* Please notify the agency immediately if any of the emergency contact information changes.
* You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.
I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you.
Clear
I have applied to Del Community Home Care for employment/rostering. I hereby release from all liability the company and/or person completing this form and authorize them to release all information regarding my employment with them.
Employed from: to
APPLICANTS MOVE TO THE NEXT PAGE
Del Community Home Care conducts a complete reference check, prior to hiring, on each applicant for employment/rostering. All information you supply is confidential. Any statements you wish to make that would help us determine a placement for this applicant may be entered in the space provided for "Comments” or you may call the office for a confidential conversation. We appreciate your prompt reply.
Please rate the applicant using the following guidelines
OFFICE USE ONLY
Del Community Home Care Agency conducts a complete reference check, prior to hiring, on each applicant for employment/rostering. All information you supply is confidential. Any statements you wish to make that would help us determine a placement for this applicant may be entered in the space provided for "Comments” or you may call the office for a confidential conversation. We appreciate your prompt reply.
FACE-TO-FACE INTERVIEW REVIEW APPLICANTS MOVE TO THE NEXT PAGE
INTERVIEW REVIEW APPLICANTS MOVE TO THE NEXT PAGE
CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION
It is both the Agency's and the employee's responsibility to ensure that every patient's health information is always protected. By signing below, you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency's policy regarding patient's Protected Health Information will be provided to you upon hire. I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated with the use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with HIPAA Rule and Regulations. I will protect all Electronic Records including passwords as outlined in the HIPAA manual.
There are specific guidelines to ensure a patient's Protected Health Information is kept private. I understand that my employment with the agency involves handling Protected Health Information. I will ensure patient's records are protected by enforcing the following measures: • Patient Protected Health Information will be transported in a protected travel chart when traveling. • When transmitting and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area. • Patient Protected Health Information will be returned to the agency upon acknowledgement of the patient being discharged. I pledge to make every effort to keep patient's Protected Health Information always protected.
CONFLICT OF INTEREST STATEMENT
I have read and am fully familiar with the Agency's policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other matter in which I would profit or gain directly or indirectly because of my membership on the Agency's Board of Directors or its committees, (if applicable), and/or my employment with the Agency. I will disclose all known relationships that may present a conflict of interest. Furthermore, I agree to immediately disclose any such interest or outside employment which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the Agency's business that might result in any profit or gain, directly or indirectly for myself.
HIPAA CONFIDENTIALITY AGREEMENT
EMPLOYEE CONFIDENTIALITY AGREEMENT OF PATIENT HEALTH INFORMATION AND PERSONAL INFORMATION IN ACCORDANCE WITH HIPAA REGULATIONS For good consideration and as an inducement for Del Community Home Care Agency (Agency/Employer) to employ (Employee), the undersigned Employee hereby agrees not to directly or indirectly use, manipulate or copy any patient health information (PHI), to include personal health information or personal contact information (address, phone, email address, etc.) with the business of the Agency and its successors and assigns during the period of employment. Misuse of PHI or personal contact information will result in termination and report with action to HIPAA federal agencies. Fines related to civil and criminal offences for gross misconduct with the above information are the direct responsibility of said employee. The Employee acknowledges that the Agency shall or may in reliance of this agreement provide Employee access to trade secrets, customers and other confidential data and goodwill. Employees agree to retain said information as confidential and not to use said information on his or her own behalf or disclose same to any third party or for their own personal or monetary gain. The Employee agrees not to copy and to return all such Agency supplied Information immediately upon termination of employment. Furthermore, the Employee agrees not to solicit any of the customers or employees of the Agency for any purpose for a period of two years after termination. This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.
CORPORATE COMPLIANCE STATEMENT
ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING. The Corporate Compliance Statement provided below is to be acknowledged and signed by every Agency employee as well as every employee working for the Agency on a contract basis. CORPORATE COMPLIANCE POLICY As you know, our Home Care Agency and our Staff members have always been committed to providing exceptional health care and upholding ethical conduct standards and legal compliance. Our policy formally and clearly states that there is zero tolerance to any form of fraud or misconduct. This Agency believes that every employee or agent plays a key and active role in maintaining its image and reputation. I hereby acknowledge that I have been apprised of and agree to comply with the Agency’s Corporate Compliance Policy. I understand that in no way does this create an obligation or contract of employment and that I, as well as the Agency, have the right to end the employment relationship at any time.
