization document issued by the Department of Homeland Security
	8. Native American tribal document
	9. Driver's license issued by a Canadian government authority
	For persons under age 18 who are unable to present a document listed above:
	10. School record or report card
	11. Clinic, doctor, or hospital record
	12. Day-care or nursery school record

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

NYS Department of Health, Criminal History Record Check Unit chrc@health.state.ny.us
The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.
SECTION 1 — SUBJECT INDIVIDUAL INFORMATION
Last Name	First Name	Middle Initial	Maiden Initial
Date of Birth	Alias/AKA	Mother Maiden Initial
Mailing Address (street)	City	State	ZIP Code
SECTION 2 — ATTESTATION
1. I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI). 2. I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI. 3. I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary. In accordance with applicable laws, DOH will furnish appropriate summary information to the agency to which I applied for @ position to provide direct care or supervision to residents or Patients. I have been advised that the criminal history record summary will indicate whether T have a criminal history, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential Pursuant to applicable federal and state laws, rules and regulations and shall ‘only be disclosed to persons authorized by law. I have been informed that upon receiving notification from DCJS that there is a subsequent pending criminal action Or proceeding or conviction, the DOH shall promptly notify an authorized Person(s) of a provider of the additional allegation or new conviction. 4. I hereby consent to DOH sharing with any DCJS agency to which I applied for a Position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place. 5. I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and Procedures established by the DCJS and the FBI. If I believe an error has been made by DCIS for any New York State conviction/charge or the FBI for any non-New York State conviction/charge, I understand that I should notify DCJS and/or the FBI to report and request correction of this error to the addresses below.
NYS Division of Criminal Justice Servuces Criminal History Bureau Record Review Unit-5^th Floor 4 Tower Place Albany, NY 12203 (518) 485-7675		Federal Bureau of Invastigation Criminal Justice Information (CJIS) Division 1000 Custer Hollow Road Clarkburg, WV 26306
6. I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or dedined, regardless of whether an agency, DOH or I have reviewed my criminal history information. 7. I certify to the best of my knowledge and belief that I (check as appropriate): Have Have not been convicted of a crime in New York State or any other jurisdiction Do Do not have a final finding of patient or resident abuse If you checked either “Have” and/or “Do”, please provide a brief explanation. (Optional) 8. My current mailing or home address is indicated in Section 1 of this form. 9. Thave read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the re-disclosure of any convictions or open charges on my criminal history record, received by DOH from DCIS, to the requesting agency in accordance with applicable laws. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be ited are my own.
Applicant Signature: Date: Name and Signature of Parent or Legal Guardian: (if subject individual is under 18 years of age) Date:
SECTION 3 — AGENCY AUTHORIZED PERSON INFORMATION
Agency Name:		Operating License Number (PFI):
Print Name of Authorized Person:		Title:
Signature of Authorized Person:		Date:

NYS Department of Health

CRIMINAL HISTORY RECORD CHECK

DHO use only. Leave blank

Reaubmission

Type or Print all information - USE CAPITAL LETTERS.

Inaccurate, Incomplete or illegal information will delay processing

SECTION 1 — SUBJECT INDIVIDUAL INFORMATION
Social Security Number*			Date of birth mm/dd/yyyy
Last Name			First Name	M.I.
Maiden Name			Alias (AKA)
Street Nmbr		Street Name		Apt #
City		State	ZIP	Home Phone
Sex		Birth Country Place	Cell Phone
Race	Height (ft-inch)	Weight	Hair	Eye

SECTION 2 — SUBJECT INDIVIDUAL IDENTIFICATION
Please Select the Type of PICTURE IDENTIFICATION (select one): Drivers License/ DMV ID Passport Milatry School Other Identity:
Issuing State/Country/Armed Force/School:	ID Number	ID Expire Date mm/dd/yyyy

SECTION 3 — AGENCY IDENTIFICATION
Nursing Home CHHA LTHHCP PFI# LHCSA LICENSE
Full name of Agency where applicant will be working		Telephone number with area code
Authorized Person Last Name		Authorized Person First Name
Agency's Street Nmbr		Street Name
City	State	Zip
Authorized Party's e-mail
The subject Individual, whose identification I have confirmed, will provide direct care or supervision to individual receiving care and/or service and is a subject individual whom a criminal history record check is required by law (Article 28-E of the Public Health Law and Section 845-B of the executive Law). I understand that the results of criminal history record check will be used solely for purpose authorized by law and I will abide by the confidential requirements set forth in law. Informed consent (DOH CHRC Form 102) has been given by the subject individual and is on file. Signature of Agecy Authorized Person Date

