Application - Florida Concierge Home Care Inc.

Step 1 of 14 - Step 1

Application for Employment

Date

MM slash DD slash YYYY

SECTION 1: Name/Address

Last Name

First Name

Middle

Address

City

State

Zip

Tel

Cell

Social Security #

SECTION 2: Desired Employment

Position Applied for

Position

Hourly

Visits

Live-In

Other

Date you can start

MM slash DD slash YYYY

Please Specify

Are you currently employed?

Yes

If employed, may we inquire of your current employer?

Yes

Have you applied to this registry before?

Yes

Salary desired

Years of experience

SECTION 3: General Information

Do you own a car?

Yes

Registration #

Driver’s License #

Car Insurance Company

Car Model

Year

Have you ever been convicted of a crime?

Yes

SECTION 4: Education

High School: Name & Location of School

Date Graduated

Degree

University/College Undergraduate: Name & Location of School

Years Attended

Date Graduated

Degree

University/College Graduate: Name & Location of School

Years Attended

Date Graduated

Degree

Trade, Business or Correspondence School: Name & Location of School

Years Attended

Date Graduated

Degree

SECTION 5: Employment History

Employer

Supervisor

Job Title

Address

Phone

Duties

Salary

Date From

MM slash DD slash YYYY

Date To

MM slash DD slash YYYY

Reason for Leaving

Employer

Supervisor

Job Title

Address

Phone

Duties

Salary

Date From

MM slash DD slash YYYY

Date To

MM slash DD slash YYYY

Reason for Leaving

SECTION 6: Physical Record

Do you have any Physical disabilities that would prevent you from performing the work for which you are applying?

Yes

If yes, please describe

Have you ever been injured?

Yes

Provide Details

SECTION 8: License/Certification

List

TYPE

LICENSE/CERT.#

EXPIRATION DATE

STATE ISSUED

SECTION 9: Additional Areas of Expertise

Areas of specialized study, research or additional experience

List the foreign languages you speak fluently

Read

Write

U.S. Military Services

4. Is the applicant eligible for rehire?

Yes

I voluntarily give FLORIDA CONCIERGE HOME CARE the right to make a thorough investigation of my past employment. I agree to cooperate in such an investigation. I understand that my employment will be based in part on the accuracy of the information provided on this application and for no definite period of time.

Applicant Signature

Date

MM slash DD slash YYYY

REGISTRY AUTHORIZED REPRESENTATIVE INTERVIEWER

HIRED?

Yes

Signature

Reference Check Form

ATTN

Date

MM slash DD slash YYYY

ORGANIZATION

ADDRESS

Phone

FAX

The applicant listed below is applying for a position as,

Enter position here

and has provided your name as an employment reference. As we place great importance on the thorough screening of our applicants, we would appreciate a prompt and thoughtful response.

Thank you in advance

SECTION 1 – To be completed by the applicant

owner of the Social Security #,

hereby authorize FLORIDA CONCIERGE HOME CARE to contact you as my previous employer.

APPLICANT’S SIGNATURE

SECTION 2 – To be completed by the previous employer

1. Length of employment from

MM slash DD slash YYYY

2. Functioned in the capacity of RN

LVN/LPN

HHA/CNA

3. Reason for leaving

Present Membership in National Guard or Reserve

Yes

PLEASE COMMENT ON THE APPLICANT’S ATTRIBUTES USING THE FOLLOWING SCALE:

POOR (P), FAIR (F), GOOD (G), VERY GOOD (VG), EXCELLENT (E)

Ability to follow instructions

Reliability and Attendance

Professional dress and grooming

Ability to work with others

Willingness to assume responsibility

Quality of work

Skills / Proficiency

Job Knowledge

Overall Job Performance

Additional Comments

Name (please print)

Signature

Position/Title

Date

MM slash DD slash YYYY

Thank you!

WHEN COMPLETED PLEASE EMAIL TO: Joe@flconciergehomecare.com

PER DIEM Independent Contractor Agreement

Date

MM slash DD slash YYYY

Broward County

Yes

Palm Beach County

Yes

Full Name

Position

Initial

Contractor:

Sign By

Print Name

Date

MM slash DD slash YYYY

Registry:

Sign By

Print Name

Date

MM slash DD slash YYYY

FOR DISPLAY ONLY

Employment Health Release of T.B Signs and Symptoms

Name

Date

MM slash DD slash YYYY

Have you ever had tuberculosis?