I understand that copies of the policy and procedure manuals are available and that it is my responsibility to read, understand and conform to all applicable Agency policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions. I have read the Agency’s Policy and Procedure on Abuse, Neglect and Exploitation and agree to Comply with and am bound by the Policy. I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its employees, nor is it an expression of my term of employment. I affirm that I have auto insurance coverage as required by this state and the Agency and I agree to keep it fully in force on any vehicle I use for the conduction of Agency business during the term of my employment. The Agency has the right to request proof of insurance at any time during the term of employment and I am required to follow all Agency requirements and state and local laws. I understand that only the Agency has the authority to admit clients and will supervise with appropriate personnel all services provided. As a caregiver, I will carry out the plan of treatment, submit time sheets, clinical and progress notes as appropriate and, at a minimum, on a weekly basis, I will participate in developing and reviewing plans of care, periodic client evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend the required staff meeting and in-service training. Home health aides are required to have 12 hours of in-service training annually. I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided. I understand that all information, both written and verbal, regarding client and employee health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease; testing, results or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, drug or alcohol abuse is protected under specific law. All information in connection with the examination, care or provision of services to any client will not be disclosed without the individual's written consent except as may be necessary to provide services as required by law. Information may be used in statistical or other summary forms or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of client/ employee confidentiality is subject to civil and criminal penalties. If I mistakenly exceed my accrued or earned sick or vacation leave balance, I authorize the Agency to deduct any amount from my paycheck(s) to correct my accrued or earned sick or vacation leave balance. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will.
Please read this agreement carefully. Your signature indicates that you acknowledge and agree to the information below. A copy of this agreement will be kept in your file. I have been provided a copy of Del Community Home Care policies and procedures and comply with the policies contained in this handbook and any revisions made to it. I understand that I am responsible for asking my supervisor if I have any questions. I give permission to Del Community Home Care to contact two of my professional references to seek out two satisfactory references. I acknowledge that I have completed a nurse aide training program, an HHA program, OR some other acceptable nonmedical training program before hire. If I have not, I agree to pass a written competency examination for Del Community Home Care. I acknowledge that I:
Have been a Pennsylvania resident for the past two (2) consecutive years.
Have NOT been a Pennsylvania resident for the past two (2) consecutive years.
If you have not been a Pennsylvania resident for the past two consecutive years, you will be given information to complete the FBI criminal background check at your expense. Upon hiring, Del Community Home Care will reimburse me the $27.75 cost for the FBI transmittal form. The provision and acceptance of the FBI background check does not constitute an offer of employment by Del Community Home Care. I acknowledge that all applicants and employees listed and confirmed on any of the exclusion lists, (GSA, EPLS, OIGLEIE, SAM, and PA Medicheck) will not be hired and terminated. I understand that I will be performing non-medical home health services including but not limited to: light housekeeping, light cooking, personal care assistance and any other tasks assigned by Del Community Home Care. If I am unsure of a task, I will first check with my supervisor. I acknowledge that I am a healthy, capable person that can perform the tasks asked of my supervisor. I understand that I must "clock in and clock out" at each client's house by dialing into the attendance system or logging in to any designated EVV mobile platform. I also agree to complete the communication logs with the tasks completed and times worked for that shift. I understand that for certain clients I must either fax, mail, email, or drop off the communication logs every Monday by noon. Failure to do so will result in late paychecks and possible deductions from that paycheck. I understand that I will only be paid for my scheduled shift. I may not clock in early or clock out later than the contracted shifts. I acknowledge that I am receiving a pay rate of $/ hour. I understand that I will not make any private arrangements with or provide care independently to any client of Del Community Home Care during my employment and for two years after employment with Del Community Home Care. I certify that I will not refer any friends or relatives to work for any Del Community Home Care clients. If I work with another home health agency, I do not service any client of Del Community Home Care