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Connected Home Care ensures equal opportunity to all employees and applicants regardless of their race, color, gender, sex, religion, age, creed, marital status, familial status, national origin, ancestry, past or present physical or mental disability, sexual orientation, gender identity, affectional preference, veteran status, citizenship status, genetic information, uniform service member status, and any other classification protected by law.

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I affirm that the information in this application is complete and true. I understand that if employed, false statements will be a cause for dismissal.

Ihave applied for a position as a HHA / PCA with Conncected Home Care. All of the information I have submitted is true to the best of my knowledge. All certificates are valid (or copies of originals) and all background information is correct. I authorize Connected Home Care to obtain any information regarding and pertaining to my employment and health status. I understand that this may include contacting the following to obtain information to verify signatures, dates, forms and data.

Medical providers (M.D. lab, etc )

Previous Employes

Schools & Traning Programs

Personal and professional references

I further release Connected Home Care of any liability that may occur as a result of

my personal negligence or as a result of any information that I wrongfully or fraudulently submitted to Connected Home Care or in the course of applying for a position during my association with them. I understand that any information fraudulently submitted will result in my immediate termination.

As a job applicant/employee of Connected Home Care, I hereby attest to the fact that I have received no special inducements, remuneration, or promises thereof to work for this agency. I understand that I will receive a salary commensurate and also in line with what other employees of this agency are receiving for similar work and experience. All other benefits that I may be eligible for will be in accordance with policies established by Connected Home Care.

The hiring of personnel, salaries, and benefits are awarded without regard to race, religion, disability, marital status, sexual orientation, or any other protected classification. Connected Home Care is an equal opportunity employer. I have read the preceding statement and I understand and agree with its contents.

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. ANTI-DISCRIMINATION NOTICE: It is 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 Attestation (Employees 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

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):

 

DOH Criminal History Record Check 

Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information 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.

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

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 a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I 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 DCJS for any New York State conviction/charge or the FBI for a 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 Services Criminal History Bureau Record Review Unit-5th Floor 4 Tower Place, Albany, NY 12203 (518) 485-7675

Federal Bureau of Investigation Criminal Justice Information Services (CJIS) Division 1000 Custer Hollow Road, Clarksburg, WV 26306 (304) 625-5590

6.I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information.

I certify to the best of my knowledge and belief that I (check as appropriate): Have Do not have a final finding of patient or resident abuse

Have not been convicted of a crime in New York State or any other jurisdiction

Iunderstand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV This is to certify that I have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept the Hepatitis B (HBV) vaccine.

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline 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 Icontinue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Declination of Influenza Vaccination

Ihave been advised that I should receive the influenza vaccine to protect myself and the patients I serve.

I have read the Centers for Disease Control and Prevention's (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have had the opportunity to discuss the statement and have my questions answered by a healthcare provider. I am aware of the following facts:

Influenza is a serious respiratory disease that kills thousands in the United States each year.

Influenza vaccination is recommended for me and all other healthcare personnel to protect this facility's patients from influenza, its complications, and death.

If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.

If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or non-existent.

I understand that the strains of virus that cause influenza infection change almost every year and, even if they don't, my immunity declines over time. It is for these reasons that vaccination against influenza is recommended each year.

I understand that I cannot get influenza from the influenza vaccine.

The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including all patients in this healthcare facility, coworkers, my family, and my community.

Because I have refused 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

I acknowledge that I have read this document in its entirety and fully understand it. Despite these facts, I have decided to decline the influenza vaccine by my signature below. I realize that I may re-address this issue at any time and accept vaccination in the future.