1JOB TITLE

2JOB DESCRIPTION / CHECK LIST

3Candidate Information

4My Experience

5Professional references

6Application Questions

7Form I-9, Employment Eligibility Verification

8W-9 Form

9W-4 Form

10Vaccines and immunization Survey

11Acknowledgement

JOB TITLE

Registered Nurse (RN) *

Physical Therapist *

Physical Therapy Assistant *

Speech Language Pathologist *

Medical Social Worker *

Medical Social Work Assistant *

Occupational Therapist *

Occupational Therapy Assistant *

Home Health Aide *

Registered Nurse (RN)

JOB SUMMARY:

A Registered Nurse administers skilled nursing care to patients on an intermittent basis in their place of residence.This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Clinical Services/Nursing Supervisor.

QUALIFICATIONS:

Graduate of an approved school of professional nursing and currently licensed in the state(s) in which practicing.
Two (2) years’ nursing experience, preferred.
Acceptance of philosophy and goals of this Agency.
Ability to exercise initiative and independent judgment.

RESPONSIBILITIES:

Provides services in accordance with the plan of care.
Makes the initial evaluation visit and regularly reevaluates the patient’s nursing needs.
Initiates the plan of care and necessary revisions.
Provides those services requiring substantial specialized nursing skills.
Initiates appropriate preventive and rehabilitative nursing procedures.
Prepares clinical and progress notes for each patient visit and summaries of care conferences on his/her patients in a timely manner as per Agency policy.
Coordinates services.
Informs personnel of changes in the condition and needs of the patient.
Counsels the patient and family/significant others in meeting nursing and related needs.
Participates in and presents inservice programs.
Understands and adheres to established Agency policies and procedures.
Processes orders and notifies physician of patient needs and changes in condition. Completes certification/recertification orders and discharge summaries.
Determines the amount and type of nursing needed by each individual patient.
Refers to Physical Therapist, Speech Language Pathologist, Occupational Therapist and Medical Social Worker those patients requiring their specialized skills.
Supervises and teaches other nursing personnel.
Conducts patient care conferences on patients assigned to his/her care.
Participates in peer review and Quality Assessment and Performance Improvement as assigned.
Gives total patient care as needed.
Takes on-call duty nights, weekends and holidays, as assigned.
Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames.
Appropriately utilizes ICD-10 codes.

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIPS:

Supervised by: Director of Clinical Services/Nursing Supervisor
Workers Supervised: Licensed Practical Nurse, Home Health Aide

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.
Ability to work for extended period of time while standing and being involved in physical activity.
Heavy lifting.
Ability to do extensive bending, lifting and standing on a regular basis.

INITIAL COMPETENCY CHECKLIST RN/LPN/LVN

Layout

Urinary catheters *

Suprapubic insertion/removal *

Continuous *

Equipment: *

Enteral pumps *

Oxygen tank *

IV therapy *

Adm fluids/meds *

Irrigations *

Colostomy *

Suctioning *

Oral *

Tracheal *

TPN *

Labs *

Additives *

Transporting lab specimens *

Aseptic technique *

Standard Precautions *

Gowns *

Shoe covers *

Foley insertion–male/female *

Enteral Feedings: *

Bolus *

Central Cath Lines *

Removal/insertion PEG tubes *

IV pumps *

Oxygen concentrator *

Nebulizer *

Peripheral/INT *

Dressing change *

Bladder *

Nasal *

Tracheostomy Care *

Administration *

Starting/stopping *

Venipunctures *

Wound care: *

Sterile technique *

Gloves *

Gloves (copy) *

CPR resusci masks *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Registered Nurse, I will perform these duties to the best of my knowledge and ability. *

Registered Physical Therapist (PT)

JOB SUMMARY:

A Registered Physical Therapist (PT) administers physical therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Clinical Services/Nursing Supervisor.

QUALIFICATIONS:

Graduate from a physical therapist curriculum approved by the Commission on Accreditation in Physical Therapy Education, American Physical Therapy Association, or the Committee on Allied Health Education and Accreditation of the American Medical Association, or the Council of Medical Education of the American Medical Association and American Physical Therapy Association.
Currently licensed in the state(s) in which practicing.
Two (2) years’ experience, preferred.
Acceptance of philosophy and goals of this Agency.
Ability to exercise initiative and independent judgment.

RESPONSIBILITIES:

Understands and adheres to established policies and procedures.
Provides physician prescribed physical therapy.
Improves or minimizes residual physical disabilities of the patient.
Returns the individual to optimum and productive level within the patient’s capabilities.
Participates with all other home care personnel in patient care planning.
Directs and supervises personnel as required.
Takes initial history and makes initial evaluation.
Performs all skilled procedures as ordered by physician.
Consults with physicians regarding change in treatment.
Writes reports to physicians regarding patient’s progress.
Instructs patients and family/significant others in home programs and activities of daily living.
Participates in inservice programs and presents inservice programs as assigned.
Participates in Quality Assessment and Performance Improvement activities as assigned.
Attends all patient care conferences as scheduled.
Prepares clinical and progress notes.
Assists physician with evaluating level of function.
Helps develop the plan of care and revise as necessary.
Consults with family and Agency personnel.
Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames.
Appropriately utilizes ICD-10 codes.

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIP:

Supervised by: Director of Clinical Services/Nursing Supervisor
Workers Supervised: Physical Therapy Assistant and Home Health Aide as assigned

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.
Ability to work for extended period of time while standing and being involved in physical activity.
Heavy lifting.
Ability to do extensive bending, lifting and standing on a regular basis.

