Edison Home Healthcare HHA-PCA Employment Application

PRE-APPLICATION TEST
Your Name *

First Name Middle Initial Last Name
Date *

Month Day Year
Date

Quiz *

True

False

Before helping a client out of a wheelchair to their bed, you should make sure the wheelchair wheels are locked

The First thing I should do if the patient falls is call 911

Something that will help to prevent accidents in the patients home is to keep the hallways free of clutter

The Aide should communicate with the client who has hearing loss is by facing the client when speaking

Proper hand washing requires lathering with soap for at least *

20 seconds 3 minutes 5 minutes

HOME CARE EMPLOYMENT REFERENCE REQUEST
To: *
Title: *
Agency *
Position Applied for: *

Release of Information:
Name *

First Name Last Name
I {name}, hereby authorize the release of all information requested by Edison Home Health Care. I release you from all responsibility/liability regarding the information provided by you from our past association.
Applicant's Signature: *

Clear
Date *

Month Day Year
Date
Name *

First Name Middle Initial Last Name

Release Form
Name

First Name Middle Name Last Name
I, {name}, have applied for a position as a
HHA / PCA with Edison Home Health 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 Edison Home Health 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 employers
- Schools and training programs
- Personal and professional references
I further release Edison Home Health 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 Edison Home Health 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 Edison Home Health 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 employee 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 Edison Home Health Care.
Hiring of personnel, salaries and benefits are awarded without regard to race, religion, disability, marital status, or sexual orientation. Edison Home Health Care is an equal opportunity employer. I have read the preceding statement and I understand and agree with its contents.
Employee Signature *

Clear
Date *

Month Day Year
Date

NYS Department of Health, Criminal History Record Check Unit
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.

SECTION 1 - SUBJECT INDIVIDUAL INFORMATION
Name *

First Name Middle Name Last Name
Maiden Name
Mother's Maiden Name *
Date of Birth *

Month Day Year
Date
Alias/AKA
Address *

Street Address

Street Address Line 2

City State

Zip Code

SECTION 2 - ATTESTATION

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.
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.
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.
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 any 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		Federal Bureau of Investigation
Criminal History Bureau		Criminal Justice Information Services
Record Review Unit-5th Floor		(CJIS) Division
4 Tower Place		1000 Custer Hollow Road
Albany, NY 12203		Clarksburg, WV 26306
(518) 485-7675

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

Do Do not have a final finding of patient or resident abuse
If you checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
- My current mailing or home address is indicated in Section 1 of this form.
- I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the re-disclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency in accordance with applicable laws. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own.
Signature *

Clear
Date *

Month Day Year
Date

FINGERPRINT INFORMATION
Name *

First Name Middle Name Last Name
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Last 4 of Social *
Date of Birth *

Month Day Year
Date
Birth Country/Place: *
Gender *
Race *
Height Feet: *
Height Inches: *
Weight: *
Eye Color: *
Hair Color: *
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Employment Eligibility Verification

Department of Homeland Security
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.)
Name *

First Name Middle Name Last Name
Other Last Names Used (if any)
Address *

Street Address

Street Address Line 2

City State

Zip Code
Date of Birth *

Month Day Year
Date
Social Security Number *
SSN Copied
First 1 of Social
2 of Social
3 of Social *
4 of Social *
5 of Social *
6 of Social *
7 of Social *
8 of Social *
9 of Social *
Email
example@example.com
Telephone Number
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.
Citizenship/Immigration Status *
Name *

First Name Middle Name Last Name
I attest, under penalty of perjury, that I am (check one of the following boxes) *

A citizen of the United States A noncitizen national of the United States A lawful permanent resident An alien authorized to work until
Expiration Date

Month Day Year
Date
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
Alien Registration Number/USCIS Number:
Form I-94 Admission Number:
Foreign Passport Number:
Country of Issuance
Signature of Employee *

Clear
Date *

Month Day Year
Date
Preparer and/or Translator Certification *

I did not use a preparer or translator A preparer(s) and/or translator(s) assisted the employee in completing section 1.
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator *

Clear
Date *

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code

HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM
ACCEPTANCE:
I understand that due to my occupational exposure to blood or other potentially infectiousmaterials 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.