under that agency. Any violation of this policy will result in financial liability to Del Community Home Care. All monies received from clients during the private arrangement will be given to Del Community Home Care. If monies are not given immediately, a suit will be filed, and employees will reimburse Del Community Home Care for all attorney and court fees. I understand that the following are grounds for immediate termination from Del Community Home Care; accepting money from client or any family members, using client's home (including phone) for personal use, coming to work under the influence of drugs or alcohol, sleeping during any shift unless as prescribed for the client, canceling assignments frequently without acceptable medical explanations (doctor's notes may be necessary), leaving a client's home before the shift is over or leaving during the shift and returning back to the client's home without authorization from Del Community Home Care's office. I understand that my schedule will vary based on consumer's needs. There is no guarantee in the number of work hours I will be working per diem or on an as needed basis (PRN), without any number of hours guaranteed. If I am unable to work my shift, I must notify my supervisor immediately. I will provide at least 24 hours' notice if unable to work the shift. If less than 24 hours are given a doctor's note must be provided to Del Community Home Care. I agree to give Del Community Home Care two (2) weeks' notice if I voluntarily quit. I understand that if I refuse more than two consecutive assignments, it will be considered voluntarily resigning from Del Community Home Care. I understand that if I fail to show up for a scheduled shift and fail to notify Del Community Home Care at (610)553-7938 and (267) 688-3228, the action indicates that I have voluntarily quit my job without notice. Del Community Home Care has agreed to comply with the provisions of the Federal Civil Rights Act of 1964 and the Pennsylvania Human Relations Act and all requirements imposed pursuant thereto the end that no person shall, on the grounds of race, color, national origin, ancestry, age, sex, religious creed, or disability, be excluded from participation in, be denied benefits of, or otherwise be subject to discrimination in the provision of any care or service. Complaints of discrimination in this paragraph may be filed with the office of Equal Opportunity, Pennsylvania Department of Health, and/or the Pennsylvania of Human Relation Commission. Reasonable accommodation will be provided for handicapped employees.
Del Community Home Care requires adherence to the following Standards and Procedures: 1. All employees are expected to dress in a manner appropriate to the health environment, or as directed by the consumer’s family. This includes personal hygiene, jewelry, hair, and makeup. 2. Please do not smoke in the presence of a consumer. 3. Always wear your ID badge. 4. You are expected to arrive on time for all assignments that you accepted. However, if an emergency or any situation should cause you to be five minutes late, or more or to be totally absent from the assignment you must notify the Agency immediately. PLEASE DO NOT CALL YOUR CONSUMER DIRECTLY. You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment. A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION! 5. If you have any problem, incident, or accident on the job, do not discuss it with the consumer, but call the Agency immediately. 6. If the consumer asks you to stay longer than your assignment or to leave earlier, you must call the Agency first, for approval. 7. Paraprofessional personnel (i.e., Aids) hereby acknowledge that they WILL NOT, UNDER ANY CONDITIONS, DISPENSE OR ADMINISTER ANY MEDICATION. 8. UNDER NO CIRCUMSTANCES are you to ask for or accept any money from your consumer or take home property that belongs to the consumer. 9. There should not be any involvement with the consumer’s financial affairs (i.e., check writing). 10. You are expected to honor the confidentiality of any consumer information which is obtained in the regular course of your employment. 11. No personal telephone calls should be made or received by you while on assignment. 12. Please do not discuss your pay to any other personal affairs with the consumer family. 13. As an employee of this Agency, you are not authorized to accept any direct employment that may be offered to you by your consumer family. If you are requested to do so, please have the consumer contact us. 14. It is imperative that all signed notes and documentation, including the Daily Log, be filled out properly and returned to the office as per our schedule. If the consumer is unable to sign your note, a family member or responsible party may sign. 15. During employment, this Agency proprietary materials (i.e., forms, medical records) will be used only about employment and will not be disclosed to anyone without authorization from the Agency.
PERSONAL PROTECTIVE EQUIPMENT FOR SAFETY AND INFECTION CONTROL ACKNOWLEDGMENT I understand a Personal Protective Equipment (PPE Kit) is available in the office and contains the following: • Barrier Safety Goggles • CPR Shield Face Barrier • Fluid Resistant Gown • Gloves • Biohazard Bag • Sharps Container • TB Mask (N95 or similar purchased from Uline.com) I have been instructed in the use of this equipment and understand that I must comply with the Policies and Procedures regarding use of personal protective equipment.