INITIAL COMPETENCY CHECKLIST

Physical Therapist

Layout

Re-eval & Treatment *

Strength *

Coordination *

Bed mobility *

W/C mobility *

Sensation *

Endurance *

Pt teaching *

Equipment *

Walker *

Hemi walker *

Platforms for walker/crutches *

Sliding board *

Free weights *

Modalities *

TENS *

Cold pack *

Back brace *

ROM/Goniometry *

Balance *

Functional mobility *

Transfers *

Gait *

Muscle tone *

Positioning *

Body mechanics *

Gait devices *

Crutches *

Straight cane *

Wheelchair *

Overhead pulley *

CPM *

Ultrasound *

Hot pack *

Splints *

Cervical collar *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Registered Physical Therapist, I will perform these duties to the best of my knowledge and ability.. *

Licensed Physical Therapy Assistant (LPTA)

JOB SUMMARY:

A Licensed Physical Therapy Assistant (LPTA) administers physical therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Registered Physical Therapist (PT).

QUALIFICATIONS:

Graduate from a two-year college level program approved by the American Physical Therapy Association.
Currently licensed, registered or certified in the state(s) in which practicing.
Two (2) years’ experience, preferred.
Acceptance of philosophy and goals of Agency.
Ability to exercise initiative and independent judgment.

RESPONSIBILITIES:

Understands and adheres to established Agency policies and procedures.
Provides physician prescribed physical therapy under a plan of care established by the PT.
Improves or minimizes residual physical disabilities of the patient.
Returns the individual to optimum and productive level within the patient’s capabilities.
Participates with all other health care personnel in patient care planning.
Performs all skilled procedures as ordered by physician and according to the plan of care established by the PT.
Consults with PT regarding change in treatment.
Instructs patients and family members in home programs and activities of daily living.
Participates in inservice programs and presents inservice programs as assigned.
Participates in QAPI activities as assigned.
Attends all patient care conferences as scheduled.
Prepares medical records, progress notes and updates care plans for each patient visit in a timely manner as per Agency policy.
Performs services planned, delegated and supervised by the PT.
Assists in preparing clinical and progress notes.
Participates in educating the patient and family.

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIP:

Supervised by: Registered Physical Therapist/Director of Clinical Services/Nursing Supervisor

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.
Ability to work for extended period of time while standing and being involved in physical activity.
Heavy lifting.
Ability to do extensive bending, lifting and standing on a regular basis.

INITIAL COMPETENCY CHECKLIST

Physical Therapy Assistant

Layout (copy)

Re-eval & Treatment *

Strength *

Coordination *

Bed mobility *

W/C mobility *

Sensation *

Endurance *

Pt teaching *

Equipment *

Walker *

Hemi walker *

Platforms for walker/crutches *

Sliding board *

Free weights *

Modalities *

TENS *

Cold pack *

AFO *

Back brace *

ROM/Goniometry *

Balance *

Functional mobility *

Transfers *

Gait *

Muscle tone *

Positioning *

Body mechanics *

Gait devices *

Crutches *

Straight cane *

Wheelchair *

Overhead pulley *

CPM *

Ultrasound *

Hot pack *

Splints *

Cervical collar *

Knee immobilizer *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Licensed Physical Therapy Assistant, I will perform these duties to the best of my knowledge and ability. *

Speech Language Pathologist (SLP)

JOB SUMMARY:

A Speech Language Pathologist (SLP) administers speech therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Clinical Services/Nursing Supervisor. Speech therapy services are furnished only by or under the supervision of a qualified speech pathologist or audiologist.

QUALIFICATIONS:

A person who has a master’s or doctoral degree in Speech Language Pathology, and is licensed as a Speech Language Pathologist by the state where they furnish services, or
A person who has successfully completed 350 clock hours of supervised clinical practicum (or be in the process of completing), at least nine months of supervised full-time SLP experience, and has successfully completed a national examination approved by the Secretary.
Currently licensed in the state(s) in which practicing.
Two (2) years’ experience, preferred.

RESPONSIBILITIES:

Improves or maximizes the communication of the patient.
Returns the individual to optimum and productive living within the patient’s capabilities.
Periodically participates with all other home care personnel in patient care planning.
Provides full range Speech Language Pathology Services as ordered by physician.
Directs and supervises personnel, as assigned.
Takes initial history and makes initial evaluation.
Performs all skilled procedures.
Consults with physicians regarding change of treatment.
Writes reports to physicians regarding patient’s progress.
Instructs patients and family members in home programs.
Periodically presents an inservice to the Agency’s staff members.
An initial evaluation, including plan of treatment and goals, must be completed and submitted to the physician for approval. A recertification by physician every 60 days is necessary if further treatment is to be continued. A progress note is written each visit. A reevaluation is written when expected duration of treatment is reached. A summary is written upon patient’s discharge.
A supervisory visit is made every fourteen days on each patient seen by a home health aide as assigned.
Assists the physician in evaluating level of function.
Helps develop the plan of care and revises as necessary.
Prepares clinical and progress notes.
Advises and consults with the family and other Agency personnel.
Participates in inservice programs.
Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames.
Appropriately utilizes ICD-10 codes.
Participates in QAPI activities as assigned.

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIP:

Supervised by: Director of Clinical Services/Nursing Supervisor
Workers Supervised: Home Health Aide as assigned

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.
Ability to work for extended period of time while standing and being involved in physical activity.
Moderate lifting.
Ability to do extensive bending, lifting and standing on a regular basis.