SECTION 4 — FINGERPRINTING METHOD/IDENTIFICATION
Fingerprint Method: Ink & Roll Live Scan	Name & Address of Location where fingerprint services were performed City State Zip
Identification verified before fingerprinting(refer to instruction #4): Yes No	The subject Individual, whose identification I have confirmed, appeared befor me for fingerprinting. I secured his/her fingerprint via the method indicate Signature First Name Last Name Title	Date Fingerprinted

* The Authorized Person shall inform the subject that disclouser of the Social Security Number (SSN) is voluntary and not mandatory and that it will be used to assist DOH-CHRC Until in performing criminal history record checks.

3 SURREY LANE MANORVILLE, NY 11949
781 SUFFOLK AVENUE BRENTWOOD, NY 11717
PHONE: (631) 503-7209
FAX: (632) 909-2445

EMERGENCY CONTACT INFORMATION

In case of an emergency, please contact the following person(s)

Employee Name:

Address:

Home Phone:

Cell Phone:

Contact Person 1

Name:

Address:

Home Phone:

Cell Phone:

Contact Person 2

Name:

Address:

Home Phone:

Cell Phone:

JOB TITLE

Home Health Aide

REPORT TO

Filed Staff Coordinator Supervisor and Director of Clinical Services

SUMMARY:

A person who carries out health care tasks under the supervision of a Registered Nurse and who may also provide assistance with personal hygiene, housekeeping, and other related supportive tasks to a client with health care needs in his/her home.

JOB DUTIES:

Personal Care — assists with:
1. Bath (bed, bath, tub, shower)
2. Oral hygiene (mouth, denture care)
3. Care of Hair (shampoo, dry and comb)
4. Care of nails
5. Skin care/lotion massage
6. Position change
7. Provide for elimination (bedpan, commode, toilet)
8. Assist with dressing
9. Take temperature and pulse

Treatments — assists with:
1. Transfer and Ambulation
2. Test urine
3. Non-sterile dressings
4. Use of prosthesis
5. Active exercises
6. Use of special equipment
7. Take vital signs as ordered
8. Intake and output
9. Alcohol sponge
10. Assist self-medicating clients with medication

Homemaking — assists with:
1. Meal planning and preparation (prepare, serve, feed)
2. Assist with feeding
3. Linen change
4. Laundry
5. Light housekeeping (making beds, dust and vacuum, tidy kitchen and bathroom, wash dishes after meals)
6. Grocery shopping, opening mail, banking and errands
7. Grocery shopping, opening mail, banking and errands

The following functions are generally performed only after demonstration by the coordinating nurse:
1. Tub, bath, or shower
2. Care of catheter drainage bag
3. Reinforce dressings and change simple, non-sterile dressings
4. Ace bandage/elastic stockings
5. Ice bag
6. Simple soaks
7. Range of motion or prescribed services
8. Change of Ostomy equipment
9. Use of rehabilitative devices such as walker, wheel-chair, crutches, cane
10. Special skin care
11. Application of binders and other supports
12. Oxygen equipment
13. Relearning of household skills
14. Measure intake and output
15. Prepare modified diets
16. Collect stool and urine specimens
17. Prepare formula
18. Breast care for nursing mother
19. Perform alcohol sponge baths

An aide is NOT allowed to perform the following functions except as indicated in the Matrix entitled Permissible and Non-Permissible Activities: Home Health Aide (HHA) Services published by the New York State Department of Health on 8/19/1992.
1. Enema
2. Colostomy or catheter irrigation
3. Tracheostomy care
4. Gastric lavage or gavage
5. Administer medications
6. Change sterile dressings
7. Tube feedings
8. Give any medication — oral or inj
9. Apply any form of heat
10. Vaginal irrigation (douche)
11. Decubiti care
12. Make medical and/or nursing judgements
13. Ant care not included in the nursing care plan

Documents care daily on all cases, reports to coordinating nurse any incidents or changes in condition of client.

Participates in Quality Improvement activities as indicated.

Attends staff meetings and in-service presentations, as required,

Attends case conferences as indicate.

Communicates effectively with all those providing care.

Immediately notifies agency of any unforeseen circumstances or changes in the client’s condition.

Maintains client safety and confidentiality.

