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Pre-Screening Notice and Certification Request for the Work Opportunity Credit
Information about Form 8850 and its separate instructions is at www.irs.gov/form8850
OMB No. 1545-1500
Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.
Your name
Social security number
Street address where you live
City or town, state, and ZIP code
County
Telephone number
If you are under age 40, enter your date of birth (month, day, year)
MM slash DD slash YYYY
Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.
• l am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months. • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months. • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. • I am at least age 18 but not age 40 or older and I am a member of a family that: a. Received SNAP benefits (food stamps) for the past 6 months; or b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them. • During the past year, I was convicted of a felony or released from prison for a felony. • I received supplemental security income (SSI) benefits for any month ending during the past 60 days. • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
Check here if any of the following statements apply to you.
• l am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
• I am at least age 18 but not age 40 or older and I am a member of a family that:
a. Received SNAP benefits (food stamps) for the past 6 months;
or
b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
• During the past year, I was convicted of a felony or released from prison for a felony.
• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year
Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged released from active duty in the U.S. Armed Forces during the past year.
Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
• Received TANF payments for at least the past 18 months; or • Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
Check here if you are a member of a family that:
• Received TANF payments for at least the past 18 months;
or
• Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years;
or
• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
Signature-All Applicants Must Sign
Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.
Job applicant's signature
Date
MM slash DD slash YYYY
For Employer's Use Only
Employer's name
Telephone no.
EIN
Street address
City or town, state, and ZIP code
Person to contact, if different from above
Telephone no.
Street address
City or town, state, and ZIP code
If, based on the individual's age and home address, he or she is a member of group 4 or 6 (as described under Members of Targeted Groups in the separate instructions), enter that group number (4 or 6).
Date Applicant
Gave information
MM slash DD slash YYYY
Was offered job
MM slash DD slash YYYY
Was hired
MM slash DD slash YYYY
Started job
MM slash DD slash YYYY
Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.
Employer's signature
Title
Date
MM slash DD slash YYYY
Privacy Act and Paperwork Reduction Act Notice
Section references are to the Internal Revenue Code.
Section 51(d)(13) permits a prospective employer to request the applicant to complete this form and give it to the prospective employer. The information will be used by the employer to complete the employer's federal tax return. Completion of this form is voluntary and may assist members of targeted groups in securing employment. Routine uses of this form include giving it to the state workforce agency (SWA), which will contact appropriate sources to confirm that the applicant is a member of a targeted group. This form may also be given to the Internal Revenue Service for administration of the Internal Revenue laws, to the Department of Justice for civil and criminal litigation, to the Department of Labor for oversight of the certifications performed by the SWA, and to cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:
Recordkeeping — 6 hr., 27 min. Learning about the law or the form — 24 min. Preparing and sending this form to the SWA — 31 min.
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can send us comments from www.irs.gov/formspubs . Click on "More Information" and then on "Give us feedback." Or you can send your comments to:
Internal Revenue Service Tax Forms and Publications 1111 Constitution Ave. NW, IR-6526 Washington, DC 20224
Do not send this form to this address. Instead, see When and Where To File in the separate instructions.
Abuse, Neglect, and Sexual Harassment Policy
DEFINITIONS
PHYSICAL ABUSE:
Physical abuse is any act by another individual involving physical contact intended to cause pain, injury, physical suffering, or bodily harm.
PSYCHOLOGICAL ABUSE:
Psychological abuse is verbal or non-verbal behavior that subjects or exposes a person to actions that may cause mental trauma, including anxiety, chronic depression, or post-traumatic stress disorder.
SEXUAL ABUSE AND HARASSMENT:
Sexual abuse includes forcing undesired sexual behavior on another person. It also includes improper dressing or conduct that exposes body parts and may lead to sexual provocation. Sexual harassment may be physical, verbal, written, or visual in nature.
VERBAL ABUSE:
Verbal abuse includes, but is not limited to: countering, withholding, discounting, making jokes at another’s expense, blocking or diverting conversation, accusing, blaming, judging, criticizing, trivializing, undermining, threatening, name-calling, or teasing directed toward the client.
GRATIFICATION:
Any monetary or non-monetary reward or benefit given to induce pleasure or express satisfaction.
POLICY AND COMMENTS:
1. All caregivers share in the responsibility of ensuring that all clients receive services that are free from abuse and neglect.
2. All clients shall be treated with respect and shall not be demeaned, belittled, or degraded.
3. All caregivers must always appear professional, with scrubs and name tags properly displayed while on duty in the client’s home.