INITIAL COMPETENCY CHECKLIST

Speech Language Pathologist

Layout

Able to eval., recommend restorative potential and provide a therapeutic plan *

Electrolarynx *

Dysphasia *

Non-oral communication *

Voice disorders *

Esophageal speech *

Language disorders *

Articulation disorders *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Speech Language Pathologist, I will perform these duties to the best of my knowledge and ability. *

Medical Social Worker (MSW)

JOB SUMMARY:

A Medical Social Worker (MSW) provides social work services to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Clinical Services/Nursing Supervisor. Services are furnished by a qualified social worker or by a qualified social work assistant under the supervision of a qualified social worker.

QUALIFICATIONS:

A person who has a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has one year of social work experience in a health care setting, or
Has a baccalaureate degree in social work, psychology, sociology or other field related to social work, and has had at least one year of social work experience in a health care setting (functions as an assistant).
Two (2) years of appropriate experience (for assistant).
One (1) year experience in home care, preferred.
Acceptance of philosophy and goals of Agency.
Ability to exercise initiative and independent judgment.
Ability to work with individuals to enlist cooperation of many people to perform/achieve a common goal.

RESPONSIBILITIES:

Understands and adheres to established Agency policies/procedures.
Understands and promotes principles of QAPI.
Acts as a consultant to other Agency personnel.
Participates in the coordination of Agency’s services with the services of other community resources; uses community resources.
Observes confidentiality and safeguards all patient information.
Serves as a resource person to employees, patients, physicians and other allied healthcare providers.
Develops a cooperative relationship and communicates effectively and professionally with physicians.
Accepts responsibility for regular attendance and punctuality.
Maintains current knowledge of Medicare Conditions of Participation for social work services.
Immediately reports any accident, incident, lost articles or unusual occurrence to Director of Clinical Services/Nursing Supervisor.
Participates in inservices and/or continuing education programs.
Participates in patient care conferences.
Maintains contact with community support groups and provides professional expertise as required.
Plans/coordinates all social services within the Agency.
Documents all patient/family services provided as required by Agency policy.
Assists physician and other team members in understanding the significant social and emotional factors related to health problems.
Participates in the development of the plan of care.
Prepares clinical and progress notes.
Works with the family.
Participates in discharge planning.
Other duties assigned by Director of Clinical Services/Nursing Supervisor (or Social Worker, if Social Work Assistant).

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIPS:

Supervised by:

Director of Clinical Services/Nursing Supervisor

If Social Work Assistant: Social Worker

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity and to do bending, lifting and/or standing on a regular basis.
Light lifting may be required.
Ability to work for extended period of time while sitting or standing.

INITIAL COMPETENCY CHECKLIST

Medical Social Worker

Layout

Provide skilled assess of social and emotional factors *

Eval home/family situation *

Promote community services andprovide education *

Counsel andassist with financial problems and entitlements *

Assist with strengthening the family support system *

Identify andadvocate for patients at risk for physical or mental abuse and/or neglect *

Identify andeval patients with inadequate food, medications and/or medical supplies *

Provide assess of pt’s need for long-term care *

Counsel andassist with out-of-home placement *

Provide advocacy, referral andlinkage with community services *

Provide goal-oriented intervention directed toward management of a terminal illness *

Assist with resolution of conflict related to illness *

Identify andeval patients at high risk for suicide *

Develop care plan according to patient needs andphysician orders *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Medical Social Worker, I will perform these duties to the best of my knowledge and ability. *

Medical Social Worker Assistant

JOB SUMMARY:

A Medical Social Worker Assistant provides social work services to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Clinical Services/Nursing Supervisor. Services are furnished by a qualified social worker or by a qualified social work assistant under the supervision of a qualified social worker.

QUALIFICATIONS:

A person who has a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has one year of social work experience in a health care setting, or
Has a baccalaureate degree in social work, psychology, sociology or other field related to social work, and has had at least one year of social work experience in a health care setting (functions as an assistant).
Two (2) years of appropriate experience (for assistant).
One (1) year experience in home care, preferred.
Acceptance of philosophy and goals of Agency.
Ability to exercise initiative and independent judgment.
Ability to work with individuals to enlist cooperation of many people to perform/achieve a common goal.

RESPONSIBILITIES:

Understands and adheres to established Agency policies/procedures.
Understands and promotes principles of QAPI.
Acts as a consultant to other Agency personnel.
Participates in the coordination of Agency’s services with the services of other community resources; uses community resources.
Observes confidentiality and safeguards all patient information.
Serves as a resource person to employees, patients, physicians and other allied healthcare providers.
Develops a cooperative relationship and communicates effectively and professionally with physicians.
Accepts responsibility for regular attendance and punctuality.
Maintains current knowledge of Medicare Conditions of Participation for social work services.
Immediately reports any accident, incident, lost articles or unusual occurrence to Director of Clinical Services/Nursing Supervisor.
Participates in inservices and/or continuing education programs.
Participates in patient care conferences.
Maintains contact with community support groups and provides professional expertise as required.
Plans/coordinates all social services within the Agency.
Documents all patient/family services provided as required by Agency policy.
Assists physician and other team members in understanding the significant social and emotional factors related to health problems.
Participates in the development of the plan of care.
Prepares clinical and progress notes.
Works with the family.
Participates in discharge planning.
Other duties assigned by Director of Clinical Services/Nursing Supervisor (or Social Worker, if Social Work Assistant).