Yes

If yes, please explain, including date of positive test, circumstances and treatment involved:

Have you ever had the BCG vaccine?

Yes

Year received

Have you ever had a positive TB skin test?

Yes

Date of positive test

Date of last Chest X-ray

If you were treated please include the dates treated and type of treatment

THE EARLY SIGNS AND SYMPTOMS OF TUBERCULOSIS ARE: Cough, Night Sweats, Fever, Loss of Weight, Loss of Appetite, Coughing Blood. Do you currently have any of the symptoms mentioned above? If yes which one:

I have read the above information and do not have any of these signs or symptoms at this time. If any of these signs or symptoms developsI will contact my supervisor immediately for follow up. *Please include any Annual TB Screening Forms.

Applicant Name (Please Print)

Title

Applicant Signature

Date

MM slash DD slash YYYY

Witness

Date

MM slash DD slash YYYY

APPLICANT NOTICE

This is a notice to all potential Per Diem Independent Contractors of FLORIDA CONCIERGE HOME CARE that to inform that the Registry does not provide full time employment and cannot guarantee 40 hours of employment per week to any of our Per Diem Independent Contractors. Placement staggers and working hours vary day-to-day and week-to-week

When service begins between a Client and Per Diem Independent

Contractor, and the assignment has been accepted, the Registry expects the Per Diem Independent Contractor to show up for the case and complete the accepted hours. If a situation should arise that does not allow the Per Diem Independent Contractor to fulfill the commitment, the Registry expects a prompt notice to the office staff with sufficient time for it to provide a replacement. A no show or failure to notify the office of an absence is a reason for immediate termination.

SAFETY POLICY

The success of oursafety and health programs will only be achieved by the active leadership, direct participation, and enthusiastic support from all department heads, and case managers

Each member of FLORIDA CONCIERGE HOME CARE is obligated to observe safe practices and obey all safety rules, this direct personal involvement is the only way we can attain our goal of accident reduction and elimination.

I have read and fully understand and agree to the above statements.

It is the policy of FLORIDA CONCIERGE HOME CARE to provide a safe and healthful environment for all employees/caregivers/ contractors and visitors who are associated with our company

Safety and health programs dedicated to the elimination of accidents causes, will be emphasized and sponsored throughout the facility and department work safety rules, the investigation of accidents and the inspection of work procedures and facilities. These on-going programs eliminate unsafe work practices/conditions and to reduce the potential for accidents and personal injury.

Applicant Signature

Interviewer

Date

MM slash DD slash YYYY

TRANSPORATION RESPONSIBILITY POLICY

It has been explained to me that I am being offered employment with the understanding that I have personal transportation at my disposal to be used for travel to and from patient assignments.

I further understand that I am responsible for maintaining automobile liability to include bodily injury and property damage.

Should I be unable to make patient visits assigned to be because of transportation problems, I will give FLORIDA CONCIERGE HOME CARE, a minimum of one working day or eight hours’ notice.

Failure to comply with the above may result in the immediate termination of my employment contract without further notice.

HOURS OF OPERATIONS POLICY

Office hours are from 9:00 am to 5:00 pm, Monday through Friday. Should an incident occur which requires immediate attention Per Diem Independent Contractor is required to notify the Registry as soon as possible. A 24-hour / 7-days a week answering systems is provided for this purpose.

By signing this agreement you are stating that you understand that any incident involving you or the client must be reported to FLORIDA CONCIERGE HOME CARE, immediately.

You also understand that proper documentation must be completed and submitted to the office in a timely manner. Nursing Notes are due Every Thursday.

Any other matter you are wishing to discuss with the Registry personnel, the calls should be placed during office hours.

PATIENT ABANDONMENT POLICY

It is the policy of this Registry that if a caregiver abandons a patient, the Per Diem Independent Contractor/caregiver will be immediately dismissed. The patient will be assigned another caregiver to continue care. The supervisor must contact the case manager to inform of the situation.

Leaving a patient before your shift is completed without the knowledge and approval of Florida Concierge Homecare is considered patient abandonment. The above mentioned actions will be taken.

Applicant Signature

Date

MM slash DD slash YYYY

DRESS CODE POLICY

To present a professional health care individual image to the public at large and specifically to our clients and their family members.

