A One Home Care Services

1159 Monte Drive,

Marietta, GA 30062

Application for Employment

Personal Information

Name (Last, First, Middle): ______Date:______

Social Security Number:______

Home Address:______

City:______State:______Zip Code:______

Home Phone:______Business / Mobile Phone:______

Emergency Contact:______Phone:______

Date of Birth:______

List Handicaps or ailments that would prevent you from performing on-the-job duties:

______

List days absent in the past two years due to illness:______

Have you ever had an industrial accident or occupational disease?______

Have you ever abused drugs and/or alcohol?______

Would you agree to be bonded?______Do you have your own liability insurance?______

Position you are applying for:______

Title:______Salary Requirement:______

Referred by:______Date you can start:______

Education Record

High School (Name, City, State):______

Graduation Date:______

Business or TechnicalSchool (Name, City, State):______

Dates Attended:______Degree Earned:______

UndergraduateCollege (Name, City, State):______

Dates Attended:______Degree, Major:______

GraduateSchool:______

Dates Attended:______Degree, Subject:______

Work History

(Give information about your last three jobs, starting with the most recent)

  1. Employer:______

Address:______

City:______State:______Zip:______

Phone:______Ending Salary:______

Title/Duties:______

Manager’s Name and Title:______

Employment Dates:______

  1. Employer:______

Address:______

City:______State:______Zip:______

Phone:______Ending Salary:______

Title/Duties:______

Manager’s Name and Title:______

Employment Dates:______

  1. Employer:______

Address:______

City:______State:______Zip:______

Phone:______Ending Salary:______

Title/Duties:______

Manager’s Name and Title:______

Employment Dates:______

Business Reference

(If applying for your first job, you may use academic references)

  1. Name:______

Work Phone:______Home Phone:______

Address:______

City:______State:______Zip Code:______

Relationship to you:______

  1. Name:______

Work Phone:______Home Phone:______

Address:______

City:______State:______Zip Code:______

Relationship to you:______

  1. Name:______

Work Phone:______Home Phone:______

Address:______

City:______State:______Zip Code:______

Relationship to you:______

Please Read and Sign

I certify that all information provided by me in this application is true and accurate. I understand that any falsification or misinterpretation may result in termination of employment even if the job offer is extended. I understand and permit A One Home Care Services to conduct necessary investigation on me to determine my eligibility of employment.

A One Home Care Services is an equal opportunity employer. It employs without regard to race, age, color, religion, sex or national origin.

______

Signature Date

A ONE HOME CARE SERVICES

Orientation Checklist

Please initial each item, sign and date

  1. Received, read and understood the policies and procedures manual ______
  1. Read and signed Client rights and responsibilities ______
  1. Read and signed TB Exposure Statement ______
  1. Read and signed confidentially of client form ______
  1. Read and signed Handling of complaints______
  1. Read and signed employee’s job responsibilities ______
  1. Read and understood emergency procedures ______
  1. Agree to complete CLTC task sheet and submit to the office monthly ______
  1. Agree to complete time sheet weekly and submit to the office ______
  1. Agree to inform nursing supervisor of any changes in client status, environment and/or change in the level of any services provided ______
  1. Agree to notify supervisor of any changes in my address and/or phone numbers ______
  1. Agree to notify this office of any changes in my address and/or phone numbers ______
  1. Agree to notify nursing supervisor at least three hours before any scheduled visit to client house, if I am unable to report for work and on emergency situations, call my nursing supervisor immediately ______
  1. Agree to keep my CPR(every 2 years) and PPD(yearly) current and submit proof to office ______
  1. Agree to attend in-service provided by this company ______

______

Signature Date

A ONE HOME CARE SERVICES

Staff Orientation

A One Home Care Services provides personal care task and companion or sitter tasks in the Atlanta region.