Observes and practices Standard and Universal Precautions.

Follows agency policy and procedure and provides care within the Home Health Aide Scope of Practice in a legal and ethical manner

QUALIFICATIONS:

Has successfully completed a basic home health aide training program approved by the New York State Department of Health and poses written evidence of such completion, or
Hass successfully passed an equivalent exam approved by the New York State Department of Health and possesses written evidence of such completion.
Has not been disqualified from employment resulting from a Criminal History Record Check submitted to the New York State Department of Health.

PHYSICAL REQUIREMENTS:

The health status of all new personnel is assessed prior to assuming direct client care responsibilities. The assessment will include:

A statement reflecting that the person is free from health impairment which is of potential risk to a client or which might interfere with the quality of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol, or other drugs or substance which might alter the individual’s behavior;
Documentation of immunization against rubella.
Documentation of immunization against measles for all personnel born on of after January 1, 1957.
Baseline TB screening using a two-step tuberculin skin test (TST) — i.e., Mantoux method or an approved whole blood assay for individuals with no PPD result sin the past year and a history of negative PPD. Documentation of negative chest x-ray and appropriate follow up, if applicable.
Annual health assessment and TB screening (PPD or T8Q and appropriate follow up as needed) thereafter.

WORK ENVIRONMENT:

Works in the home environment with regular exposure to client elements and occasional stress.

COGNITIVE REQUIREMENTS:

Provides direct care according to the established client plan of care.
Must work cooperatively with others and perform a wide variety of complex and complete tasks.

FUNCTIONAL ABILITIES:

Must be able to read twelve point or larger type and have normal color perception.
Must be able to walk up and down stairs, lift, stoop, push, bend, reach, stand, sit, twist, and lift repeatedly throughout the day effectively so as to be able to perform the above listed functions.
Must be able to hear adequately with no more than one amplifier on the phone and speak in a manner understood by most persons;
Must be able to look at a computer monitor up to 2 hours daily
Must have an acute sense of smell for normal perception

Signature of Home Health Aide

Date

Signature of Field Staff Coordinator Supervisor

Date

From 8850
(Rev. March 2016)
Department of the Treasury
Internet Revenue Service

Pre-Screening Notice and Certification Request

for the Work Opportunity Credit

Information about Form 8850 and its seperate instructions is at www.irs.gov/form8850

OMB No. 1545-1500

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side

Your Name

Social Security Number

Street address where you live

City or town, state, and ZIP code

County

Telephone Number

If you are under age 40, enter your date of birth (month, day, year)

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.

Check here if any of the following statements apply to you.
- I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
- I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
- I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work Program, or the Department of Veterans Affairs.
- I am at least age 18 but not age 40 or older and I am a member of a family that:
  a. Received SNAP benefits (food stamps) for the past 6 months; or
  b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
- During the past year, I was convicted of a felony or released from prison for a felony.
- I received supplemental security income (SS!) benefits for any month ending during the past 60 days.
- I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.

Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a Period or periods totaling at least 6 months during the past year.

Check here if you are a member of a family that:
- Received TANF payments for at least the past 18 month:
- Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
- Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.

Signature - All Applicants Must Sign

Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct and complete.

Job applicant's signature

Date

Please fill up these forms slowly and legibly.
(no script) Rev. 2/25/16

Company Name: Bethesda Elite Care

Company Code for Online Users:

This company participates in various federal and state tax credit Programs. This information in no way will negatively impact any hiring, retention decision. Your responses to the questions will only be shared with your employer's management and federal, state, or local governmental agencies as needed in administration of these Programs. By completing this form, you knowingly and voluntarily waive any objection to provi ling your social security number. Any information provided will be used in a manner consistent with the American Disability Act. Under penalty of perjury, I certify that this information is true and correct to the best of my knowledge. I hereby authorize this company’s management, and federal, state, and local government agencies to provide information to TC Services USA, Inc., and/or SWA, to determine eligibility. I understand that the information above may be subject to verification.

Employment Start Date

Starting Wage

Position

Signature

Today's Date

New York State Department of Health
Division of Home and Community Based Services

RRDC:

EMPLOYEE VERIFICATION OF QUALIFICATIONS

HOME AND COMMUNITY BASED SERVICES MEDICAID WAIVER

Nursing Home Transition and Diversion (NHTD)

Employee to provide the Waiver Service

HSCC

Bethesda Elite, Care Inc

Service Provider Name

Waiver Service you are applying for

HSCC

Waiver Service Position, if applicable

3 surrey Lane Manorville NY 11949
Address

(631) 400-9020
Telephone

I have submited my resume and supporting documents which accurately reflects my education and work experience.