PROCEDURE
Dress Code for All Personnel:
1. Good personal hygiene
2. Minimal jewelry – accessories simple and uncluttered
3. Clean, well-groomed fingernails
4. Neat, clean hair – no extreme non-professionalstyles
5. Appropriate undergarments
6. Hemlines no more than 2 inches above the knee or 2 inches below the knee
7. Make-up natural – no extreme colorings, lashes or sparkles

Dress Code for All Direct Care Personnel:
1. All of the above plus:
2. Clean, wrinkle-free uniforms (may be scrub-type)
3. Clean, closed-toe, flat shoes
4. Clean, short-trimmed and groomed fingernails
5. Avoid heavy perfumes and colognes
6. Office RN’s must wear white lab coat if not in uniform and visiting patients, hospital, physician’s offices, etc

Items Not Acceptable (All Staff):
1. Glitter or sequin-covered clothing
2. Jean-type clothing
3. Tight pants or leggings
4. Shorts
5. Beach-type sandals
6. Long, dangling or hoop earrings
8. See-through fabrics
9. Tank tops
10. Open-back tops or plunging necklines
11. No exposed body piercing except ears
12. Long dresses/skirts due to safety hazard

Applicant Signature

Date

MM slash DD slash YYYY

CONFIDENTIALITY STATEMENT

I acknowledge that I have read and understood FLORIDA CONCIERGE HOME CARE , here in referred to as Registry, Confidentiality Policy, HIPAA regulations and the Privacy Statement. I acknowledge that during my employment/placement/volunteer/project work with Registry I may have access to confidential information.

I acknowledge that it is a term and condition of my work with Registry that I will at all times respect the privacy of clients and their families, students, volunteers and employees, and the confidential nature of the business of Registry. I will closely protect confidential information to prevent it being inappropriately accessed, used or disclosed either directly by me, or by virtue of my password to systems, or by permitting breaches in physical security to occur. If I become aware of any violation of confidentiality, or lose any record containing confidential information or any key or other item that could be used to violate confidentiality, I will notify my supervisor or another responsible Registry supervisor at the first reasonable opportunity. I understand that violations to confidentiality may include, but are not limited to:
- Accessing personal or organizational information that I do not require in order to properly carry out my duties;
- Using or disclosing personal/organizational information (verbally, through the computer system, or in hard copy) without proper authorization;

- Inappropriately sharing passwords, keys, codes or other identification devices without proper authorization.

I will only access, use, transfer or disclose private and confidential information as required by the duties of my position. I agree to cooperate with Registry in any audit or investigation relating to confidential information and to provide any records requested in connection with such audits or investigations. I understand and agree to abide by the conditions outlined in this agreement both during and after my employment or association with Registry. I understand that a violation of this agreement may result in disciplinary action that may include termination/dismissal from employment or association with Registry, or that I may be subject to civil or criminal liability.

I understand that no information is to be released without the written “Release of Information” consent signed by the patient or patient’s legal representative.

It is understood that breaks in the policies and procedures of Registry concerning confidentiality may result in immediate terminate without put further notice.

Name (Please Print)

Applicant Signature

Date

MM slash DD slash YYYY

BACKGROUND CHECK AUTHORIZATION

I voluntarily consent to and authorize FLORIDA CONCIERGE HOME CARE, here in referred to as Registry, and or their assigned agents, associates, or consumer reporting agencies to request and receive any criminal background reports, consumer reports, investigative consumer reports containing information as to my character, general reputation, personal characteristics and mode of living, or information concerning me as part of the pre-employment background review process. Reports requested may include any of the following: Law Enforcement Records, Criminal Records, Civil Records, Motor Vehicle/ Driving Records, Credential Verification, Employment Verifications, Past Employment Verifications, Education Verifications, Reference Checks, Military Service Verifications, and Consumer Credit Reports in accordance with the provisions of the Fair Credit Reporting Act and similar State laws.

I authorize any persons, organizations, companies, corporations, consumer reporting agencies, courts of law, licensing agencies, schools, and any current or past employer to furnish Registry and or their assigned agents, associates or consumer reporting agencies with any and all information concerning me. I further agree to release Registry and or their assigned agents, associates, or consumer reporting agencies and all persons and organizations providing information from any and all claims, liability and responsibility arising out of the release ofsuch information in connection with this research.

This authorization shall remain on file and shall serve as an ongoing authorization for Registry to procure criminal records, consumer reports, including investigative consumer reports, at any time during the contracting period. By signing below, I hereby release Registry, its employees, agents, and all persons, agencies and entities providing information or reports about me from any and all liability arising out of the release of any such information or reports.

