Home Health Care Worker Employment Application

Home Health Care Worker Employment Application
Name:*

Last NameFirst Name | Middle Initial
Birth Date*

MonthDayYear
Social Security Number*
Example: xxx-xx-xxxx
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Mobile:*

Area CodePhone Number
Other Phone:

Area CodePhone Number
Driver License Number*
E-mail Address:
Has your driver's license ever been suspended or revoked? *
Choose One
If Yes, Please Explain:
Have you ever entered a plea of guilty contendere to or been convicted of a felony of anything other than a minor traffic violation?*
Choose One
If Yes, Please Explain:
Have you ever been bonded? *
Choose One
Are you a U.S citizen*
Choose One
Are you authorized to work in the U.S*
Choose One
Full or Part Time?*
Choose One
Starting Salary
USD / Hour
How were you referred to us?*

Walk-InEmployeeNewspaper AdFacebookTwitterCraigslistOther (please specify)
Others
Hours of Availability and Location
In an effort to ensure we meet the needs of all clients, please complete the following section indicating your availability.

Please leave the days you are unavailable blank*

	FROM	TO
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

Depending on the client and the assignment you are on, it may require you to work weekends and holiday.
Are you available to work weekends?*

YesNo
holidays?*

YesNo
Please indicate the areas you are willing to work and or travel to*

Saint Louis CityNorth CountySouth CountyWest CountySt. Charles
Upload Resume :

Upload a File
Please Complete Application in its Entirety After Resume has been Uploaded Cancelof
Education
Name of High School*
Phone Number*

Area CodePhone Number
Did You Graduate?*
Choose One
G.P.A*
Scale of 1.0 - 4.0
Business / Trade / College
Phone Number

Area CodePhone Number
G.P.A
Scale of 1.0 - 4.0
Course of Study
Did You Graduate?
Choose One
How Many Years Attended
I understand if requested, I must provide a transcript and or diploma from the school or University i attended as proof of enrollment
Choose One
Licenses / Certifications
Please Include State | Number | Expiration Date
Work History
Company Name
Position Held
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Supervisor's Phone Number

Area CodePhone Number
Duties Performed
Starting Salary
USD/Hour
May we contact this employer?
Choose One
Company Name
Position Held
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Supervisor's Phone Number

Area CodePhone Number
Duties Performed
Starting Salary
USD/Hour
May we contact this employer?
Choose One
The information I have provided is complete and accurate to the best of my knowledge. I also understand that falsifying information may disqualify me from further consideration. I also authorize this agency to make any necessary investigation(s) of my personal, financial, and/or credit and background screening including but not limited to obtaining a credit report (also known as "consumer report" under the Fair Credit Reporting Act/ Consumer Reporting Act) for the purpose of evaluating your qualifications of employment. This authorization extends for twelve monts from today's date.
Full Name*
Last 4 digits of SSN*
XXX-XX-XXXX

Acknowledgement of Mandatory Requirements of New Hire

PPD/TB Test and CPR Training are two (2) mandatory items new hires must take care of as soon as possible. In addition, all employees are required to attend monthly company trainings.

PPD / TB Test (To be completed within the first seven (7) days of hire: Free PPD / TB testing is offered on Saturdays (9am – 12 Noon) at the St. Louis Augustine Catholic Church, 1371 Hamilton at Minerva (314-385-1934). The test is conducted in the school attached to the church on the Minerva site. When you go on Saturday, plan to return on Monday to get the test read (test results). It must be read within 48-72 hours after administration and is not complete unless you return. Testing can be received at the John Murphy Clinic for $24. If hired, you must get TB tested within the first seven (7) days of hire.

CPR Training: If hired, you must seek to obtain CPR training as soon as possible, unless you have a current CPR card indicating your certification for training you attended in the past year.

Monthly Trainings: As an employee of Elite Home Health Care LLC, all employees are required to attend monthly trainings as scheduled.
If hired, I acknowledge my responsibility to attend CPRTraining as soon as possible, get TB tested within the next seven (7) work daysand attend monthly trainings.*

YesNo
Full Name*
Last 4 digits of SSN*
XXX-XX-XXXX

Applicant Minimum Qualifications

Department of Health and Senior Services – Division 70 – Division of Missouri Health Net Chapter 91 – Personal Care Program – 13 CSR 70-91-.30 – Page 5 – (3c) Page 6-(4)

Applicant must fulfill the following minimum requirements for hire as an in-home advanced personal care aid.