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIPS:

Supervised by:

Director of Clinical Services/Nursing Supervisor

If Social Work Assistant: Social Worker

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity and to do bending, lifting and/or standing on a regular basis.
Light lifting may be required.
Ability to work for extended period of time while sitting or standing.

INITIAL COMPETENCY CHECKLIST

Medical Social Work Assistant

Layout

Provide skilled assess of social andemotional factors *

Eval home/family situation *

Promote community services andprovide education *

Counsel andassist with financial problems and entitlements *

Assist with strengthening the family support system *

Identify andadvocate for patients at risk for physical or mental abuse and/or neglect *

Identify andeval patients with inadequate food, medications and/or medical supplies *

Provide assess of pt’s need for long-term care *

Counsel andassist with out-of-home placement *

Provide advocacy, referral andlinkage with community services *

Provide goal-oriented intervention directed toward management of a terminal illness *

Assist with resolution of conflict related to illness *

Identify andeval patients at high risk for suicide *

Develop care plan according to patient needs andphysician orders *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Medical Social Worker Assistant, I will perform these duties to the best of my knowledge and ability

Occupational Therapist (OT)

JOB SUMMARY:

An Occupational Therapist (OT) administers occupational therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Clinical Services/Nursing Supervisor.

QUALIFICATIONS:

Graduate of an Occupational Therapy curriculum accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Occupational Therapy Association (AOTA) and/or certified by successfully completing the National Certification examination, or
Is eligible for the National Registration Examination of the American Occupational Therapy Association.
Currently licensed in the state(s) in which practicing, unless licensure does not apply.
Two (2) years’ experience, preferred.

RESPONSIBILITIES:

Improves or minimizes residual physical disabilities of the patient.
Returns the individual to optimum and productive living within the patient’s capabilities.
Periodically participates with all other home care personnel in patient care planning.
Provides prescribed occupational therapy.
Directs and supervises personnel as required.
Takes initial history and makes initial evaluation.
Performs all skilled procedures.
Consults with physicians regarding change in treatment.
Writes reports to physicians regarding patient’s progress.
Instructs patients/family members in home programs and fine motor movement exercises.
An initial evaluation, including plan of care and goals, must be completed and submitted to the physician for approval. A recertification by physician every 60 days is necessary, if further treatment is to be continued. A progress note is written each visit. A reevaluation is written when expected duration of treatment is reached. A summary is written upon patient’s discharge.
Periodically presents an inservice to the Agency staff.
Assists the physician in evaluating level of function.
Helps develop the plan of care and revises as necessary.
Prepares clinical and progress notes.
Advises and consults with the family and other Agency personnel.
Participates in inservice programs.
Participates in QAPI activities as assigned.

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIP:

Supervised by: Director of Clinical Services/Nursing Supervisor
Workers Supervised: Certified Occupational Therapy Assistant and Home Health

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.
Ability to work for extended period of time while standing and being involved in physical activity.
Moderate lifting.
Ability to do extensive bending, lifting and standing on a regular basis.

INITIAL COMPETENCY CHECKLIST

Occupational Therapist

Layout

Eval andperform active andpassive ROM *

Eval andtrain ADLs/IADLs *

Eval andtrain home management tasks *

Eval andrecommend home modifications *

Eval andtrain functional mobility *

Eval, train and/or fabricate adaptive equipment *

Eval andperform muscle strengthening activities *

Eval andtrain self care *

Eval andtrain leisure activities *

Eval, recommend and/or fabricate UE orthotics/splints *

Eval andtrain cognitive skill related to ADLs/IADLs *

Demonstrates ability to perform standard eval (e.g., dynamometer, pinch gauge, goniometer *

I have read the above job description and fully understand the conditions set forth therein, and if employed as an Occupational Therapist, I will perform these duties to the best of my knowledge and ability. *

Certified Occupational Therapy Assistant (COTA)

JOB SUMMARY:

A Certified Occupational Therapy Assistant (COTA) administers occupational therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Occupational Therapist and Director of Clinical Services/Nursing Supervisor.

QUALIFICATIONS:

A person who is a graduate and meets the requirements for certification as an Occupational Therapy Assistant from a program accredited by the Accreditation Council for Occupational Therapy Education of the American Occupational Therapy Association (AOTO).
Certification is maintained by the National Board for Certification in Occupational Therapy, Inc.
Currently certified in the state(s) in which practicing.
Is licensed or otherwise regulated, if applicable, as an Occupational Therapy Assistant by the State in which practicing, unless licensure does not apply.
Two (2) years’ experience, preferred.

RESPONSIBILITIES:

Understands and adheres to established Agency policies and procedures.
Improves or minimizes residual physical disabilities of the patient.
Returns the individual to optimum and productive level within the patient’s capabilities.
Participates with all other home care personnel in patient care planning.
Performs all skilled procedures as ordered by physician and according to the plan of care established by the OT.
Consults with OT regarding change in treatment.
Instructs patients and family members in home programs and fine motor movement exercises.
Participates in in-service education and presents inservice programs as assigned.
Participates in QAPI activities as assigned.
Attends all patient care conferences as scheduled.
Prepares medical records and updates care plans for each patient visit in a timely manner as per Agency policy.
Performs services planned, delegated and supervised by the OT.
Assists in preparing clinical and progress notes.
Participates in educating the patient and family.

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIP:

Supervised by: OT/Director of Clinical Services/Nursing Supervisor

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.
Ability to work for extended period of time while standing and being involved in physical activity.
Moderate lifting.
Ability to do extensive bending, lifting and standing on a regular basis.

