Careers Form

* Required Information

Application for Employment

Client hire date

Client Company

Personal information

Name *

Social Security Number *

Present Address: Street *

City *

State *

Zip *

Permanent Address: Street *

City *

State *

Zip *

Phone Number *

If you are under 18, can you furnish a work permit?

Yes

All positions are PRN/ per- Diem
* All positions are TEMPORARY until completion of 90-day probationary period.

Position *

Date you can start *

Salary *

Are you employed now?

Yes

May we inquire of your present employer?

Yes

Ever applied for this company before?

Yes

Where?

When?

Are you on layoff and subject to recall?

Yes

Will you travel if required?

Yes

Will you relocate if job requires it?

Yes

Will you work overtime if required?

Yes

Are you able to meet the attendance requirements of this position?

Yes

Have you ever been Bonded?

Yes

Have you ever been convicted of a felony in the past 7 years?

Yes

Such conviction may be relevant if job related but does not bar you from employment. If yes - explain:

Driver’s license number

State

Education

ACADEMIC: Currently Attending

Name and location of School

Number of years Completed

Did you Graduate?

Yes

Subjects Studied

ACADEMIC: Last Completed

Name and location of School

Number of years Completed

Did you Graduate?

Yes

Subjects Studied

TRADES OF BUSINESS: Currently Attending

Name and location of School

Number of years Completed

Did you Graduate?

Yes

Subjects Studied

TRADES OF BUSINESS: Last Completed

Name and location of School

Number of years Completed

Did you Graduate?

Yes

Subjects Studied

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with this company

Employment History

Date: Month and Year

Name and address of employer

Salary

Job

Reason for Leaving

Date: Month and Year

Name and address of employer

Salary

Job

Reason for Leaving

Date: Month and Year

Name and address of employer

Salary

Job

Reason for Leaving

References

Give the names of three persons not related to you to whom you have known at least 1 year

Name

Address

Phone Number

Years acquainted

Name

Address

Phone Number

Years acquainted

Name

Address

Phone Number

Years acquainted

List any foreign language(s) and check the box that best describes your skill level.

Language

Read and write Read and speak Speak only

Language

Language
Read and write Read and speak Speak only

In case of Emergency notify

Name

Address

Relationship

Phone Number

Conditions of Employment – please read carefully

Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company. Panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

This application is current for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

Signature of Applicant *

Date

State of Employability

By the execution of this document I acknowledge that I have been informed by Restorer Home Health Services LLC, that a Criminal history check may be performed on my current name, and all past names. Mentioned above are all the names I have ever used (i.e. maiden, aliases, nicknames, etc.)

Information required to obtain criminal checks:

My date of birth is:

Social Security

First

Middle

Last

First

Middle

Last

First

Middle

Last

I understand that I may be employed on a temporary emergency basis pending the result of the criminal background check. I understand that a person convicted of an offense listed may not be employed in a position with which the duties involve direct contact with a consumer. I have NOT been convicted on any of the following offenses. (The list is provided for you on the next page)

I acknowledge that if I am found to have been convicted of any other offenses, they may cause my employment to be terminated. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

Signature of Applicant *

Date

EMPLOYEE REFERENCE CHECK

Restorer Home Health Services LLC has my authorization to check my reference in accordance with the General Assemble of Pennsylvania civil liability shield law.

APPLICANT NAME *

Applicant Signature *

Date

Previous Employer

Phone Number

Fax Number

Do not fill in below this line

The above applicant is seeking employment with our company. It is our policy to ask for references prior to employment. Please complete this form for our records and sign below. We would greatly appreciate your assistance.

PLEASE VERIFY EMPLOYMENT DATES:

Position Held

From

To

ELIGIBLE FOR REHIRE
Yes No

If no, please state reason

Other Comments

Information was Received By
Phone Mail Fax

Company contact signature and title

Date

EMPLOYEE REFERENCE CHECK

Restorer Home Health Services LLC has my authorization to check my reference in accordance with the General Assemble of Pennsylvania civil liability shield law.

APPLICANT NAME

Applicant Signature

Date

Previous Employer

Phone Number

Fax Number

Do not fill in below this line

The above applicant is seeking employment with our company. It is our policy to ask for references prior to employment. Please complete this form for our records and sign below. We would greatly appreciate your assistance.

PLEASE VERIFY EMPLOYMENT DATES:

Position Held

From

To

ELIGIBLE FOR REHIRE
Yes No

If no, please state reason

Other Comments

Information was Received By
Phone Mail Fax

Company contact signature and title

Date

EMPLOYEE REFERENCE CHECK

Restorer Home Health Services LLC has my authorization to check my reference in accordance with the General Assemble of Pennsylvania civil liability shield law.

