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  • PRE-APPLICATION TEST

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  • Employment Application

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    • Home Care Employment History  
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    • Emergency Contact Information  
    • Availibility  
    • You understand and agree that text messages will be provided for informational purposes only. Some fees and text messaging rates
      may apply based on the plan you have with your cellphone carrier.

    • Edison Home Health 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. 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.

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  • HOME CARE EMPLOYMENT REFERENCE REQUEST

    • Release of Information:  
    • 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.

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  • Release Form

  • 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.

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  • 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  
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    • SECTION 2 - ATTESTATION  
      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).
      2. 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 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.

      • 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.
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  • FINGERPRINT INFORMATION

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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.)

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    • 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.

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    • 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.

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    • 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.

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  • 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.

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  • 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.

  • 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.

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  • HOW DID YOU HEAR ABOUT EDISON?




  • ASK ABOUT OUR "REFER A FRIEND" PROGRAM

  • 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

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