As a representative of A One Home Care Services:

  1. You must provide competent, state of the art care to its patients
  1. Follow the ‘Client Service Plan’ to perform the tasks agreed upon
  1. For security reasons, you shall not disclose or knowingly permit the disclosure or any information in a client record except to appropriate provider staff, the client responsible party(if applicable), the client’s physician or other health care provider, the regulatory department, other individuals authorized by the client in writing or by subpoena.
  1. In case of any emergency at a client’s home, you must immediately contact the client’s emergency contact name (as stated in the client’s file), and notify the A One Home Care Services office.
  1. You must notify the A One Home Care Services office and the client’s responsible party of any changes in the client’s condition.
  1. As a part of a commitment to quality, we encourage you to report to the office any changes that may improve the quality of care a patient is receiving.
  1. Intake sheets have been provided to keep track of every service that is being provided. You must note the service provided, date it and initial it.
  1. You must report known exposure to Tuberculosis and Hepatitis to A One Home Care Services.

I certify that I have read the above and understand it.

______

Print Name

______

Signature

______

Date

A ONE HOME CARE SERVICES

I, ______do hereby state and declare that I have never been shown by credible evidence (e.g. a court of law or jury, a department investigation or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidence by oral or written statement to this effect obtained at the time of application. I also promise hereby to promptly notify the A One Home Care Services, if any of these events occur in the future.

Name:______Sign:______Date:______

A ONE HOME CARE SERVICES

JOB DESCRIPTION

PERSONAL CARE ASSISTANT

Qualifications:

  1. Must be able to read and write, follow verbal and written instructions, and complete written report of care given.
  1. Must present documentation of nurses aide certification from the department of medical assistance or must have received 40 hours training, at least 20 hours of training prior to seeing the client and the additional 20 hours to be completed within 6 months of employment to include items covered under policies and procedures of personal support services, part 2 chapter 1400 pages xiv-8 to xiv-9.

Responsibilities:

  • Provide or assist with any of the appropriate duties as Personal Care Assistant with minimum qualifications of
  1. Never have been shown by credible evidence (e.g. a court of jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of application.
  2. Participate in the orientation and training required by the rule.
  3. Not have made any material false statements concerning qualification requirements either to the department or the A One Home Care Services.
  • Encourage client to make decisions and to remain as independent as possible.
  • Encourage family members to be involved and responsible for care of client.
  • Report changes in client condition to the nurse supervisor.
  • Maintain progress note indicating changes in the client’s condition, problems that hinder services delivery and additional needs of the client.
  • Complete the PSS service documentation on monthly basis for each client.
  • Apply information acquired through training.

Signed:______

Date:______

A ONE HOME CARE SERVICES

P O Box 70277

Marietta, GA30007 – 0277

Independent Worker Agreement

I, ______an independent contractor, agree to provide service to clients referred to me by A One Home Care Services(AHC) at the rate of $______/hr.

As an independent contractor, I understand and agree to the following:

  1. That nothing in the relationship between AHC and me creates an employer/employee relationship.
  1. That no direct daily supervision of my work will be conducted by this company. The client directly supervises my work and reports to the agency(AHC) on his/her satisfaction with my performance.
  1. That the agency serves as a referral agency and sub contracts this work to me.
  1. That I will be responsible to pay all applicable fees and taxes including, but not limited to, federal and state taxes as required by the Internal Revenue Service and Georgia Department of Revenue, worker compensation insurance, and any other tax agency as required by law.
  1. That the agency reserves the right to withdraw work not performed according to care plan and upon client’s request.

______

Independent Contractor Date

______

A One Home Care Services Date

A ONE HOME CARE SERVICES

I, ______, understand that all medical information contained in the patient’s records is confidential and should not be released without a valid patient’s consent. I am aware of the written and verbal policy of A One Home Care Services and I understand fully. I also understand that failure to comply with the company policy of patient confidentiality and release of information may result in punitive action, and that I may subject to instant dismissal and possibly legal repercussion or prosecution.

______

Signature of Employee

______

Dated