APPLICANT NAME

Applicant Signature

Date

Previous Employer

Phone Number

Fax Number

Do not fill in below this line

The above applicant is seeking employment with our company. It is our policy to ask for references prior to employment. Please complete this form for our records and sign below. We would greatly appreciate your assistance.

PLEASE VERIFY EMPLOYMENT DATES:

Position Held

From

To

ELIGIBLE FOR REHIRE
Yes No

If no, please state reason

Other Comments

Information was Received By
Phone Mail Fax

Company contact signature and title

Date

HEPATITIS B IMMUNIZATION CONSENT/WAIVER FORM

Employee Name

Date of Hire

Social Security Number

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 me; 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 I continue 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.

I have been advised of my rights to accept or decline the HBV Vaccine. HBB (Hepatitis B Virus) has been fully explained to me.

I choose to waive my rights to receive the HBV Vaccine

I choose to receive the HBV Vaccine and I understand that the vaccine is given in a 3-part series.

Series 1 Date

Series 2 Date

Series 3 Date

Employee Signature *

Date

Agency Rep. Signature

Date

Home Health Interviewing Tool (Face-to-Face)

Applicant Name

Applying For
Full Time Part Time Pier Diem

Discipline / Department

Tell me a little about yourself?

Why do you want to work in Home Health Care?

Why do you want this particular job?

How do you react to change?

What areas do you feel you would need/like improvement in?

Describe your organizational skills/time management skills?

Why are you available for this job?

What is your definition of company loyalty?

How can you be of value to this Agency?

What are your career objectives?

Where do you want to be in the next five (5) years?

Employee Name *

POLICIES & PROCEDURES ORIENTATION ACKNOWLEDGEMENT

I acknowledge that I have been oriented to agencies Policies and Procedures Manual and agree to follow all guidelines, both written and verbal. I understand that, if the guidelines, policies and procedures are not followed, that I may be immediately terminated. I also had the opportunity to ask questions regarding the Policy and Procedures Manual, and I know where it’s located for future reference.

Employee's Signature *

Today's Date

Agency Representative Signature

Today's Date

NON - DISCRIMINATION POLICY
The Civil Rights Act; Title VI and VII

RESTORER HOME HEALTH SERVICES, LLC does not discriminate against any person on the basis of race, color, national origin, disability, sex or age, in admission, treatment, or participation in its programs, services, activities or employment. No person shall be excluded from participation in or denied the benefits of any services or be subjected to discrimination because of race, color, nationality, religion, sex, age, or disability. RESTORER HOME HEALTH SERVICES, LLC will make reasonable accommodation for handicapped employees. Any individual/personnel, who believe they have been discriminated against, may file a complaint of discrimination with:

RESTORER HOME HEALTH SERVICES, LLC
10065 Sandmeyer Lane,
Suite 301
Philadelphia, PA 19116

PA Human Relations Commission
Harrisburg Regional Office
Riverfront Office Center
Harrisburg, PA 17104

U.S. Dept. of Health & Human Services
Office of Civil Rights
Suite 372, Public Ledger Bldg.
150 South Independence Mall West
Philadelphia, PA 19106-9111

Employee's Signature *

Today's Date

Agency Representative Signature

Today's Date

Employee Name *

HEALTH & SAFETY AGREEMENT

I do understand the physical requirements of my job and understand proper lifting and moving techniques, which I am expected to use to moving and lifting objects and/or patients.

I have been informed and do fully understand that any injury claimed by me while on the job must be reported immediately to my supervisor and documented on an Accident/Incident Report Form. I understand that unless an incident report is completed immediately and signed by me, the agency may not consider a voluntary payment of any medical bills or any other benefits as a result of my failing to follow policy/procedure, the agency may not be expected to cover medical payments.

I do fully understand that I am not encouraged to lift or transfer any object or patient by myself unless I know that I can safely lift or transfer alone. If I believe there is no one readily available to assist me in lifting or moving patients or equipment while on duty, I am to wait until I can obtain assistance before moving or lifting.

I have had the opportunity to review and have all questions answered regarding Health & Safety..

Employee's Signature *

Today's Date

Agency Representative Signature

Today's Date

Release of Information Authorization

I empower RESTORER HOME HEALTH SERVICES, LLC. and its agents to retrieve information from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the federal, state or county level, worker’s compensation agencies or individual, relating to my past activities, to supply any and all information concerning my background, and release the same from any liability resulting in providing such information. That receipt may include, but is not limited to academic, residential, achievement, job performance, attendance, litigation, personal history, credit reports, driving history, disciplinary and conviction records. By my signature below, I hereby release any individual or institution, including its officers, employees or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at the time result to me, because of compliance with this authorization and request to release information or any attempt to comply with it. I herby certify that all the statements and answers set forth on the application form and/or my resume are true and complete to the best of my knowledge, an I understand that if subsequent to employment any such statements and/or answers are found false or that information has been omitted, such false statements and or omissions will be just cause for the termination of my employment.