I understand that if an adverse decision on my application for employment is made, based in whole or in part on information contained in any consumer report, I will be so informed. I will also be provided an opportunity to obtain a copy of that consumer report and to dispute any inaccurate or incomplete information.

I agree that a photocopy, facsimile, or other electronic forms of this information can be furnished to Registry, and that it will have the same authority and authenticity as the original. I also understand that any misrepresentation, falsification or omission of facts herein may be considered cause for rescinding and offer of employment, termination of employment, or denial of consideration for future employment.

Name (Please Print)

SSN

Other names under which previously employed (Print Name)

Applicant Signature

Date

MM slash DD slash YYYY

COMPANY DISCIPLINARY ACTION FOR A POSITIVE CONFIRMED DRUG AND / ALCOHOL SCREEN

If a Per Diem Independent Contractor/Employee refuses to take a periodic, random, post-accident, routine fitness for duty or reasonable suspicion Drug and/or Alcohol screen, he/she will be terminated from employment.

Any Per Diem Independent Contractor/Employee using, selling, purchasing, possessing, soliciting or distributing drugs and/or alcohol on duty or at company’s property, it will be terminated from the contract.

This company hereby states its policy relating to those individuals who test positive on a drug and/or alcohol screen to be as followed;

Any Per Diem Independent Contractor/Employee who tests positive on a Drug and/or Alcoholscreening will be terminated from their contract. If he/she is able to successfully obtain substance abuse treatment, at their own expense, and their contract is still available, he/she will be given one

(1) chance to be retired, upon a negative return-to-work Drug and/or Alcohol screen he/she will then undergo random Drug and/or Alcohol screensfor a period of (2) years as follow-up treatment. If he/she tests positive on any of their follow-up Drug and/or Alcoholscreens, he/she will be terminated from their employment.

Applicant Signature

Date

MM slash DD slash YYYY

INFECTION CONTROL UNIVERSAL ISOLATION

POLICY:

The procedures of “University Isolation” as recommended by the Center for Disease Control will be carried out. “UNIVERSAL ISOLATION” precautions meansthat blood and body fluids precautionsshould be consistently used for all patients.

PROCEDURE:

1) Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin for all patients, for handling items orsurfacessoiled with blood or body fluids, and for performing venipuncture and other vascular access procedure.

2) Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluidsto prevent exposure of mucous membranes of the mouth, nose, and eyes.

3) Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids.

4) Hands and other skin surfaces should be washed immediately and thoroughly if contaminated. Hands should be washed immediately after removing gloves.

5) Needles should not be recapped, bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand.

6) Mouthpieces, resuscitation bags, or other ventilation devicesshould be available for use in areasin which the need for resuscitation is Predictable

7) Health-care workers who have exudative lesion or weeping dermatitisshould refrain from direct patient care and from handling patient-care equipment until the condition isresolved.

Applicant Signature

Date

MM slash DD slash YYYY

EMERGENCY CONTACTS

EMPLOYEE/CONTRACTOR

NAME

Phone

ADDRESS

EMERGENCY CONTACT #1

NAME

RELATIONSHIP TO YOU

ADDRESS

CELL #

HOME #

WORK #

EMERGENCY CONTACT #2

NAME

RELATIONSHIP TO YOU

ADDRESS

CELL #

HOME #

WORK #

EMERGENCY CONTACT #3

NAME

RELATIONSHIP TO YOU

ADDRESS

CELL #

HOME #

WORK #

MEDICAL QUESTIONNAIRE

State of Purpose:

The purpose of this questionnaire is to provide FLORIDA CONCIERGE HOME CARE with information regarding preexisting conditions or disabilities that the employee/contractor might suffer

The intent if this questionnaire is not to discriminate against any qualified individual in regards to the procedure of this job application

Name of Employer: FLORIDIA CONCIERGE HOME CARE

NAME OF CONTRACTOR

Contractor SSN Number

Height

Weight

1. Do you have any of the following

Epilepsy (convulsions, seizures)

Yes

Diabetes (Medication?)

Yes

Marie-Strum Pell disease (inflammation of vertebrae)

Yes

Amputation of foot, leg, arm, or hand.