INITIAL COMPETENCY CHECKLIST

Occupational Therapy Assistant

Layout

Re-eval andperform active and passive ROM *

Re-eval andtrain ADLs/IADLs *

Re-eval andtrain home management tasks *

Re-eval andrecommend home modifications *

Re-eval andtrain functional mobility *

Re-eval, train and/or fabricate adaptive equipment *

Re-eval andperform muscle strengthening activities *

Re-eval andtrain self care *

Re-eval andtrain leisure activities *

Re-eval, recommend and/or fabricate UE orthotics/splints *

Re-eval andtrain cognitive skill related to ADLs/IADLs *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Certified Occupational Therapy Assistant, I will perform these duties to the best of my knowledge and ability. *

Home Health Aide (HHA)

JOB SUMMARY:

A paraprofessional person who is specifically trained, competent and performs assigned functions of personal care to the patient in their residence under the direction, instruction and supervision of the registered nurse (RN).

QUALIFICATIONS:

Must meet Medicare Conditions of Participation for Home Health Aide training program and competency.
Have a sympathetic attitude toward the care of the sick and elderly.
Ability to carry out directions, read and write.
Maturity and ability to deal effectively with the demands of the job.

RESPONSIBILITIES:

Understands and adheres to established Agency policies and procedures.
Performs personal care, bath and hands-on care as assigned.
Completes appropriate visit records in a timely manner as per Agency policy.
Reports changes in the patient’s condition and needs to the RN.
Performs household services essential to health care in the home as assigned.
Ambulates and exercises the patient as assigned.
Performs simple procedures as an extension of the therapy or nursing services, e.g., range of motion (ROM) exercises as assigned.
Assists with medications that are ordinarily self-administered as assigned.
Attends inservice and continuing education programs as scheduled and necessary.
Attends patient care conferences as scheduled.

WORKING ENVIRONMENT:

Works indoors in Agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIPS:

Supervised by: Director of Clinical Services/Nursing Supervisor/RNs, PTs, OTs, SLPs

RISK EXPOSURE:

High risk

LIFTING REQUIREMENTS:

Ability to perform the following tasks if necessary:

Ability to participate in physical activity.
Ability to work for extended period of time while standing and being involved in physical activity.
Heavy lifting.
Ability to do extensive bending, lifting and standing on a regular basis.

INITIAL ON-SITE COMPETENCY CHECKLIST

Home Health Aide

Layout

T, P, R, BP: reading and recording *

Sponge, tub and shower bath *

Oral hygiene *

Normal range of motion and positioning *

Ambulation *

Reporting change in patient condition *

Complying with infection prevention and control policies and procedures *

Documenting pt status and care furnished *

Elements of body function and changes to report to supervisor *

Physical, emotional and developmental needs and ways to work with patients *

Respect for patient privacy *

Bed Bath *

Shampoo; sink, tub and bed *

Toileting and elimination *

Safe transfer techniques *

Fluid intake and adequate nutrition *

Maintaining open communication process with patient/caregiver *

Following patient’s plan of care for completion of assigned tasks *

Maintenance of clean, safe and healthy environment *

Recognition of emergencies and knowledge of emergency procedures *

Honoring patient rights *

Respect for patient property *

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Home Health Aide, I will perform these duties to the best of my knowledge and ability. *

Name *

First

Middle

Last

Address *

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State *

Zip Code *

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Phone *

Select one if your all answer is same

Are you 18 years old? *

Do you have access to public transportation? *

Have you been convicted of a felony crime? *

NIC/Social Security *

Do you have access to a car? *

Do you have a driver’s license? *

If yes, please explain: *

What are your preferred working hours & days?

How did you hear about our agency?

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Education

Name

Address-City, State

Graduated?

Degree or Major

High School

Name Of High School

Address Of High School

Graduated from High School?

Degree or Major

College

Name Of Collage *

Address Of Collage *

Graduated from Collage? *

Degree or Major *

Other

Other

What languages do you speak?

Previous Employment. Please list at least three employers.

Employment

Name of Company: *

Supervisor:

Salary:

Start Date:

Ph:

Why did you leave?

End Date:

Position:

Employment

Name of Company:

Supervisor:

Salary:

Start Date:

Phone:

Why did you leave?

End Date:

Position:

Employment

Name of Company:

Supervisor:

Salary:

Start Date:

Phone:

Why did you leave?

End Date:

Position:

Reference Check

Please do not include your relatives as references

Reference Check

Name *

Relation

Phone: *

Reference Check

Name *

Relation

Phone: *

Reference Check

Name *

Relation

Phone: *

BACKGROUND CHECK CONSENT FORM *

I Agree

As a prospective employee of the Agency, I understand that it is the Agency’s policy to secure conviction criminal history information as part of their pre-employment screening process. I authorize the Agency to use the information for the sole purpose of obtaining a conviction only Criminal History File Search.

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Date Of Birth *

HAIR COLOR *

PLACE OF BIRTH *

RACE *

EYE COLOUR *

DRIVERS LICENSE NUMBER *

SEX *

WEIGHT *

Read instructions carefully before completing this form. The instructions must be available during completion of this form

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)

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Name *

First

Last

Maiden Name

Address (Street Name and Number) *

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City

D.O.B *

State

Social Security/NIC *

Zip Code

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):

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A citizen of the United States

A lawful permanent resident (Alien #)

(Alien #)

A noncitizen national of the United States (see instructions)

An alien authorized to work (Alien # or Admission #)

(Alien # or Admission #)

Preparer and/or Translator Certification:

(To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

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Print Name

Address (Street Name and Number, City, State, Zip Code

Date (month/day/year)

Preparer's/Translator's Signature

Section 2. Employer Review and Verification

(To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and expiration date, if any, of the document(s).)