Non-Competition: As an Employee of DCHCA and as a condition of continued employment I hereby agree during the period of my employment and for twelve (12) months thereafter ("the Non-Solicitation Period"), I will not, directly or indirectly, engage in (or own an interest in any entity which engages in) activities in competition with the business or potential business of DCHCA, namely providing non-medical in-home care and or related services within a radius of five (5) miles of DCHCA’s office(s) and/or area(s) to which I was assigned and/or performed employee services for DCHCA during my employment. Non-Solicitation of Patients: For the entire Non-Solicitation Period, I will not, directly, or indirectly, solicit, provide services to or attempt to solicit or provide services to DCHCA's current Patients at my termination; Patients for whom DCHCA provided services within twelve (12) months prior to my termination and prospective Patients at the time of my termination from whom DCHCA has or plans actively to solicit business. Non-Solicitation of Employees: During the entire Non-Solicitation Period, I will not, directly, or indirectly, solicit, hire or attempt to persuade any employee(s) or agent of DCHCA to terminate his/her relationship with DCHCA. I agree that the period provided for non-competition and non-solicitation in this Agreement shall be extended for any period of time during which I am in violation of any of the provisions of this Agreement. I expressly agree that any breach (or threat of breach) of this provision in the Handbook by me shall entitle DCHCA, in addition to any other legal remedies at law or equity available to it, to apply to any court for an injunction, temporary and/or permanent, to present any violation of this provision within Agreement, and I recognizes, acknowledges and agrees that such injunction would be necessary to protect DCHCA business interests. DCHCA shall also be entitled to recover the costs of prosecuting any action hereunder, including, but not limited to, reasonable attorneys’ fees. In the event it is necessary for DCHCA to sue to enforce the provisions of the restrictive covenant, the applicable period on non-competition by me shall be extended by a period equal to the duration of such litigation. I agree that throughout the term of this Agreement I shall make full and complete disclosure of the existence of this Non-Compete Provision and the entire contents hereof to any Home Care and or similar or competing business within ten (10) miles of DCHCA main office.
CAREGIVER AVAILABILITY
During orientation each employee is asked to complete and sign a DCHCA Availability Sheet. This sheet details the times each week that you (as a caregiver) are available to work for DCHCA. When new cases (Patient hours) become available, staffing is performed using this information. Therefore, the more available time(s) each caregiver can commit to - the more likely that they will be placed on the new case. Should your availability change, please call the office to ensure that your caregiver availability profile is updated in the system. Each week a schedule will be created and communicated (via email, mail and/or phone) to each caregiver and Patient. Once this is done, each caregiver is expected to commit to the schedule and/or immediately call the office with questions or issues. If you don't get a weekly schedule by Wednesday (for the following week), please contact the office immediately. It is the caregiver’s responsibility to know their schedule each week. If you are scheduled for a shift and do not properly call out (TEXTING A MESSAGE IS NOT ALLOWED) there is an issue of Patient safety and well-being and DCHCA must honor its commitments to our Patients therefore, this is grounds for immediate termination. In the event you are unable to report as scheduled, you must call your immediate supervisor, (text message is not acceptable).This should be done no later than three (3) hours prior to your starting time and occur each day until you either return or are given other reporting instructions.Leaving a message with a co-worker does not relieve you of your reporting responsibility. If you fail to call in for two (2) consecutive workdays, DCHCA will accept this as your voluntary resignation from the company. CARE GIVER AVAILABILITY SHEET: Please complete the following schedule and provide times that you can work for DCHCA. We provide services 24 hours a day, 7 days a week. How you complete this form is very important. The work hours that are provided for you by DCHCA are driven by two primary business issues; the needs of the Patients and your availability to work.
The sheet above designates the times that I am committing myself to be available to work for DELCHHA. By signing this sheet, I acknowledge that the decision to hire me will be based in part on the above availability. I agree any changes to my availability must be approved and signed by my supervisor. I understand that there is no guarantee of hours if I am offered a position with DCHCA. I understand that it can take time to reach and sustain my desired number of hours per" week and that multiple factors affect this goal including my availability, Patient requests, my stalls, and my ability to please the Patient to whom I am assigned. Nothing in this statement is to be construed as a direct, implied, or inferred contract of employment. I understand I am not authorized to provide medical care independently and agree that if a medical emergency arises while I am with a Patient, I will call 911 and follow their instructions accordingly.
