A Quality HomeHealthCare Agency Employee Application

A Quality HomeHealthCare Agency

Employee Application

EMPLOYEE FILE OF:

___________________________________________________________________________

CONFIDENTIAL

Home Health Aide

Home Health One LTD.

Employee's Name:

EMPLOYEE'S CHECKLIST

The employee must have the following items in his/her file to be completed. Please check when items

are inserted into file:

In File

Not In File

1. Completed Application

If Not, Missing:

2.

Orientation Checklist

3. Glucometer Competency Assessment

4. Employee Handbook (Release Form w/ Signature)

5. Clinical Skilled Assessment

6. OSHA Training

7. Confidentiality Agreements

a. Employer

b. Client

8. Job Description (Signed)

9. Medical Data:

a. Health Exam / Record (current)

10. Tuberculosis Surveillance Record

11. Waiver Hepatitis B Vaccination

12. Clinical Competency Evaluations

13. Employment Eligibility Verification (INS)

14. W-4 Information *(the agency is issuing 1099 at the

end of year, the worker is responsible to pay

taxes as required)

15. Employment Agreement (Payroll Schedule, Pay

Rate, Reception)

a. Areas of Coverage (If Applicable)

16. Hire Date (Column 1) & Termination Date (Column 2)

17. Identification (2) from List A. Book

a. Driver¡¯s License (Current)

b. State ID (Current)

c. Social Security Card (Copy)

18. Current License Applicable

a. Clinical Licensures (Copy)

b. CPR Card (Current)

c. Auto Insurance (Copy)

19. Applicable Performance Evaluations as indicated

(timely)

20. Record at current In-service

21. Others

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Home Health One LTD.

Personal Data

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Home Health One LTD.

AN EQUAL OPPORTUNITY EMPLOYER

Equal access to employment is available to all persons. Those applicants requiring reasonable accommodation for the

application and/or interview process should notify the Personnel Director

You must fully and accurately complete this Application for Employment. Incomplete applications will

not be

considered.

This application for employment will be inactive after ninety (90) days. If you want to be considered after that

time, you must complete a new Application of Employment.

PERSONAL INFORMATION

LAST NAME

FIRST NAME

MIDDLE INITIAL

ADDRESS

TELEPHONE NO.:

SOCIAL SECURITY NO.:

ARE YOU 18 YEARS OR OLDER?

YES

NO

If hired, can you supply the required documentation to verify your lawful right to work in the United States?

YES

NO

Have you ever been convicted of a crime?

If YES, please explain:

YES

NO

POSITION APPLIED FOR:

Date Available for Work:

Full-Time

Salary Desired:

Part-Time

If Part-Time, Days Available:

Are you currently employed?

YES

NO

Have you ever been employed by Home Health One LTD.?

If Yes, give dates: FROM

/

/

TO

YES

/

NO

/

& Location:

Referred by:

EDUCATIONAL BACKGROUND

NAME & SCHOOL

LOCATION

NO. OF YEARS

ATTENDED

DID YOU

GRADUATE?

HIGH SCHOOL

YES

NO

COLLEGE

YES

NO

TRADE, BUSINESS /

CORRESPONDENCE

SCHOOLS

YES

NO

DEGREE /

DIPLOMA

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Home Health One LTD.

EMPLOYMENT HISTORY

Provide the following from your past and current employers, assignments or volunteer activities- starting with the

most recent (use additional sheets if necessary).

EMPLOYER

TELEPHONE

DATES EMPLOYED

TYPE OF WORK

ADDRESS

JOB TITLE

HOURLY RATE STARTING

IMMEDIATE SUPERVISOR AND TITLE

HOURLY RATE FINAL

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE?

EMPLOYER

TELEPHONE

YES

NO

LATER

DATES EMPLOYED

TYPE OF WORK

ADDRESS

JOB TITLE

HOURLY RATE STARTING

IMMEDIATE SUPERVISOR AND TITLE

HOURLY RATE FINAL

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE?

EMPLOYER

TELEPHONE

YES

NO

LATER

DATES EMPLOYED

TYPE OF WORK

ADDRESS

JOB TITLE

HOURLY RATE STARTING

IMMEDIATE SUPERVISOR AND TITLE

HOURLY RATE FINAL

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE?

YES

NO

LATER

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