4. Caregivers must not engage in any form of sexual behavior with clients, including— but not limited to—discussing personal sexual preferences or engaging in any act that implies intended sexual misconduct.
5. Caregivers must not accept any form of gratification—monetary, gifts, or any other reward—from clients.
6. Caregivers must report any form of abuse or suspected abuse—physical, psychological, or sexual—to the agency at the first occurrence.
7. A1-Omega Healthcare Services will not hire individuals with a conviction or prior history of abuse, neglect, or mistreatment of children, elderly individuals, or any vulnerable population. Past employment references will be checked per federal, state, and local rules and regulations.
8. A1-Omega Healthcare Services will actively and thoroughly investigate all allegations of abuse and/or neglect. Upon the initial report, formal investigative procedures will be followed.
9. Immediately upon observing or discovering any abuse or neglect, a report must be made to the Agency Administrator or Supervisor. Failure to report may result in disciplinary action, up to and including termination.
10. Guardians, advocates, care coordinators, case managers, and appropriate state or federal agencies will be notified in accordance with federal, state, and local regulations.
11. A preliminary decision regarding all allegations shall be made within five (5) calendar days of the report, unless doing so would conflict with protective services procedures. A final written report must be completed within seven (7) days of the incident.
12. All employees and contractors will receive training at least annually on preventing and reporting abuse, mistreatment, or neglect, as well as training in appropriate approaches for working with individuals with Alzheimer’s and Parkinson’s disease.
13. Any person who experiences retaliatory action after making a report of abuse, neglect, or exploitation—or whose report is ignored without cause—must immediately contact the Agency Director or RN Supervisor.
14. Any employee or contractor found guilty of retaliatory action may be subject to disciplinary action, including termination.
15. Caregivers must not engage in third-party arrangements with clients to provide services while on duty or while employed by A1-Omega Healthcare Services.
16. Any request by clients for additional or extra services must be submitted through the agency and properly documented.
17. All weapons are prohibited in the office and in client homes.
I
have read and understood A1-Omega Healthcare Services’ policy on Abuse and Neglect. I agree to abide by this policy. I understand that failure to comply with this policy may result in disciplinary action, including termination of contractual employment and reporting to regulatory authorities.
Employee Signature
Date
MM slash DD slash YYYY
Agency Representation
Date
MM slash DD slash YYYY
Orientation Check List
Policies and Procedures
Introduction
Vision and Philosophy
Introductory Period
Ethics
Sexual Harassment
Accepting Gifts from Clients
Client Abuse and Neglect
Third Party Arrangement
Misappropriation of clients' funds and property
Affirmative Action and Equal Opportunity
Disability Act
Immigration Reform and Control Act
No Solicitation
Family and Medical Leave of Absence
Civic Duties
Confidentiality
Complaint Resolution
Smoke Free Environment
Drug Test
Personnel
Application/Resume'
Job Description
Criminal Background Check
TB and Hepatitis Clearance
Reference Checks
RN/CNA/PCA License Verification
OIG Clearance
Competency Evaluations
Skills Supervision
In-Service Trainings
Code of Conduct
Professional Appearance
Name Badge
Personal Property
Telephone Usage
Performance Guidelines
Demeanor
Customer Service
Client Complaints
Schedules
Use of Electronic Visit Verification (EVV)
Documentation (Time Sheets/Care - Given)
Cancellation Policy
Personal Medical Emergencies
Risk Management (Incident Reports)
Personal Safety
Client's Homes
Prohibition of all weapons at the client's and office.
Compensation
Salary
Pay Periods/Time Sheets
Overtime and Holidays
I have read and discussed all of A1-Omega Healthcare Services policies and procedures. I understand them and fully agree to adhere to them, at all times.
Employee Name
Date
MM slash DD slash YYYY
Employee Signature
Company Representative
Date
MM slash DD slash YYYY
i9
START COMPLETION HERE: Read of this instructions form. Employers carefully before completing this form. The instructions must be available, either in paper or electronically, 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.)
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 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):
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 slash DD slash YYYY
Preparer and/or Translator Certification (check one):
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 of Preparer or Translator
Today's Date
MM slash DD slash YYYY
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Hours of Availability
Name
Date
MM slash DD slash YYYY
Days
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Evenings
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Overnights
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Please list all areas you are willing to wore outside of your town:
Please specify your preference
Mornings
Afternoons
Evenings
Split Shift
No Preference
Employee’s Acknowledgement of Client’s Bill of Right
Each client of A1-Omega Healthcare Services, Inc. will have the right:
1. To participate in the development and future changes in his/her plan of care.
2. To be treated with respect, consideration, dignity, and full recognition of his or her individuality and right to privacy.