Employee Signature

Date

This individual has Met the eligibility criteria for this position in the following manner:

Education:

A copy of this individual's diploma or official sealed transcript license is attached to this form.

Experience:

This individual's experience, relevant to this Position, is highlighted on his/her attached resume. (“Please circle this person’s relevant experience on the attached resume for quick reference for the interviewers).

I have interviewed this individual and reviewed his/her resume. I verified his/her education, required licensures and work experience. Per waiver eligibility criteria, this individual is qualified to provide waiver services in the above named position and has been hired as an employee of our agency.

Service Provider Representative

Title

Signature

Date

New York State Department of Health
Division of Home and Community Based Services

RRDC:

EMPLOYEE VERIFICATION OF QUALIFICATIONS

HOME AND COMMUNITY BASED SERVICES MEDICAID WAIVER

Traumatic Brain Injury (TBI)

Employee to provide the Waiver Service

HCBS

Bethesda Elite, Care Inc

Service Provider Name

Waiver Service you are applying for

HCBS Aide

Waiver Service Position, if applicable

3 surrey Lane Manorville NY 11949
Address

(631-400-9020) / (631) 503-7209
Telephone

I have submited my resume and supporting documents which accurately reflects my education and work experience.

Employee Signature

Date

This individual has Met the eligibility criteria for this position in the following manner:

Education:

A copy of this individual's diploma or official sealed transcript license is attached to this form.

Experience:

Service Provider Representative

Title

Signature

Date

781 SUFFOLK AVENUE BRENTWOOD NY 11717 PH (631)503-7209 FX (631)909-2445

HISTORY & PHYSICAL

NAME

ADDRESS

PHONE #

LAST 4 OF S.S. #

DATE OF BIRTH:

DATE OF EXAM:

VITAL SIGNS: HEIGHT: WEIGHT: BP: TEMP: RESP:

SEROLOGY

ANTIBODY	TITER	IMM	NONIMM	DATE
RUBELLA
RUBEOLA
MUMPS
HBs AB
VARICELLA

IMMUNIZATOINS

VACCINE	N/A	GIVEN	DATE
TD
MMR
HEPATITS B
INFLUENZA

1^st PPD/MANTOUX DATE IMPLANTED: DATE READ: INDURATION: LOT # MANUFACTURER: EXP:

Positive

Negative

2^nd PPD/MANTOUX DATE IMPLANTED: DATE READ: INDURATION: LOT # MANUFACTURER: EXP:

Positive

Negative

3^rd Annual Blood Test QuantiFERON GOLD (alternative to TST)
Blood test IFN concetration: IU/ML Test Date

Positive

Negative

Intermediate

CHEST X-RAY (IF PPD IS POSITIVE):
Date: RESULT PLEASE ATTACH CHEST X-RAY REPORT.

DRUG SCREEN DATE: PLEASE ATTACH LAB REPORT
DIPTHTHERAPIA DATE GIVEN: BOSTER REQUIRED EVERY 10 YEARS.
TETANUS DATE GIVEN: PLEASE ATTACH BOSTER REQUIRED EVERY 10 YEARS.

FITNESS TO WORK
BASED ON THE HEALTH HISTORY, PHYSICAL EXAM, AND LAB TEST PERFORMED, THIS PERSON IS:

FIT TO WORK WITHOUT LIMITATIONS OR RESTRICTIONS

FIT TO WORK WITH LIMITATIONS OR RESTRICTIONS

DR. SIGNATURE AND STAMP:

DATE:

U.S. Citizen:	Yes No	If no, Immigrant ID/Card		Expiration Date
Position Appling for:	Admin RN LPN PCA Homemaker PT/OT/RT MSW Clerical Other

Minimum Salary Requirement: Date Available To Begin:
Daily Available To Work: (check all that apply)	Sat Sun Mon Tue Wed Thu Fri
Hour Available To Work: (check all that apply)	4 hours AM 4 hours PM 8 hours 12 hours PM Live In
Which Language can you speak: (check all that apply)	Spanish Polish Russian Yiddish Hungarian Other