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List A OR

Document title:

Issuing authority:

Document #:

Expiration Date (if any):

Document #:

Expiration Date (if any):

List B

Document title:

Issuing authority:

Document #:

Expiration Date (if any):

And List C

Document title:

Issuing authority:

Document #:

Expiration Date (if any):

CERTIFICATION: Under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee is authorized to work in the United States to the best of my knowledge, and that the date the employee began employment is on month/day/year. (State employment agencies may omit the date the employee began employment.) *

I Attest

Date the employee began employment is on month/day/year

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Print Name

Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

Signature of Employer or Authorized Representative *

Title

Date (month/day/year)

Section 3. Updating and Reverification

(To be completed and signed by employer.)

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A. New Name (if applicable)

B. Date of Rehire (month/day/year) (if applicable

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.

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Document Title:

Document #:

Expiration Date (if any):

l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

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Signature of Employer or Authorized Representative

Date (month/day/year)

LISTS OF ACCEPTABLE DOCUMENTS

All documents must be unexpired

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List A OR

Documents that Establish Both
Identity and Employment
Authorization

U.S. Passport or U.S. Passport Card
Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine readable immigrant visa
Employment Authorization Document that contains a photograph (Form I-766)
In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations
identified on the form
Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

List B

Documents that Establish
Identity

Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
School ID card with a photograph
Voter's registration card
U.S. Military card or draft record
Military dependent's ID card
U.S. Coast Guard Merchant Mariner Card
Native American tribal document
Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

AND List C

Documents that Establish
Employment Authorization

Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States
Certification of Birth Abroad issued by the Department of State (Form FS-545)
Certification of Report of Birth issued by the Department of State (Form DS-1350)
Original or certified copy of birth certificate issued by a State, county, municipal authority, or
territory of the United States bearing an official seal
Native American tribal document
U.S. Citizen ID Card (Form I-197)
Identification Card for Use of Resident Citizen in the United States (Form I-179)
Employment authorization document issued by the Department of Homeland Security

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) ▶ 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.
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)

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

6 . City, state, and ZIP code

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

Part I Taxpayer Identification Number (TIN)

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Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter

Social security number

Or

Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

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
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
I am a U.S. citizen or other U.S. person (defined below); and
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.

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Signature of U.S. person

Date:

Employee’s Withholding Certificate

Complete Form W4 so that your employer can withhold the correct federal income tax from yourpay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.

Step 1: Enter Personal Information

(A) . Name *

First

Middle

Last

Address

City or town, state, and ZIP code

(B) . Social security number

Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

Single or Married filing separately
Married filing jointly or Qualifying surviving spouse
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, other details, and privacy.

Step 2:
Multiple Jobs or Spouse Work

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

Reserved for future use.
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. Thisoption is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate

TIP: If you have self-employment income, see page 2

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:
Claim Dependent and Other Credits

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000

Multiply the number of other dependents by $500

Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here

Step 4
(optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here

Step 5:
Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete. *

Employee’s signature (This form is not valid unless you sign it.)

Employers Only

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Employer’s name and address

First date of employment

Employer identification number (EIN)

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TB Symptom Screening

Have you had any of the following symptoms within the past year?

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Chills *

Unexplained weight loss *

Loss of appetite *

Fever *

Lasts more than 3 or more weeks *

Night Sweats *

Cough *

Fatigue *

Hemoptysis *

Pain with breathing or coughing *

EMPLOYEE TB SCREENING ACKNOWLEDGMENT

Acknowledged

TUBERCULOSIS DISEASE: Tuberculosis (TB) Infection is transmitted from person to person by airborne infectious particles called droplet nuclei. Chronic lung infection is the most common clinical presentation of TB.
TUBERCULIN SKIN TEST: The Tuberculin Purified Protein Derivative (PPD) skin test is used to screen and identify apparently well individuals infected with M. Tuberculosis. The PPD. test will be used for TB skin test screening and is performed by the Intra-dermal injection of 0.1 ML of Tuberculin PPD into the skin of the flexor surface of the forearm.
INTERPRETATION OF THE TEST: The test should be read 48 to 72 hours after administration. Sensitivity is indicated by indurations usually accompanied by erythemia. Any palpable indurations of 10mm or more is considered a positive reaction. Health care workers who test negative and who cannot document a history of a negative tuberculin skin test within the past year should have a second skin test within 1-3 weeks to establish a true baseline skin test. I have been informed that CDC guidelines require mandatory screening for possible tuberculosis. I agree to the use of the Tuberculin PPD skin test. I have been informed of the possible side effects.If I have a positive reaction to testing or have had previous positive test results, I agree to obtain chest X-rays if requested. I agree to seek medical attention from my attending physician or other health care provider should it be requested by the Director of Clinical Services. If treatment is requested, this treatment is mandatory, and proof of treatment must be provided to the Director of Clinical Services. If treatment is refused, employment may be terminated

HEPATITIS B VACCINE
REQUEST/REFUSAL FORM

I have received instruction concerning the risk of exposure to Hepatitis B as a health care worker. I have also been instructed in Universal Precautions and other safety measures that will prevent contracting this virus

I understand that although there are risks associated with the Hepatitis B Vaccine, it does reduce the risk of serious disease should exposure to the Hepatitis B Virus occur.