3. To receive care and services that are adequate, appropriate, and in compliance with relevant federal and State laws and rules and regulations.
4. To voice grievances about his or her care and not be subjected to discrimination or reprisal for doing so.
5. To have his or her personal medical records kept confidential and not be disclosed without appropriate written consent.
6. To be free of mental and physical abuse, neglect, and exploitation.
7. To receive a written statement of services provided by the agency and the charges the client is liable for paying.
8. To be informed of the process for acceptance and continuance of service and eligibility determination.
9. То ассept or refuse service.
10. To be informed of the agency's on-call service.
11. To be informed of the supervisory accessibility and availability.
12. To be advised of the agency's procedures for discharge.
13. To receive a reasonable response to his or her requests of the agency.
14. To be notified within 10 days when the agency's license has been revoked, suspended, cancelled, annulled, withdrawn, recalled, or amended.
15. To be advised of the agency's policies regarding patient responsibilities.
16. To be provided a copy of the agency's policies regarding client responsibilities as it relates to safety and care plan compliance.
17. To be advised of the address and telephone number for information, questions, or complaints about services provided by the agency:
A1-Omega Healthcare Services, Inc.
(5870 Faringdon Pl. Ste. 2 Raleigh NC 27609)
18. Division of Health Service Regulation complaints hotline number:
Complaint Intake Unit
Division of Health Service Regulation
2711 Mail Service Center
Raleigh, NC 27699
800-624-3004 (Toll Free), (919) 855-4500 (Out of Town)
19. To be provided a copy of the declaration of home care clients' rights in advance care being furnished.
20. To expect that the agency shall investigate, within 72 hours, complaints made to the agency by a client or the client's family.
As a client with this agency, I have the responsibility to:
1. Client and/or family participate in the development of the Plan of Care and subsequent modifications.
2. Client/family is responsible for assisting in providing a safe, non-abusive environment.
3. Client/family has responsibility to notify A1-Omega Healthcare Services when scheduled visits cannot be kept.
4. Client/family is responsible for supplying accurate and complete information about the client's medical history.
5. Client/family is responsible for his/her actions if the Plan of Care is not observed.
6. Client/family is responsible for notifying A1-Omega Healthcare Services if they do not understand the instructions or if they cannot be followed.
7. Client/family has the responsibility to inform the agency of admission and discharge to any institution that conflict with their care, scheduled or unscheduled.
I understand that any violation of this rights and client's confidentiality will result to disciplinary action up to and including immediate termination of my employment.
Employee Name
Date
MM slash DD slash YYYY
Employee Signature
Company Representative
Client Confidentiality Agreement
I understand that all information relating to my clients and their families must be held in strict confidence so as to guarantee the client's right to privacy and ensure that their information will not be disclosed without proper authorization.
I understand that all information includes all medical and personal information about the client, whether spoken or documented.
I understand that I am only entitled to access information that is necessary to complete my job and that I am only allowed to discuss this information with those authorized. I also understand that any discussion should be conducted in such a manner as to prevent the overhearing of that information.
I understand that I am to be extremely careful in my handling of all documentation containing the client's information, and I will not leave it in areas where it can be viewed by unauthorized persons.
In the event that I have a question as to whether I am authorized to disclose information relevant to my client's care, I will contact my immediate supervisor for guidance on issues concerning confidentiality.
I understand that any violation of this confidentiality statement, whether intentional or not, may result in disciplinary action—up to and including immediate termination of my employment.
Employee Name
Date
MM slash DD slash YYYY
Employee Signature
Company Representative
Company Confidentiality and Now-Compete Agreement
As an Omega Healthcare Services employee, I understand that we have developed very valuable and confidential customer, sales, and marketing information, which is vital to our success.
I understand that all confidential information includes financial and accounting data, marketing plans, strategic long-term plans, vendor and resource information, client and caregiver information, and any other information that the Omega Healthcare Services agency deems as confidential. I will not disclose any confidential information, directly or indirectly, at any time.
I agree that while employed by Omega Healthcare Services and for a period of two (2) years after the termination of my employment, for any reason whatsoever, I will not directly or indirectly work for or accept employment with any private client of Omega Healthcare Services performing the same or similar duties.