RECEIPT OF EMPLOYEE HANDBOOK
This is to acknowledge that I have received a copy of the Agency Employee Handbook and understand that it sets forth the terms and conditions of my employment as well as the duties, responsibilities, and obligations of employment with the company. I understand and agree that it is my responsibility to read the Employee Handbook and abide by the rules, policies, and standards set forth in the Employee Handbook. I acknowledge that my employment with the Agency is not for a specified period, and I can be terminated at any time for any reason, with or without cause or notice, by me or by the company. I acknowledge that no oral or written statements or representations regarding my employment can alter the foregoing. I also acknowledge that no employee has the authority to enter into an employment agreement-express or implied-providing for employment other than at-will. I acknowledge that except for the policy of at-will employment, the company reserves the right to revise, delete, and add to the provisions of this Employee Handbook. All such revisions, deletions, or additions must be in writing and must be signed by the President of the company. No oral statements or representations can change the provisions of this Employee Handbook. I also acknowledge that, except for the policy of at-will employment, terms, and conditions of employment with the company may be modified at the sole discretion of the company with or without cause or notice at any time. No implied contract concerning any employment-related decision, term of employment, or condition of employment can be established by any other statement, conduct, policy, or practice. I understand that the foregoing agreement concerning my at-will employment status and the company's right to determine and modify the terms and conditions of employment is the sole and entire agreement between me and our Agency concerning the duration of my employment, the circumstances under which my employment may be terminated, and the circumstances under which the terms and conditions of my employment may change. I further understand that this agreement supersedes all prior agreements, understandings, and representations concerning my employment with the company. If I have questions regarding the content or interpretation of this handbook, I will bring them to the attention of my supervisor.
SECTION 2
JOB ACCEPTANCE STATEMENT
I have read, understood, and agree to the terms specified in this job description for the position I presently hold. A copy of this job description has been given to me. I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.
JOB DESCRIPTION: Companion/Caregiver Job Classification: Non-Exempt Job Summary: Responsible for (Non-Medical), in-home provide for the comfort and general supervision of Patients as well as home management services. Provides companionship to those individuals requiring socialization arid/or minimum guidance to assure a safe, protected, dean, and orderly environment. Qualifications: Minimum of ninth education; high school diploma or GED preferred. Must demonstrate satisfactory completion of any stated mandated training. Applicant must be bondable and meet or exceed minimum qualifications for each of the following background checks: Criminal Background Investigation, Motor Vehicle Driving Record, Credit History, Professional and Persona! Reference Checks and give permission to submit to random drug and alcohol testing. Must have reliable transportation and fulfill assignments with reliability and punctuality. Must have a valid driver's license and automobile insurance. Must satisfactorily complete DCHCA, training and orientation program(s). Must accept responsibility for learning and adhering to DCHCA policies and procedures, be able to function in the home setting with minimal direct supervision and maintain satisfactory relationships with administrative staff, Patients, and family members. Must be able to follow verbal and written instructions and document services provided. Must be genuinely concerned about helping people and have high moral standards of honesty and integrity. § 611.55. Competency requirements. (a) Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: 1. Obtained a valid nurse’s license in this Commonwealth. 2. Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsections (b) and (c). 3. Successfully completed one of the following: A competency examination or training program developed by an agency or registry for a direct care worker must address, at a minimum, the following subject areas: 1. Confidentiality. 2. Consumer control and the independent living philosophy. 3. Instrumental activities of daily living. 4. Recognizing changes in the consumer that need to be addressed. 5. Basic infection control. 6. Universal precautions. 7. Handling of emergencies. 8. Documentation. 9. Recognizing and reporting abuse or neglect, and 10. Dealing with difficult behaviors. Essential Functions: 1. Provides general attention to Patient’s non-medical needs in accordance with an established Plan of Care, 2. Provides companionship for the Patient including, but not limited to talking and listening, reading aloud, providing social and emotional support, 3. Promotes the Patient's mental alertness through involvement in activities of interest. Provides emotional support and promotes a sense of well-being, 4. Provides for a dean, safe, and healthy environment for Patients and family members. Provides light housekeeping tasks including laundering of Patient's garments and linens, 5. May prepare and serve meals as directed. Ensures that dishes are washed and kitchen cleaned after each meal, 6. Assists Patient in completing necessary phone calls, letter writing, etc. Accompanies Patient on walks, community trips, doctor's office, bank, beauty salons, etc, 7. Reminds Patient to take self-administered medications, 8. Observes and reports any changes in the Patient's mental, physical, or emotional condition or home situation to immediate supervisor in a timely manner, 9. Establishes and maintain effective communication and a professional relationship with 10. Patients, family members and co-workers, 11. Participates in in-service and continuing education programs, staff meetings, and Patient conferences as requested by supervisor, 12. Completed required documentation of services delivered and submits to office in a manner per policy, 13. Uses equipment and supplies safely and properly, 14. Maintains confidentiality regarding patient information, and 15. Other reasonable related duties as assigned. Working Environment:Patient home setting and automobile. Contact with blood or other body fluids may pose a risk for exposure to blood borne pathogens and infectious diseases. Position Physical Demands: The work requires light physical exertion on a regular and reoccurring basis, such as driving, assisting the Patient in activities, and light housekeeping. You are regularly required to sit, walk, talk, hear and occasionally required to reach and lift. DCHCA requires all employees prior to any offer of employment being extended; all employees must successfully pass a state mandatory criminal background check. DCHCA prohibits hiring and or retaining any individual(s) with a prohibited conviction or Department of Aging ineligibility determination. As described below: As required under PA Code § 611.52. (e) Prohibition.The home care agency or home care registry may not hire, roster or retain an individual if the State Police criminal history record reveals a prohibited conviction listed in 6 Pa. Code § 15.143 (relating to facility responsibilities), or if the Department of Aging letter of determination states that the individual is not eligible for hire or roster.