Yes

Total loss ofsight of one or both eyes, or partial loss

Yes

Corrected vision of more than 75% bilaterally

Yes

Polio (poliomyelitis}

Yes

Cerebral Palsy

Yes

Multiple Sclerosis

Yes

Parkinson’s disease

Yes

Vascular (blood vessel) disorder

Yes

Psychoneurotic disability (emotional or nervous disability)

Yes

Hemophilia

Yes

Chronic Osteomyelitis (infection in bone)

Yes

Ankylosis of major weight-bearing joint (frozen joint)

Yes

Hyperinsulinism

Yes

Muscular dystrophy

Yes

Thrombophlebitis

Yes

Herniated disk

Yes

Surgical removal of disk

Yes

Total deafness

Yes

Other

Hepatitis B Vaccination Informed Consent

I understand that due to my risk of occupational exposure to blood or other potential infectious material, I may be at risk of acquiring Hepatitis B virus(HBV) infections. I have read the information concerning the Hepatitis B vaccine and I am aware of the availability and benefit thatsuch vaccination providesin the preventions of infection with Hepatitis B virus.

I understand the benefits and risks of Hepatitis B vaccination and have had the opportunity to ask questions. I understand that:

1. The vaccination will be administered in a series of three (3) doses; the initial one, the second one a month later, and the third dose six (6) months after the first dose. I understand I must complete the seriesfor full immunization at my own expense.
2. If I receive the vaccine, I have 90-95% chance of developing antibodies to the Hepatitis B surface antigen and therefore immunity to the infection of the Hepatitis B virus.
3. The vaccine may not be effective, if I am already incubating the Hepatitis B Virus.
4. The duration of the immunity is unknown at thistime and I may require a booster in five (5) years.
5. The vaccine only protects against Hepatitis B virus and does not confer immunity against the Hepatitis A, Hepatitis C, or non-A/non-B agents.
6. After receiving the vaccine minorside effects,such asinfectionssite soreness and redness, Low-grade fever, malaise and nausea have been reported.

request vaccination with Hepatitis B vaccine.

Pregnant

Yes

Allergies

Yes

List

Date vaccinated

Lot No.

Signature of person receiving vaccine

Date

MM slash DD slash YYYY

Signature of registry witness

Date

MM slash DD slash YYYY

HEPATITIS B VACCINE DECLINATION

decline vaccination with the Hepatitis B vaccine. I have read the above information and realize that I am potentially at increased risk of exposure or Development of the Hepatitis B infection. I choose not receive the Hepatitis B vaccine at this time.

Signature of person receiving vaccine

Date

MM slash DD slash YYYY

Signature of registry witness

Date

MM slash DD slash YYYY

CONDITIONS OF EMPLOYMENT

APPLICATION:
Upon receipt of yourreferences, your application and exam will be reviewed by ourstaff and yourlicense will be verified by the State Board of Nursing. You will be notified approximately one week after your interview until your application has been approved.

PROBATION: When references have cleared and you have been offered your first assignment, you are considered a probationary caregiver.

Probationary statusisin effect for 90 daysfrom the date of your first assignment. One or more incidents could cause usto discontinue offering you assignment, and will result in your termination.

Some examples are:
a. Infractions of the “Nurse Practice Act”.
b. Reportsfrom facilities of clientsthat your work is not accepted.
c. Not showing up for an assignment that you have accepted.
d. Too many sick or emergency cancellations.
e. Any serious misconduct while on or off duty that may reflect on First Premier Healthcare Services Inc.
f. Infractions of policies or procedure of facilities.
g. Violation of “Conditions of Employment”.

REQUIREMENTS: When you work for FLORIDA CONCIERGE HOME CARE, it is you’re responsibility to call in your availability to our office on a weekly basis. If you fail to do so your file will be placed inactive and you will be considered resigned. If you change your telephone number, or it becomes disconnected, it is your responsibility to provide our office with an alternative phone number until this requirement is met. If our office cannot reach you due to the reason above, your file will be place inactive and you will be considered resigned. All employees/caregivers/contractors must comply with AHCA requirements within 30 days from the date of your first assignment. Any violation of AHCA requirements, either by not complying when hired or at renewal times, are groundsfor termination

Applicant Signature

Date

MM slash DD slash YYYY

POLICY STATEMENT

Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975.
FLORIDA CONCIERGE HOME CARE agreesto comply with provisions of title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975, and all requirements imposed pursuant thereto, to the end that no person shall on the grounds of race, color, national origin, handicap or age, be excluded from participation in, be denied benefits of, or otherwise be subjected to discrimination in the provisions of any care of services.

Specifically, the above includes (but is not limited to) the following characteristics:
1. Care will be provided in a manner that is not discriminated against person on the basis of race, color, national origin, handicap, or age.
2. Employees will be assigned to clients services without regard to the race, color, national origin, handicap, or age of either the client or employee.
3. Staff privileges will not be denied professionally qualified personnel on the basis of race, color, national origin, handicap or age.
4. All facilities of the Registry will be utilized without regard to race, color, national origin, handicap or age.