Upon termination of employment with Omega Healthcare Services, I will not solicit any client (or prospective client) of theirs with whom I have had personal contact during my employment, for the purpose of obtaining the business of said client in competition with the Omega Healthcare Services agency.
I understand that I am employed by Omega Healthcare Services at will. I will perform my job faithfully and to the very best of my ability.
Employee Name
Social Security #
Employee Signature
Date
MM slash DD slash YYYY
Company Representative
Date
MM slash DD slash YYYY
Implementing Patient Rights
1. A1-Omega Healthcare Services will provide all clients with a written copy of the Patient Bill of Rights after going over each point together during the initial assessment meeting.
2. A1-Omega Healthcare Services will provide written copies of the Patient Bill of Rights to every new employee after reviewing each point during Orientation Training.
3. A1-Omega Healthcare Services will have every employee review the Patient Bill of Rights on a yearly basis.
4. A1-Omega Healthcare Services will ensure, at every client home visit, that employees are protecting those rights.
I have read and understand these rights.
(Employee's Name -Printed)
Date
MM slash DD slash YYYY
Employee's Signature
Cancellation Policy
When you are called and asked if you would be interested in caring for a particular client, you were chosen because we feel that you are the most qualified caregiver to meet their needs. We have taken into great consideration your needs and time constraints as well.
When you have accepted that assignment, we feel that you agree with us on the vital importance of having continuity of care for that client (as well as for their family members), as changes in caregivers and client routines are extremely disruptive to the quality of care that we offer our clients.
When you are introduced to your clients and accept their case, we consider that a commitment on your part to be there on time, appropriately dressed, and ready to do the very best job that you can for them.
If you need to cancel your hours for any reason:
1. We need a 4-hour notice so that we can do our best to get your hours covered.
2. You need to personally speak to someone in the office — you cannot email, text, or leave a voicemail message!
3. Any NO SHOW/NO CALL for any shift will result in immediate termination, as we can never leave a client unattended.
4. If you are a CNA (Certified Nursing Assistant) and are a NO SHOW/NO CALL for any client, you will be reported to the NC Board of Nursing for abandoning a client.
Employee's Signature
Date
MM slash DD slash YYYY
Company Representative
Date
MM slash DD slash YYYY
Employee Complaint Process
It is the Omega Healthcare Services policy to promptly document and respond to all complaints. All complaints will be documented, including the action that was taken and the final resolution of the specific complaint. Complaints may be confidentially submitted to the agency. All complaints are to be accepted fully without fear of reprisal, discrimination, or disruption of services.
Procedure:
• A Complaint Log shall be maintained by the owner of the agency, indicating the dates of receipt, results of the investigation, and resolution of all complaints received by the agency, including the date and type (oral or written) of response.
• All complaints shall be routed to the owner of the agency, who will conduct an investigation and respond to it immediately in the case of an emergency, or otherwise within 15 working days to the patient or his/her designee.
• An employee may appeal the decision to the owner, who will review the complaint, take appropriate action, and respond to that employee within 30 days of the receipt of the appeal.
• A Reportable Event Form shall be completed for any significant complaint as required by the Omega Healthcare Services Quality Assurance Plan.
I have read and received a copy of these rights and responsibilities. They have been discussed with me prior to the start of employment by the office and staffing coordinator of the agency. I understand these rights and responsibilities as witnessed by my signature.
Employee Name
Date
MM slash DD slash YYYY
Employee Signature
Company Representative
New Employee Worksheet
First Name
Middle Initial
Last Name
Address
Street Address
City
State
Zip
Email Address
Phone Address
Department
Pay Type
Date of Hire
MM slash DD slash YYYY
Rate of Pay
Social Security #
Pay Frequency
Filing Status
Head of Household
Single or Married filing separately
Married filing jointly
Federal Exemptions
Employee Number
State Exemption
Date of Birth
MM slash DD slash YYYY
Sick / Personal
Accrual Rate
Vacation
Accrual Rate
Deductions
Health
401K
Life
Other
Special Instructions
Manager Signature/Approval
Post-Job Offer Medical Questionnaire
Employee Name
Social Security Number
Date of Birth
MM slash DD slash YYYY
Height
Weight
NOTICE TO OFFEREES:
In compliance with the Americans with Disabilities Act of 2008 (ADA), you have received a conditional offer of employment. This medical history statement is required of all offerees. The answers to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with ADA requirements. The job offer, which you have received, is conditioned upon satisfactory completion and review of this medical questionnaire and any required medical examination or follow-up.