I, , acknowledge receipt and understanding of this job description, I realize that this reflects a general list responsibility of the position, as well as a general description of the working environment and physical demands of the position I have accepted.
PROVISIONAL HIRE FOR 30 CALENDAR DAYS
I, swear and affirm that I have not been convicted of any of the offences contained in the Prohibitive Offences Contained in act 169 or 1996 as Amended by Act 13 of 1997 (see next page for full list). I have no knowledge of information that would disqualify me from employment pursuant to the act (see next page).
I will be monitored by the Del Community Home Care through random, direct observation and consumer feedback and document the results in the individual’s file. I will be directly supervised by the agency/registry or be accompanied by another direct care worker if I am to provide services to a consumer less than 18 years of age. In addition, I understand that if I have been a Pennsylvania resident for 2 years or more, I cannot serve a provisional period of more than 30 days; and if I have NOT been a resident of PA for 2 years or more, I cannot serve a provisional period of more than 90 days. I attest that the above information is true to the best of my knowledge.
ANNUAL & UPON HIRE EMPLOYEE TUBERCULOSIS SCREENING
All employees are required to participate in screening for Tuberculosis. All employees must complete the following screening questionnaire if the agency is determined to be low risk per the CDC Guidelines:
I further certify to the best of my knowledge the above statements are true.
STAFF PHYSICAL EXAMINATION
(1) MANTOUX-PPD (results read more than 72 hours after date given are not valid. TB time is not acceptable. IF TEST RESULTS ARE POSITIVE THEN A CHEST X-RAY MUST BE OBTAINED
Step I.
(3) The Mantoux -PPD and/ or Chest X-Ray is contraindicated currently:
PLEASE NOTE: Form must be stamped and signed. If applicable, a copy of Chest X-Ray Report must be attached.
Hepatitis B Immunization Consent/Refusal Form
I read the information given to me about Hepatitis B virus and Hepatitis B vaccine and I had the opportunity to ask questions. My questions were answered. I want to participate in the vaccination program. I understand this includes three injections at prescribed intervals over a six-month period. I understand that there is no guarantee that I will become immune to Hepatitis B. I understand that I might experience an adverse side effect as the result of the vaccination.
I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring Hepatitis B Virus (HBV). I was given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to me. However, I decline Hepatitis B vaccination now. I understand that by declining this vaccine, I continue to be at an increased risk of acquiring Hepatitis B, a serious disease. If in the future, I want to be vaccinated with the Hepatitis B vaccine, I understand that I can receive the vaccine series at no charge to me.
PRIVACY ACT INFORMATION
Agency: Del Community Home Care Address: 351 Huntley Road Upper Darby Pa 19082
The collection and use of this information are consistent with the provisions of 5 U.S.C. 552a (Privacy Act of 1974). This information is sensitive and protected by the Privacy Act. It is only available to staff on a need-to-know basis. Electronic material must be password protected and must not be used except in accordance with routine uses identified in OPM/GOVT-10, Employee Medical File System Records. Paper records must be similarly used and protected in a locked file or room that is available only to staff who have a need to know this information and in accordance with OPM/TGOVT
I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.
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