* = Required Information
Full-Time Part-Time

In Case of Emergency Notify:

Please answer the following questions

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Education

High School

Yes No

College/University

Yes No

Technical/Business School

Yes No
Professional License / Certification
RN LVN CNA Other
Technical Skills

Check all that apply to you:

Typing
Computer Programs
Foreign Language
Employment History

List the most recent position first. (Please provide at least 5 years if available)

References

List three references (not related), who have known you for at least a year

AssuranceJ Homecare Services, Inc. Is an equal opportunity employer, and selects the best-matched individual for the Job-based upon related qualifications, regardless of race, color, creed, sex, national origin, age, handicap, or other protected groups under stale, federal, or local Equal Opportunity Lows.

I UNDERSTAND AND AGREE THAT:

Any material misrepresented of deliberate omission of fact in my application may be Notification for refusal of, or if the employed term nation from employment.

It is my understanding that ASSURANCE, HOMECARE SERVICES, INC. will make a thorough in play entire work history and may verify all data given in IN application for employment, related papers, or oral interviews. I authorized such investigation and the released from liability ay person giving or receiving of any information requested by AssuranceJ Homecare Services, Inc. and released from liability any person giving or receiv.g such information. I understand that falsification of data so given or other derogatory information discovered as a result of the invalidation may prevent my being hired may subject me to immediate dismissal.

I agree that my employment may be terminated by ASSURANCE., HOMECARE SERVICES, INC. at any time without liability for wages and salary except such as may have been earned at the date of such termination. If requested by the management at any time, I agree to submit to a search of my person or locker that may be assigned to me and hereby waive all claims of damages on the account of such examination. I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of a job I am being considered prior to employment or. the flare during examination by a qualified physician at the discretion of my employer. E understand that the result of my medical exam is the property of AssuranceJ Homecare Services, Inc., and will be kept confidential to the full extent of the law.

Although management makes every effort to accommodate individual preferences, business needs may at the time the following conditions mandatory: overtime, Mitt wort, a rotating work schedule other than Monday through Friday. I understand and accept these conditions of my continuing employment.

I understand that I am employed, such employment is for no definite period of time and that association can change wages, benefits, and conditional any Moe. I agree that if for any reason I missed be.g paid during a pay period; I will be paid for the next pay period.

I, the undersigned, certify that I have read and fully comprehend this form in its entirety ad that the information provided is true and complete to the best of my knowledge. I understand that should any statement I made prove false, misleading, or erroneous, it may rain In the rejection of my application. I authorize the Agency to obtain from my present (unless otherwise ....Hand pad employers all data needed to support this application. I further understand that this application becomes the property of AssuranceJ Homecare Services, Inc., and will not be returned.

PAS Attendant

The PAS Attendant is responsible for providing personal assistance services to the client in accordance with the established service plan to enable the client to function in the home and community.

  1. Should be at least 18 yews of age
  2. Can be spouse to client. However, if living with the client cannot have job outside the home
  3. Can be neither legal nor foster parents of minor children who receive the services
  4. Must be free of communicable disease and open infections or wounds
  5. Must have reliable transportation
  6. Must be able to read and write English.
  1. Shall perform services as identified on the Service Plan
  2. Shall report to the supervisor on the day of awareness of any significant changes in the client's condition.
  3. Shall report emergency situations to appropriate individuals in accordance with the policies immediately upon awareness.
  1. Must be able to stand and walk throughout the majority of shifts on various surfaces in client's homes.
  2. Must be able to lift and carry items up to 30 pounds, such as mop buckets, groceries, and trash bags.
  3. Must be able to push/pull up to various weights while performing tasks, such as pushing the client wheelchair and transferring the client.
  4. Must be able to climb Mans at various clients' houses.
  5. Must be able to bend, turn, and reach objects when performing various job functions such as cleaning throughout the shift.
  6. Must be able to handle objects such as wheelchairs, brooms, mops, dishes, and vacuum cleaner.
  7. Must be able to communicate effectively with the client.
  8. Overall environment must be able to work in various degrees of temperature, depending upon client's house setting. Position requires working with various cleaning solvents, fumes, dust, and odors.
  9. Must be sensitive to the needs of the aged and disabled, and be conscientious about services client needs.
  10. Must not be short-tempered, rather must be slow to anger and be able to respond in a calm way as well as be able to work in an often-stressful situations when dealing with patients who maybe abusive.
  11. Must be alert and able to identify hazards should one occur, and in order to avoid them by reporting immediately, and if directed, should be able to take corrective actions.

I have read the above job descriptions and agree to adhere to them, and all questions have been answered 0 this date regarding any understanding of the above job descriptions.

The above-listed job descriptions have been reviewed and discussed with me and I have had an opportunity to ask questions regarding same.

PAS ORIENTATION CHECKLIST NEW HIRES

Topic of Orientation Initials of Preceptor Initials of Employee Date of Orientation
1) Job Responsibilities
2) Philosophy and values of community integration and consumer driven care
3) Report of abuse neglect, and change in client health condition requiring emergency procedures or health services
4) Personnel Policies
5) Agency Philosophy and objectives
6) Universal Precautions or HIV prevention and Hepatitis B
7) Safety in the home
8) Hours of business
9) Payroll
10) Patient's Rights

Providers Orientation Checklist

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Past Employment References

AUTHORIZATION

I consent to release all information requested by ASSURANCEJ HOMECARE SERVICES, INC. regarding my past employment.

Dear Past Employer:

This applicant listed above has applied for employment with us and has given your name as a reference. Please furnish the following information as soon as possible.