Request for Hepatitis B Vaccine *

I hereby elect to receive the Hepatitis B Vaccine series

Refusal of Hepatitis B Vaccine *

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B Vaccine, I can receive the vaccination series at no charge to me.

Previous Hepatitis B Vaccination. I will obtain the records of previous vaccination. *

Please answer the following questions:

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1st Dose

Are you allergic to yeast?

Are you pregnant or nursing?

2nd Dose

Have you had Hepatitis B?

Do you currently have a fever?

EMPLOYEE COVID-19 SCREENING ACKNOWLEDGMENT

EMPLOYEE COVID-19 SCREENING ACKNOWLEDGMENT *

Acknowledged

COVID-19: Coronavirus Disease 2019 (COVID-19) is caused by the SARS-CoV-2 virus and is primarily spread through respiratory droplets when an infected person talks, coughs, or sneezes. The most common symptoms of COVID-19 include fever, coughing, and shortness of breath.
COVID-19 SCREENING: To help ensure the safety of our workplace, all employees are required to undergo COVID-19 screening. This may include taking a COVID-19 test and completing a health questionnaire. The test may involve a nasal swab or a saliva sample, and the results will be used to determine if you are infected with the virus.
INTERPRETATION OF THE TEST: If you test positive for COVID-19 or have symptoms of the disease, you will be required to self-isolate and seek medical attention from your attending physician or other healthcare provider. If you have been exposed to someone with COVID-19, you may also be required to self-isolate and get tested for the virus.
I have been informed that the guidelines and protocols related to COVID-19 may change over time, and I agree to comply with all current and future guidelines and protocols. I understand that failure to comply with these guidelines may result in disciplinary action or the termination of my employment.
I agree to undergo COVID-19 screening and to notify my employer immediately if I test positive for COVID-19 or have symptoms of the disease. I also agree to follow all workplace protocols related to COVID-19, including wearing a mask, practicing social distancing, and practicing good hand hygiene.

COVID-19 Symptom Screening

Have you had any of the following symptoms within the past few days?

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Fever

Shortness of breath or difficulty breathing

Muscle or body aches

Loss of taste or smell

Congestion or runny nose

Diarrhea

Cough

Fatigue

Headache

Sore throat

Nausea or vomiting

EMPLOYEE INFLUENZA SCREENING ACKNOWLEDGMENT

EMPLOYEE INFLUENZA SCREENING ACKNOWLEDGMENT *

Acknowledged

INFLUENZA DISEASE: Influenza (flu) is a contagious respiratory illness caused by influenza viruses. It spreads through respiratory droplets when an infected person coughs, sneezes, or talks, and can cause mild to severe illness.
INFLUENZA VACCINATION: The influenza vaccine is used to prevent the flu and is recommended for all employees to reduce the risk of transmission to others. Vaccinations will be provided to all employees, and they are mandatory for those who work in patient care areas.
INTERPRETATION OF THE VACCINATION: The vaccine will be administered by injection into the upper arm. Common side effects include soreness, redness, and swelling at the injection site, as well as fever, headache, and muscle aches. These side effects are generally mild and go away on their own in a few days.
I have been informed that CDC guidelines recommend influenza vaccination for all employees, especially those who work in patient care areas. I agree to receive the influenza vaccine and understand that failure to comply may result in disciplinary action, up to and including termination.
If I have a medical condition or allergy that prevents me from receiving the influenza vaccine, I agree to provide documentation from my healthcare provider. I understand that if I am unable to receive the influenza vaccine, I will be required to wear a mask while working in patient care areas during flu season.
I agree to seek medical attention from my attending physician or other health care provider should it be requested by the Director of Clinical Services. If I have flu-like symptoms, I agree to stay home and not come to work until I am symptom-free for at least 24 hours.

Influenza Symptoms Screening

Have you had any of the following symptoms within the past few days?

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Fever

Sore throat

Body or muscle aches

Fatigue

Nausea, vomiting, or diarrhea

Cough

Runny or stuffy nose

Headache

Chills

Chest discomfort or shortness of breath

CONFIDENTIALITY *

I have read and understand Romeos Staffing Agency confidentiality policy.

PURPOSE: To state rules and regulations regarding the disclosure of client information. POLICY: Clinical records and client information are held in strict confidence by agency personnel. PROCEDURE: The Confidentiality Policy will be reviewed by agency personnel during the orientation process. A confidentiality statement will be signed and returned to the Director of Clinical Services prior to patient assignment. The signed confidentiality statement will be a part of the personnel file. Access to client information will be limited to those involved in the care/service or supervision of clients. Clients will not be discussed by clinical or non-clinical personnel outside of the clinical setting. Written consent will be required for release of any client record. The release must be signed by the client and/or his/her representative

Employee Status and Agreement to Arbitrate *

Acknowledged

I acknowledge and agree that as a condition of my employment by or continued employment with Romeos Staffing Agency. A Michigan corporation, (Employer)
Notwithstanding anything that may be contained to the contrary in any Employee Handbook or other material provided by Employer, my employment is of an at-will nature and it can be terminated by Employer or by me at any time for any or no reason
Any employment related claim or dispute shall be submitted to arbitration Association and the Circuit Court for the County of Oakland, State of Michigan will have jurisdiction to enforce this arbitration agreement and to render and enforce judgment on any arbitration award. A non-exclusive list of employment related claims that must be submitted to arbitration include breach of contract, wrongful termination, wrongful discharge, retaliatory discharge, violation of public policy and discrimination of any kind.