The non-discriminatory policy of this Registry applies to clients, physicians, independent contractors and all responsible employees.

Name of Nurse Registry

Applicant Signature

PAYCHECK POLICY

Disbursement of Funds and Pay Check Policy

FLORIDA CONCIERGE HOME CARE will issue paychecks or direct deposit every other Friday after 2:00 pm. Once a check is mailed, it is your responsibility. If a check needs to be re-issued, you will be required to pay the $50.00 bank fee, which will be deducted from your re-issued check.

Would you prefer?

(a) Pick you check up in the office

(b) Have your check mailed to you

If would like your check mailed, please confirm the address:

Name

Address

City

have read and fully understand the above policy set forth by FLORIDA CONCIERGE HOME CARE

Applicant Signature

Date

MM slash DD slash YYYY

Direct Deposit Authorization

Name

Address

City, State, Zip

Name of Bank

Account #

9-Digit Routing #

Type of Amount

Entire Paycheck

Enter Amount

Type of Account (Check One)

Checking

Savings

Attach a voided check for each bank account to which funds should be deposited (if necessary)

Max. file size: 512 MB.

Florida Concierge Home Care Inc. is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing

Employee’s Signature

Date

MM slash DD slash YYYY

Bioharzadous Waste Management Acknowledgement

APPLICANT ACKNOWLEDGEMENT OF RECEIPT ON: RECOMMENDED METHOD OF HANDLING BIOMEDICAL WASTE

Applicant Name

Date

MM slash DD slash YYYY

Please check all that are true

I have been verbally informed of the recommended method of handling biomedical Waste generated in the home care setting

I have been given written material on “Safe Sharps Disposal at Home”

I have been given written material on “Cleaning up after Injury or Accident in Your Home”

FLORIDA CONCIERGE HOME CARE has given me the chance to discuss my concern regarding biomedical waste management in my home.

Applicant Signature

Date

MM slash DD slash YYYY

Witness Signature

Date

MM slash DD slash YYYY

NON-DISCRIMINATION POLICY

In accordance with Title VI of the Civil Rights Act of 1964 and itsimplementing regulation, FLORIDA CONCIERGE HOME CARE is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRIMINATE AGAINST RACE, COLOR, CREED, RELIGION, SEX, AGE, GENDER PREFERENCE, NATIONAL ORIGIN HANDICAP (MENTALOR PHYSICAL), ETHICAL/POLITICAL BELIEFS, DECISION REGARDING ADVANCE DIRECTIVES OR COMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI.

In accordance with Section 504 of Rehabilitation Act of 1973 and it’simplementing regulation, FLORIDIA CONCIERGE HOME CARE WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP.

In accordance with the Age Discrimination Act of 1975 and it’s implementing regulation, FLORIDA CONCIERGE HOME CARE WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision ofservices, unless age is a factor necessary to normal operation or the achievement of any statutory objective.

In accordance with the Americans with Disabilities Act of 1992 (42 USC & 12101) and it’simplementing regulations, (private employers with more than 25 Registry personnel), FLORIDA CONCIERGE HOME CARE WILL NOT, DIRECTLY OR THROUGHT CONTRACTUAL OR OTHER ARRANGEMENTS
DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment thatsubstantially limits a major life activity, or for which there is a record if impairment or which causesthe individual to be regarded asimpaired.

I hereby verify that have had all my questions answered by my satisfaction and that I understand all of the material covered.

Applicant Name

Applicant Signature

Date

MM slash DD slash YYYY

Print Name

Address

Phone

Position

Schedule Availability

Monday

From (Time)

Hours

Minutes

AM/PM

To (Time):

Hours

Minutes

AM/PM

Overnight?

Yes

Tuesday

From (Time)

Hours

Minutes

AM/PM

To (Time):

Hours

Minutes

AM/PM

Overnight?

Yes

Wednesday

From (Time)

Hours

Minutes

AM/PM

To (Time):

Hours

Minutes

AM/PM

Overnight?

Yes

Thursday

From (Time)

Hours

Minutes

AM/PM

To (Time):

Hours

Minutes

AM/PM

Overnight?

Yes

Friday

From (Time)

Hours

Minutes

AM/PM

To (Time):

Hours

Minutes

AM/PM

Overnight?