I acknowledge that I fulfill the following requirements:

All in-home advanced personal care workers employed by Elite Home Health Care LLC shall meet the following requirements:
(select all that apply)*

I acknowledge that I am 18years of age or olderI acknowledge that I can read, write and follow directionsI acknowledge that I haveat least six months paid work experience as an agency homemaker, nurse aide orhousehold worker, or at least one year of experience, paid or unpaid in caringfor children, sick, or aged individuals, or have successfully completed formaltraining, such as basic nursing arts course of nurses training, nursingassistant training or home health-aid training.I acknowledge that I am not a family member of the recipient for whom personalcare is to be provided. A family member is defined as a parent, sibling, andchild by blood, adoption or marriage, spouse, grandparent or grandchild.I acknowledge that I am acertified nurse assistant or,I acknowledge that I am a licensed practical nurseor, registered nurseI acknowledge that I that Iam a competency evaluated home health aide having compeleted both written anddemonstration portions of the test required by the Missouri Department ofHealth and Senior Services and 42 CFR 484.36 or,I acknowledge that I havesuccessfully worked for the provider for a minimum of three consecutive monthswhile working at least fifteen hours per week as an in-home aide that hasreceived personal care training.
Full Name*
Last 4 digits of SSN*
XXX-XX-XXXX

Background Screening

It is mandatory that all applicants be registered with the Missouri Department of Health and Senior Services’ Family Care Safety Registry. My Electronic signature below provides Authorization for Elite Home Health Care LLC to conduct a background screening on me.
- If I am not registered I will pay the twelve dollar ($12) registration fee. If there are findings in my screening, and I want to become an employee, I agree to complete a “Good Cause waiver” application prior to being hired by Elite Home Health Care LLC. Once complete, Elite Home Health Care LLC will receive a report from the Family Registry indicating a Good Cause Waiver has been received and a case opened on my behalf. The Department of Health and Senior Services may grant (approve) a “Good Cause Waiver” at their discretion.
- If my social security number and or aliases social security numbers are fond on the EDL, I understand that I will be disqualified form employment.
Family Care Safety Registry (FCSR)
- The FCSR will be checked three times a year
E-Verify
- Elite Home Health Care LLC is required by the Department of Homeland Security to verify employment eligibility for all newly hired employees regardless of citizenship.
Employee Disqualification List (EDL)
- The Employee Disqualification List (EDL) is maintained by the Department of Health and Senior Services and is a listing of individuals who have been determined to have:
  - Abused or neglected a resident, patient, client or consumer
  - Misappropriated funds or property belonging to a resident, patient, client, or consumer; or
  - Falsified documentation verifying delivery of services to an in-home services client or consumer;
- The EDL will be checked 4 times a year.
No applicant can be employed by Elite Home Health Care LLC until they pass a screening of the EDL and until Elite Home Health Care LLC has obtained a background check on the applicant form the FCSR. Anyone listed on the EDL will not, under any circumstance, be employed by Elite Home Health Care LLC. If hired, the attendant will have a copy of the background check and EDL placed in their employee file. If any new listings appear on either of these background checks, the attendant will no longer be able to be employed by Elite Home Health Care LLC.

I have read this policy and understand my employment is conditional pending the outcome of the Missouri Department of Health and Senior Services’ final decision and determination. I also grant permission for Elite Home Health Care to verify my employment eligibility through E-Verify and EDL.
Full Name*
Last 4 digits of SSN*
XXX-XX-XXXX

Background Screening Application
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Social Security Number*
Example: xxx-xx-xxxx
Have you ever used an Alias (first and/or last names other than the name you used int his application)? *
If yes, list all the names you have ever used. (please include all maiden namesand all married names.)
Have you ever use any other Social Security Numbers?*
If yes, list all social security numbers youhave ever used?
Have you ever had any of the following: CriminalConvictions, findings of guilt, pleas of guilty and pleas of nolo contender? (a plea in a criminal prosecution that without admitting guilt subjects the defendant to conviction but does not preclude denying the truth of the charges in a collateral proceeding) *
If yes, list all criminal convictions, findings of guilt, and pleas of nolocontendere. Do not list minor traffic offenses, such as speeding tickets and parking tickets.
I hereby consent and authorize Elite Home Health Care LLC to prepare and obtain a consumer report including but not limited to, information as to my criminal record check, employment disqualification list, employment and / or credit history.

By signing below, I certify that I have read the document carefully, understand it, and agree to it voluntarily and without duress. I agree that withholding any of the information requested in this document or submitting false information in connection with this document constitutes valid grounds for termination.
Full Name*
Last 4 digits of SSN*
XXX-XX-XXXX

	Very Satisfied	Satisfied	Somewhat Satisfied	Not Satisfied	N/A
Attitude
Attendance
Quality of Work
Punctuality
Dependability
Productivity
Leadership Skills
Honesty