PRIVACY TRAINING FOR STAFF *

Acknowledged

Policy: The agency provides privacy training for all current and new employees who have contact with protected health information.
Procedure: All current members of the agency’s work force received training regarding the requirements of the HIPAA Privacy Rule prior to August 29, 2008. All new employees receive privacy training as a component of their orientation to the agency. All members of the agency’s workforce receive retraining if policies and procedures change and as necessary. All privacy training provided to members of the workforce is documented and maintained in personnel records. Documentation of privacy training is maintained by the Privacy Official according to the requirements of the Privacy Rule.

Privacy Training Content Outline *

Acknowledged

I. What is HIPAA? Background and History Administrative Simplification Transactions Rule Privacy Rule Security Rule
II. What is Protected Health Information? Any information about a patient’s physical or mental health condition that could identify the patient
III.What the Privacy Rule will mean for home care programs Required to comply – not voluntary Notice of Privacy Practices Privacy Official Authorization forms Business Associates Additional patient rights Privacy Policies and Procedures Minimum necessary uses and disclosures of and requests for protected health information Responsibility to protect patient health information
IV.What the Privacy Rule will mean for patients Increased control over the uses and disclosures of their health information The opportunity for more understanding of how their health information is used and to who it i disclosed Specific rights regarding their health information including: The right to a paper copy of the agency’s Notice of Privacy Practices The right to lodge complaints The right to request restrictions on the uses and disclosures of health information The right to receive confidential communication The right of access to their health information The right to amend health care information The right to request an accounting of disclosures of health information

CONFLICT OF INTEREST DISCLOSURE FORM

I have reviewed the Conflict-of-Interest Policy of Romeos Staffing Agency and understand its Contents. I have no current or potential associations, relationships, or circumstances, that Conflict with this organization. (You may list any situations of which you are uncertain). *

I Agree

EMPLOYEE HANDBOOK ACKNOWLEDGMENT *

Acknowledged

Welcome to Romeos Staffing Agency. We hope that you will have a long and productive relationship with our company. To help with this, we are providing you with your own copy of our employee handbook. The information in it will acquaint you with company policies and will answer many of our questions. The Orientation representative is responsible for explaining the content of the handbook. Please keep in mind that this handbook does not contain all the information you will need as an employee. You will receive other information through written notices as well as orally.
When company changes a policy, it overrides the past policy. This handbook is not an employment contract.

Upload your scan files here CNIC/Social Security Number and Educational Documents

Click or drag files to this area to upload. You can upload up to 5 files.

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Name *

Signature *

Date: *

Employment Application Form

JOB TITLE

Registered Nurse (RN)

INITIAL COMPETENCY CHECKLIST RN/LPN/LVN

Registered Physical Therapist (PT)

INITIAL COMPETENCY CHECKLIST

Physical Therapist

Licensed Physical Therapy Assistant (LPTA)

INITIAL COMPETENCY CHECKLIST

Physical Therapy Assistant

Speech Language Pathologist (SLP)

INITIAL COMPETENCY CHECKLIST

Speech Language Pathologist

Medical Social Worker (MSW)

INITIAL COMPETENCY CHECKLIST

Medical Social Worker

Medical Social Worker Assistant

INITIAL COMPETENCY CHECKLIST

Medical Social Work Assistant

Occupational Therapist (OT)

INITIAL COMPETENCY CHECKLIST

Occupational Therapist

Certified Occupational Therapy Assistant (COTA)

INITIAL COMPETENCY CHECKLIST

Occupational Therapy Assistant

Home Health Aide (HHA)

INITIAL ON-SITE COMPETENCY CHECKLIST

Home Health Aide

Previous Employment. Please list at least three employers.

Reference Check

Read instructions carefully before completing this form. The instructions must be available during completion of this form

Preparer and/or Translator Certification:

Section 2. Employer Review and Verification

List A OR

List B

And List C

Section 3. Updating and Reverification

LISTS OF ACCEPTABLE DOCUMENTS

List A OR

List B

AND List C

Request for Taxpayer Identification Number and Certification

Part I Taxpayer Identification Number (TIN)

Or

Part II Certification

Employee’s Withholding Certificate

Step 2: Multiple Jobs or Spouse Work

Step 3: Claim Dependent and Other Credits

Step 4 (optional): Other Adjustments

Step 5: Sign Here

Employers Only

TB Symptom Screening

EMPLOYEE TB SCREENING ACKNOWLEDGMENT

HEPATITIS B VACCINE REQUEST/REFUSAL FORM

EMPLOYEE COVID-19 SCREENING ACKNOWLEDGMENT

COVID-19 Symptom Screening

EMPLOYEE INFLUENZA SCREENING ACKNOWLEDGMENT

Influenza Symptoms Screening

CONFLICT OF INTEREST DISCLOSURE FORM

Healthcare Services:

Our Services:

Head Office

31300 Rexwood St, Ste A1 Farmington Hills MI 48334

Pakistan Office

Model Colony, Karachi, Pakistan

Contact@scribing.romeostaffing.com

Open Hours:

Request for Taxpayer
Identification Number and Certification

Step 2:
Multiple Jobs or Spouse Work

Step 3:
Claim Dependent and Other Credits

Step 4
(optional): Other Adjustments

Step 5:
Sign Here

HEPATITIS B VACCINE
REQUEST/REFUSAL FORM

31300 Rexwood St, Ste A1
Farmington Hills MI 48334

Model Colony,
Karachi, Pakistan