Have you worked for this Employer before? Are you a Re-hire? If Yes, enter last day of employment:		Yes No
Are you under age 40?		Yes No
Have you been unemployed for at least 27 weeks, and collected unemployment Insurance?		Yes No
Are you a Veteran of the US Armed Forces? If yes: Are you a member of a family that received SNAP (Food Stamps Benefits)? Yes No Are you entitled to compensation for a service-connected disability? Yes No Were you discharged from active duty within the last year? Yes No Were you unemployed for a combined total of 6 monthes before were you hired? Yes No		Yes No
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 months period, but you are no longer receiving it? If yes to enter question, enter Name of Primary Recipient: And City, Sate where benefits were received		Yes No
Are you a member of family that received TANF assistance for at least 18 months before you were hired? Or, did your family stop being eligible for TANF assistance within 2 years before being hired, because you reached the maximum time those benefits can be received? If yes to enter question, enter Name of Primary Recipient: And City, Sate where benefits were received		Yes No
Did you receive Supplimental Security Income (SSI Benefits) for any month, ending within the 60 days, before you were hired?		Yes No
Were you convicted of a Felony during the year before you were hired?		Yes No
Were you reffered to an employer by: A Vocational Rehab Agency approved by the state? An Employment Network under the Ticket to Work Program? The Dept. of Veteran Affairs?		Yes No Yes No Yes No
Print Name:	Social Security #:	Date of Birth:

Download New Employee 11 Pack Form

Upload Completed 11 Pack Form

Online Fill-up of New Employee 11 Pack Form

ANNUAL CONFIDENTIALITY OF INFORMATION AGREEMENT

HIV Confidentiality Law Employee Training

DECLINATION OF INFLUENZA VACCINATION

Hepatitis B and C Vaccination

STATEMENT REGARDING DRUG/ALCOHOL USE

DRUG-FREE WORKPLACE EMPLOYEE ACKNOWLEDGEMENT

DRUG-FREE WORKPLACE ATTESTATION

ANNUAL TUBERCULOSIS SCREENING QUESTIONNAIRE

ANNUAL SELF-HEALTH ASSESSMENT FORM

Acknowledgement of In-Services

Home Health Aide - Competency Skills Checklist

SAFTY ORIENTATION: For Home Helthcare Workers Quiz

FIRE SAFETY: In Home Healthcare Quiz

INFECTION CONTROL: In Home Healthcare Quiz

HIPAA - Privacy in Home Healthcare Quiz

Universal Precaution (Gloves)

Employee Orientation/AMI Program 12 Hours - 2Days

ADMINISTRATIVE ORIENTATION: PART 1

CLINICAL ORIENTATION: PART Il

Direct Deposit Enrollment/Change Form

Employee's Withholding Certificate

2020

Step 1: Enter Personal Information

Step 2: Multiple Jobs or Spouse Works

Step 3: Claim Dependents

Step 4 (optional): Other Adjustments

Step 5: Sign Here

Employers Only

Download Employment Form

Upload Completed Employment Application

BETHESDA ELITE CARE, INC. EMPLOYMENT APPLICATION

REFERRAL SOURCE

For Administrative Use Only

Employment Eligibility Verification

Department of homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-9

OMB No. 1615-0047

Expires 10/31/2022

Prepare and/or Translator Certification (check one):

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

LISTS OF ACCEPTABLE DOCUMNETS

All documents must be UNEXPIRED

Employees may represent one section from List A

or a combination of one section from List B and one section from List C.

LIST A

Documents that Estabhish

Both Identity and

Employment Autorization

LIST B

Documents that Estabhish

Identity

LIST C

Documents that Estabhish

Employment Autorization

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

NYS Department of Health, Criminal History Record Check Unit

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

SECTION 1 — SUBJECT INDIVIDUAL INFORMATION

SECTION 2 — ATTESTATION

SECTION 3 — AGENCY AUTHORIZED PERSON INFORMATION

NYS Department of Health

CRIMINAL HISTORY RECORD CHECK

Reaubmission

Type or Print all information - USE CAPITAL LETTERS.

Inaccurate, Incomplete or illegal information will delay processing

SECTION 1 — SUBJECT INDIVIDUAL INFORMATION

SECTION 2 — SUBJECT INDIVIDUAL IDENTIFICATION

SECTION 3 — AGENCY IDENTIFICATION

SECTION 4 — FINGERPRINTING METHOD/IDENTIFICATION

EMERGENCY CONTACT INFORMATION

In case of an emergency, please contact the following person(s)

Contact Person 1

Contact Person 2

JOB TITLE