DECLINATION:
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 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.
CHECK ONE: *

I DECLINE Hepatitis B vaccine inoculation I ACCEPT Hepatitis B vaccine inoculation
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date

FLU VACCINE
Dear Employee:

As of January 2020, the Department of Health requires that all employees with
direct patient contact, receive the flu vaccine during the flu season, or be required to wear a mask at all times whenever in the patient’s presence.
You MUST choose one of the two choices below to address this:
1. Go to your own doctor for the flu shot . If you decide to go to your own
  doctor for the flu shot, please have them fill out the attached document called Annual Influenza (Flu) Vaccination Verification 2020-2021 Flu Seasons . You must return this completed form to Edison or Fax it to 718-972-2323 .
2. You can decline to take the flu shot . If you decide to decline the flu shot, you must fill out the Flu Vaccine Declination form. This form must be returned to Edison . Please return this form to Edison as soon as possible or fax it to 718-972-2323. You must remember to wear a FACE MASK at all times while in the patient’s presence until the flu season ends.
Failure to comply with one of the 2 choices above will result in your eventual inability to be staffed on cases. Please make sure to respond to this situation quickly.

We thank you for your cooperation in this matter!

FLU VACCINE DECLINATION
- I have been advised that the influenza vaccine is recommended by the CDC and I should receive the vaccine to protect myself, the patients I serve, my coworkers, my family, and the community.
I acknowledge that I am aware of the following facts:
- Influenza is a serious respiratory disease that kills, on average, 36,000 Americans every year.
- Influenza virus may be shed for up to 48 hours before symptoms begin, allowing transmission to others.
- Up to 30% of people with influenza have no symptoms, allowing transmission to others.
- Flu virus changes often, making an annual vaccination a necessity.
- I understand that flu vaccine cannot transmit influenza.
- If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.
  Despite these facts, I will NOT be getting the flu vaccine for the 2020-2021 Flu season for the following
  reason(s). Please check all that apply.
Check all that apply

I have an allergy or medical contradiction to receiving the vaccine Severe allergies to eggs, vaccine components, or prior influenza vaccines History of Guillain-Barre Syndrome I believe I will get the flu if I get the shot My philosophical or religious beliefs prohibit vaccines I do not like needles I never get the flu I don't the vaccine is important
I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available.

During the flu season, I agree to wear a SURGICAL MASK at all times while in the patient’s presence until the flu season ends.

I understand that failure to comply with these requirements will put me and the patient(s) I care for at risk, and my employment with Edison HHC is conditional on meeting these requirements.
Name *
Signature

Clear
Date *

Month Day Year
Date

EDISON HOME HEALTH CARE'S SERVICES

CORPORATE COMPLIANCE CERTIFICATION OF RECEIPT OF CODE OF CONDUCT/HIPAA AND FEDERAL FALSE CLAIMS ACT SUMMARY PURSUANT TO DRA SECTION 6032
Questions?

Edison HHC encourages employees, contractors, and agents to raise questions or concerns, and seek clarification regarding these laws or related policy issues with the Compliance Officer or other designated party.

Acknowledgement:

I HAVE RECEIVED THE FEDERAL FALSE CLAIMS ACT SUMMARY OF LAWS AND EDISON HHC’S CODE OF CONDUCT AND I UNDERSTAND AND AGREE TO CONDUCT MYSELF IN ACCORDANCE WITH AND IN COMPLIANCE WITH THE FEDERAL FALSE CLAIMS ACT, THE NEW YORK FALSE CLAIMS ACT, AND NEW YORK HEALTH CARE FRAUD LAWS AND THE FACILITY’S CURRENT CODE OF CONDUCT PURSUANT TO DRA SECTION 6032
Name *

First Name Last Name
Date *

Month Day Year
Date
Employee's Signature *

Clear
Should be Empty:

PRE-APPLICATION TEST

Employment Application

HOME CARE EMPLOYMENT REFERENCE REQUEST

Release Form

NYS Department of Health, Criminal History Record Check Unit

FINGERPRINT INFORMATION

Employment Eligibility Verification

HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM

FLU VACCINE

FLU VACCINE DECLINATION

HOW DID YOU HEAR ABOUT EDISON?

EDISON HOME HEALTH CARE'S SERVICES