Yes

Saturday

From (Time)

Hours

Minutes

AM/PM

To (Time):

Hours

Minutes

AM/PM

Overnight?

Yes

Sunday

From (Time)

Hours

Minutes

AM/PM

To (Time):

Hours

Minutes

AM/PM

Overnight?

Yes

Additional Skills

Signature

Date

MM slash DD slash YYYY

Guaranteed Compatibility Caregivers

At FLORIDIA CONCIERGE HOME CARE, we guarantee our clients will be matched with a caregiver that not only precisely followstheir unique plan of care, but they are also compatible on a social levelso they have the best care experience possible. In addition, we want to provide a great match for our caregivers as well. By knowing your likes and dislikes, we will work to match you with a client where you can be most productive and effective.

Name

Date

MM slash DD slash YYYY

Watching TV / Movies

NEUTRAL

DISLIKE

Cleaning

NEUTRAL

DISLIKE

Interacting with pets

NEUTRAL

DISLIKE

Playing card games

NEUTRAL

DISLIKE

Playing board games

NEUTRAL

DISLIKE

Cooking

NEUTRAL

DISLIKE

Baking

NEUTRAL

DISLIKE

Doing crafts

NEUTRAL

DISLIKE

Light outdoor activities (bird watching,sitting outside)

NEUTRAL

DISLIKE

Moderate outdoor activities (gardening, going for a walk)

NEUTRAL

DISLIKE

Reading

NEUTRAL

DISLIKE

Listening to music

NEUTRAL

DISLIKE

Watching or talking aboutsports

NEUTRAL

DISLIKE

Singing

NEUTRAL

DISLIKE

Smoking or being in a smoking environment

NEUTRAL

DISLIKE

FLORIDA CONCIERGE HOME CARE will make every attempt to place caregivers on assignmentsthat minimize their “dislikes”. However, based on the client’s needs and plan of care, certain activities may be required. If there is a compelling reason why you are not able to perform them, please contact the Branch Manager to discuss.

Signature

Date

MM slash DD slash YYYY

VOLUNTARY SELF-IDENTIFICATION

FLOIRDA CONCIERGE HOME CARE is committed to equal employment opportunity for all employees/Independent Contractors. As a federal contractor, the Registry isrequired to take affirmative action to employ and advance in employment women and minorities, disabled individuals, disabled veterans and veterans of the Vietnam Era. To assist the Registry in properly identifying its employees and applicants, we request that you complete the following information. Completion of thisform isstrictly voluntary.

Please identify yourself as one of the following:

SEX

Male

Female

RACE

African American

Asian / Pacific Islander

Hispanic

White – Non Hispanic

Two or more races

Other

RELIGION

Christian

Jewish

Muslim

Other

DISABLED OR VETERAN STATUS

I am a Disabled Individual

I am a Disabled Veteran

I am a Vietnam Era Veteran

I am Other Eligible Veteran

None of the above

Other (please specify)

Name

Date

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Attestation of Good Moral Character

Employee/Applicant/Contractor/Volunteer

Name

By signing thisform, I affirm and attest that I meet the Moral Character requirementsfor employment asrequired pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes.

Provider/Employer Name

The following acknowledgements apply to all Direct Service Providers and/or Employees, Contract Providers, and Volunteers. Please initial each statement.

Consent

I affirm that I have not been designated as a sexual predator pursuant to s. 775.21; a career offender pursuant to s. 775.261; or a sexual offender pursuant to s. 943.0435, unless the requirement to register as a sexual offender has been removed pursuant to s. 943.04354.

Consent

I understand that I must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any similar statute of another jurisdiction, regardless of whether or not those records have been sealed or expunged.

Consent

I understand that, while employed or volunteering in any position thatrequires an APD background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest, any notice of possible criminal prosecution including any violation or infraction mandating a court appearance. Reporting must be done immediately if during normal working hours or immediately the next business day if after normal working hours.

ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED:

I attest that I have read the above carefully and state that my attestation here is true and correct and that my record does not contain any of the above listed offenses. I understand, under penalty of perjury, all employees in such positions of trust or responsibility shall attest to meeting the requirements to the background screening standardsset forth in Chapter 435 and Section 393.0655.

Signature of Affiant

Date

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OR

My record contains one or more of the applicable disqualifying acts or offenseslisted above

Signature of Affiant

Date

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Note: If you have previously been granted an APD exemption for this disqualifying offense, a copy of the APD exemption letter must be attached.