Last Name *

First Name *

Middle Name

Previous Maiden Name

Address *

Social Security Number

Date of Birth *

Driver's License Number

State of License

I am in agreement that a photocopy of this authorization can be accepted with the same authority as the original, and that this release expires one year after the date of origination.

Signature

Today's Date

CONFIDENTIALITY OF CLIENT INFORMATION POLICY

Agency personnel must read and sign their acknowledgment of the following statement:

By accepting employment with Agency, I agree to carefully refrain from discussing any client’s condition or personal affairs with anyone outside the agency, unless expressly authorized to do so. I will not share any medical information with other clients or visitors without clear instruction provided to the agency. I acknowledge that All information seen or heard regarding clients, directly or indirectly, is completely confidential and is not to be discussed, even with my family or coworkers. My job as an employee requires that I govern myself by high ethical standards. Failure to recognize the importance of confidentiality is not only a breach of professional ethics but can also involve an employee in legal proceedings. I will not share any Information about clients or the agency with the media. This is essential for protection of both the client and Agency. I have read and understood the above statement and agree to abide by these policies. I understand that a breach of policy may result in disciplinary action and possible dismissal from employment.

Employee's Signature *

Today's Date

Agency Representative Signature

Today's Date

Employee Name *

REPORTING:

ABUSE

NEGLECT

EXPLOITATION

All agency staff who have reasonable cause to suspect that a recipient is a victim of abuse, neglect, exploitation or abandonment, as described below, shall immediately make an oral report to the Area Agency on Aging (AAA). In addition to reporting to the AAA, oral reports must be made to the Pennsylvania Department of Human Services (DHS) and local law enforcement for suspected abuse or neglect involving sexual abuse, serious injury, serious bodily injury or if a death is suspicious.
Sexual harassment is an abuse that requires reporting to the AAA; however, it is not sexual abuse that requires reporting to DHS and local law enforcement.

Abuse: The occurrence of one or more of the following acts: (1) the infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish; (2) the willful deprivation by a caretaker of goods or services which are necessary to maintain physical or mental health; (3) sexual harassment, rape or abuse.

Abandonment: The desertion of an adult by a caregiver.

Exploitation: An act or course of conduct by a caregiver or other person against an adult or an adult`s resources, without the informed consent of the adult or with consent obtained through misrepresentation, coercion or threats of force, that result in monetary, personal or other benefit, gain or profit for the perpetrator or monetary or personal loss to the adult.

Neglect: The failure to provide for oneself or the failure of a caregiver to provide goods, care or services essential to avoid a clear and serious threat to the physical or mental health of an adult. The term does not include environmental factors that are beyond the control of an adult or the caregiver, including, but not limited to, inadequate housing, furnishings, income, clothing or medical care.

Serious Bodily Injury: An injury which creates a substantial risk of death or which causes serious permanent disfigurement or protracted loss or impairment of the function of a body member or organ.

Serious Injury: An injury that causes a person severe pain or significantly impairs a person’s physical or mental functioning, either permanently or temporarily.

Sexual Abuse: Intentionally, knowingly or recklessly causing or attempting to cause rape, involuntary deviate sexual intercourse, sexual assault, statutory sexual assault, aggravated indecent assault or incest.

Sexual Harassment: Sexual harassment is unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. NOTE: Sexual harassment is an abuse that requires reporting to the AAA; however, it is not sexual abuse which requires reporting to DHS and local law enforcement.

I have read and understand the information above. As a home health employee, it is my responsibility to report & document any suspected abuse, neglect, or exploitation.

Employee's Signature *

Today's Date

Employee Name *

DRUG POLICY
The use of, or being under the influence of, alcohol and illegal drugs while on duty is grounds for immediate dismissal If you are taking medication ordered by a physician that may affect your job performance, please inform your Administrator/ Nursing Supervisor before accepting work.

In an effort to maintain the safest environment for both patient and employees, RESTORER HOME HEALTH SERVICES, LLC will promote, monitor, and enforce a drug free workplace.

It is strictly prohibited for any RESTORER HOME HEALTH SERVICES, LLC employee to be involved in an unlawful manufacture, distribution, possession or use of a controlled substance in the workplace or patient’s home. This type of conduct will not be tolerated and will result in an immediate discharge of that employee.

As a condition of continued employment, all employees will abide by the above guidelines. Any criminal drug statute conviction for a violation occurring in the workplace must be reported to RESTORER HOME HEALTH SERVICES, LLC no later than five (5) days after conviction.

I HAVE READ AND UNDERSTAND THE ABOVE AND WILL COMPLY WITH THIS AGREEMENT.

Employee's Signature *

Today's Date