GINA DISCLOSURE:
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. Genetic information includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member, or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
EMPLOYEE AFFIRMATION:
I hereby affirm that the employer has made me an offer of employment, conditioned on, among other things, the satisfactory completion of this questionnaire. The purpose of this inquiry is as follows:
1. To determine whether I currently have the physical qualifications necessary to perform the essential functions of the job I have been offered;
2. To determine what accommodations, if any, may be necessary for me to perform the essential functions of the job; and
3. To determine whether I can perform the essential functions of the job without posing a significant direct threat to the health and safety of myself and others.
This information will be kept strictly confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job. The conditional job duties have been adequately described to me, and I have had an opportunity to ask questions regarding the duties.
1. Have you ever had or been treated for any of the following conditions or diseases?
Hemiated Disc
Yes
No
Knee injury
Yes
No
Surgical removal of disc or spinal fusion
Yes
No
Back injury
Yes
No
Hermia or rupture
Yes
No
Diseased process of the spine
Yes
No
Neck injury, pain or problems
Yes
No
Chest Pain
Yes
No
Shoulder injury
Yes
No
Arthritis or Rheumatism
Yes
No
Arm/hand injury
Yes
No
Wrist problems, including Carpal Tunnel Syndrome
Yes
No
Repetitive motion disorders
Yes
No
Broken bones
Yes
No
Ankylosis (immobility) of any major, weight-bearing joints (ankles, knees, hips)
Yes
No
Tendonitis
Yes
No
Head injury
Yes
No
Amputations
Yes
No
Epilepsy, fainting spells, or dizziness
Yes
No
2. Have you sought treatment from a healthcare provider for any of the above injuries and/or medical conditions?
Yes
No
3. Are you capable of performing the essential duties of this job function?
Yes
No
4. Do you have any injury or condition that requires a reasonable acconmodation in order for you to be able to perform the essential duties of this job position?
Yes
No
If "YES", whataccommodations do you need to perform the job?
5. How much weight can you lift comfortably unassisted?
<15 lbs
15-25 lbs
25-39 lbs
240 lbs
6. Has a healthcare provider placed any limitations on your ability to sit, stand, push, pull, or lift?
Yes
No
If "YES", what are the limitations?
7. Has a healthcare provider limited the amount of weight you can lift?
Yes
No
If "YES", list the weight limitation and the date that your healthcare provider issued you the limitation?
8. Are you taking any prescribed drugs that would interfere with your ability to safely perform your job
Yes
No
If yes, please list the medications.
My signature certifies that all facts and representations made by me are true, accurate and made willingly and intentionally.
Signature
Print Your Name
Date
MM slash DD slash YYYY
Company Representative
Date
MM slash DD slash YYYY
Employment Agreement
I
agree to utilize my professional skills to discharge my duties for A1-Omega Healthcare Services’ clients, as specified in my job description.
I understand that A1-Omega Healthcare Services management determines pay periods. I also understand that my employment with A1-Omega Healthcare Services is at-will, and I can end this contract if the company no longer needs my services or if I am unsatisfied with my work. I should turn in my timesheets every Monday, following the reporting week. The office staff is not responsible for non-payment of my paycheck if I do not turn them in at the appropriate time.
It is my responsibility to notify the office if I am working above my assigned hours, which will result in me being scheduled for over 40 hours a week. Failure to do so will also result in non-payment of the overage.
I have no right to initiate, suggest, or advise any A1-Omega Healthcare Services clients to change service providers. I will NOT work for any of their clients privately for the period of my employment or for two (2) years following my employment. If I am found to be working for them privately, I understand that I will pay A1-Omega Healthcare Services $5,000.00 for each client that I have taken.
It is my duty to arrive at each assigned client “on time” and to call the agency with at least four (4) hours’ notice if I am running late or unable to cover my shift. If I need to take time off, it must be properly documented and submitted to the office one month in advance for approval, enabling the office staff to properly cover my client hours.
I understand that I will behave and appear professionally while caring for my clients. There is zero tolerance for smoking while caring for a client.
Lastly, all communication regarding any and all client needs must be handled through the office and the staffing coordinator.
I have read and understand this employment agreement and agree to all of its provisions, without compulsion whatsoever.
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Hepatitis B Vaccine Notification Form
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV) infection.
I have been given the opportunity to be vaccinated with the Hepatitis B vaccine. I understand that I will pay for all three injections.
• I decline the Hepatitis B vaccination at this time.
• Yes, I wish to be vaccinated against Hepatitis B.
• I have already received the Hepatitis B vaccine.
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