OR

I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be holding a position that is within the scope of my licensed practice, and I am notsubject to the screening provisions ofsection 393.0655, Florida Statutes.

Signature of Affiant

Date

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FOR DISPLAY ONLY

Attestation of Compliance with Background Screening Requirements

Employee/Contractor Name

Health Care Provider/ Employer Name

Address of Health Care Provider

Consent

I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA).

Date of Decision

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Consent

I have been granted an Exemption from Disqualification through the Florida Department of Health.

Date of Decision

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**A copy of the Exemption from Disqualification decision letter must be attached**

If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.

Purpose of Prior Screening

Date of Prior Screening

MM slash DD slash YYYY

Screening conducted by:

Agency for Healthcare Administration

Department of Health

Agency for Persons with Disabilities

Department of Elder Affairs

Department of Financial Services

Department of Children and Family Services

Attestation

Under penalty of perjury, I,

hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed

Employee/Contractor Signature

Title

Date

MM slash DD slash YYYY

FOR DISPLAY ONLY

Receipt for AHCA Guidelines Information

hereby acknowledge the receipt of the Agency for Health Care Administration Guidelines From FLORIDA CONCIERGE HOME CARE

Date

MM slash DD slash YYYY

I have read this information and understand its contents

Print Name/Title

Signature

W9 Form

Request for Taxpayer Identification Number and Certification

1. Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2. Business name/disregarded entity name, if different from above

3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

Untitled

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Consent

Other (see instructions)

4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any

Exemption from FATCA reporting code (if any)

(Applies to accounts maintained outside the U.S.)

5. Address (number, street, and apt. or suite no.) See instructions.

Requester's name and address (optional)

6. City, state, and ZIP code

7. List account number(s) here (optional)

Part I. Taxpayer Identification Number (TIN)

Social Security Number

Employer Identification Number

Part II. Certification

Under penalties of perjury, I cenify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Signature

Date

MM slash DD slash YYYY

FOR DISPLAY ONLY

I9 Form

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.)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

MM slash DD slash YYYY

U.S. Social Security Number

Employee's E-mail Address

Employee's 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.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Untitled

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work

(Alien Registration Number/USCIS Number):

until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)

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.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

Signature of Employee

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Preparer and/or Translator Certification (check one):

Translator

I did not use a preparer or translator.

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an 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

Today's Date (mm/dd/yyyy)

MM slash DD slash YYYY

Last Name (Family Name)

First Name (Given Name)

Address (Street Number and Name)

City or Town

State

ZIP Code

Upload Documents

Drivers license

Max. file size: 512 MB.

Car Insurance (If you agree to drive for the client)

Max. file size: 512 MB.

License or certification for the job if you are applying for (HHA, CNA, LPN/RN)

Max. file size: 512 MB.

CEU’s which provided upon certification or license

Max. file size: 512 MB.

Copy of health exam including negative TB test

Max. file size: 512 MB.

Copy of liability Insurance

Max. file size: 512 MB.

Right to work document including work permit or alternately proof of US citizenship to include social security and passport

Max. file size: 512 MB.

Name

This field is for validation purposes and should be left unchanged.

561-678-0111

Application for Employment

SECTION 1: Name/Address

SECTION 2: Desired Employment

SECTION 3: General Information

SECTION 4: Education

SECTION 5: Employment History

SECTION 6: Physical Record

SECTION 8: License/Certification

SECTION 9: Additional Areas of Expertise

Reference Check Form

SECTION 1 – To be completed by the applicant

SECTION 2 – To be completed by the previous employer

PER DIEM Independent Contractor Agreement

FOR DISPLAY ONLY

Employment Health Release of T.B Signs and Symptoms

EMPLOYEE/CONTRACTOR

EMERGENCY CONTACT #1

EMERGENCY CONTACT #2

EMERGENCY CONTACT #3

Hepatitis B Vaccination Informed Consent

Direct Deposit Authorization

Bioharzadous Waste Management Acknowledgement

Guaranteed Compatibility Caregivers

Attestation of Good Moral Character

Employee/Applicant/Contractor/Volunteer

ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED:

OR

OR

FOR DISPLAY ONLY

Attestation of Compliance with Background Screening Requirements

Attestation

FOR DISPLAY ONLY

Receipt for AHCA Guidelines Information

W9 Form

FOR DISPLAY ONLY

I9 Form

Upload Documents

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Get in Touch

561-678-0111

info@flconciergehomecare.com

6501 Park of Commerce Blvd

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