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Authorization

I consent to release all information requested by ASSURANCEJ HOMECARE SERVICES, INC. regarding my past employment.

Dear Past Employer:This applicant listed above has applied for employment with us and has given your name as a reference. Please furnish us with the following information as soon as possible.

Above Average Average Poor
Above Average Average Poor
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Philosophy Organizational Structure Benefits
Employment Requirements Dress Code Communicable Disease
Infection Control Assignment Personal Protection Equipment
Availability Voluntary Termination Disciplinary Guidelines
Time Slip Procedures Charting Health Care Safety

I have received a copy of the Employee Handbook or policies listed and have read and/or had explained to me, all of the proceeding policies, procedures, rules, requirements, and conditions of employment. I understand them and agree to abide by these and any other applicable Agency policies. I further understand that my failure to abide by them may be cause for termination of employment.

Have you ever had or do you have any of the following?

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To the best of my knowledge the foregoing statements are correct and may be used to whatever extent in connection with my application for employment. I know of no condition or disability either current or in the past, which would impair my physical capability in performance of my duties I understand that falsification or fail to disclose this information is grounds for dismissal.

HEPATITIS B VACCINATION OR DEVLINE FORM

I have read and understood the Agency's Policy and Procedure regarding the Hepatitis B Vaccination Program. I understand that due to my occupational exposure to blood or other potentially infectious material; I may be at risk of acquiring the Hepatitis B virus (HBV) infection.

I have received the Hepatitis B vaccine series in the last 2 months

I have received the Hepatitis B vaccine series in the last 2 months

I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious material and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Employee Statement Regarding the Emergency Preparedness Policy and Procedures

I have been provided with a copy of the agency policy on emergency preparedness, planning, and implementation that includes agency pandemic such as COVID-19, and I understand my role in implementing that policy.

Statement of Compliance

I an employee of AssuranceJ Homecare Services, Inc., do hereby agree to comply with the agency's policy and procedures.

Statement of Employability Consent for Employment and Criminal History Checks

You cannot work in a position which involves direct client contact if you are listed in the employee misconduct registry, barred in the nurse aide registry, listed as an excluded person by the OIG or have been convicted of any of the following:

  • Chapter 19, Penal Code (criminal homicide);
  • Chapter 20, Penal Code (kidnapping and unlawful restraint);
  • Section 21.02, Penal Code (continuous sexual abuse of young chills or children);
  • Section 21.11, Penal Code (indecency with a child);
  • Section 22.011, Penal Code (sexual assault);
  • Section 22.02, Penal Code (abandoning or endangering child);
  • Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
  • Section 22.041, Penal Code (abandoning or endangering child);
  • Section 22.08 Penal Code (aiding suicide);
  • Section 25.031 Penal Code (agreement to abduct from custody);
  • Section 25.08 Penal Code (sale or purchase of a child);
  • Section 28.02 Penal Code (arson);
  • Section 29.02, Penal Code (robbery);
  • Section 29.03, Penal Code (aggravated robbery);
  • Section 21.08, Penal Code (indecent exposure);
  • Section 21.12, Penal Code (improper relationship between educator and student);
  • Section 21.15, Penal Code (improper photography or visual recording);
  • Section 22.05, Penal Code (deadly conduct);
  • Section 22.021, Penal Code (aggravated sexual assault);
  • Section 22.07, Penal Code (terroristic threat);
  • Section 33.021, Penal Code (online solicitation of a minor);
  • Section 34.02, Penal Code (money laundering);
  • Section 35A.02, Penal Code (Medicaid fraud);
  • Section 42.09, Penal Code (cruelty ti animals);
  • An offense under chapter 31, Penal Code (theft) punishable as a felony if the conviction is less than 5 years;
  • An offense under Texas Penal Code Title 5, Title 7, Title 9, Title 10 of Title 4 section (A)-(T) for an offense containing elements that are substantially similar to the elements of an offense listed under the codes stated above.
  • The Agency reserves the right to determine if any committed that is not listed above, would be a contraindication to employment therefore resulting in termination of non-offer of employment.

I have been informed that a criminal history checked may be performed on my name as mandated by Chapter 250 of the Health and Safety Code. I certify that I have not been convicted of any offense that would bar employment as listed above, and that I have informed this Agency of all names (i.e maiden, aliases) that I have used in the past. I understand that my employment is conditional upon the satisfactory completion of the required background screening and inquiry of the Employment Misconduct Registry and or Nurses Aide Registry. I further understand that should I be arrested and convicted of any of the above-listed violations, I will report this to the Agency immediately and that my services may be terminated at that time.

Pledge for Confidentiality of Protected Personal Health Information

I, the undersigned, have read and understood AssuranceJ Homecare Services, Inc.'s policy on Confidentiality of Protected Personal Health Information in consideration of my employment or association with AssuranceJ Homecare Services, Inc. and as an integral part of the terms and conditions of my employment or association, I hereby agree that I will not at any time during my employment of after my employment or associations, I hereby agree that I will not at any time during my employment or after my employment or association ends, access or use personal health information, or reveal or disclose to any person within or outside AssuranceJ Homecare Services, Inc. any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicable legislation and corporate and departmental policies governing the proper release of information. I also, understand that unauthorized use or disclosure of such information will result in disciplinary action up to and including termination of employment, contract, or association and the imposition of fines pursuant to applicable state and federal laws.

I have discussed the Confidentiality Protected Personal Health Information Policy and Consequences of a breach with the above named.

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