HOME HEALTH AIDE APPLICATION

- Step 1 of 24

EMPOWERED COMMUNITY LIVING LLC

Employment Application

Applicant Information

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Last Name

First Name

M.l

Date

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Address

Apartment/Unit

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City

State

ZIP Code

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Phone

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Date Available:

Social Security No:

Desired Salary:

Position Applied for:

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Are you a citizen of the United States?

If no, are you authorized to work in the U.S.?

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Have you ever worked for this company?

Have you ever been convicted of a felony?

If yes, when?

If yes, explain:

Education

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High School:

Address:

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From

Did you graduate?

Diploma:

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College:

Address:

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From:

To:

Did you graduate?

Degree:

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Other:

Address

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From:

To:

Did you graduate?

Degree:

References

Please list three professional references.

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Full Name:

Company:

Relationship:

Phone:

Address:

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Full Name:

Company:

Relationship:

Phone:

Address:

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Full Name:

Company:

Relationship:

Phone:

Address:

Previous Employment

Please list three professional references.

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Company Name:

Address:

Phone:

Supervisor:

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Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

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Form:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

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Company Name:

Address:

Phone:

Supervisor:

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Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

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Form:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

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Address:

Company:

Phone:

Supervisor:

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Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

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Form:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Military Service

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Branch:

From:

To:

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Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

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Signature

Date:

APPLICATION FOR REGISTRATION

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Date:

Category:

Name:

Physical Address:

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City:

Phone Number:

Date of Birth:

ZIP:

Second Phone Number:

SSN:

Educational Background: High School College Other Name and location of School for Aide Training Program or College:

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Date education was completed:

Diploma:

Certificate:

Degree:

Employment History. List most recent first:

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Name of Company:

Name of Company 2:

Name of Company 3:

Name of Company 4:

Date:

Date 2:

Date 3:

Date 4:

Position:

Position 2:

Position 3:

Position 4:

Credentials:

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License:

Certificate:

Number:

Exp Date:

I attest that to the best of my knowledge the above information is true.

Signature

PROVIDER APPLICANT REFERENCE FORM

The applicant below has applied to become a Medicaid Waiver Provider. Your cooperation in completing this reference will greatly assist the Agency for Persons with Disabilities (APD) in determining if the applicant meets the minimum qualifications to become a Waiver Provider.

INSTRUCTIONS:

Please type or print legibly.
Applicants must have references from two (2) supervisors or co-workers who are familiar with their work in a Developmental Disability setting.
APPLICANT - Complete Part I, provide this form to your references with a return self-addressed envelope. Provide the completed form from your reference with your application materials.
REFERCTCE - Complete Part II and return this farm to the applicant in the envelope provided to you.

PART I - APPLICANT

Name:

PART II - REFERENCE

REFERENCE NAME:

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ADDRESS

CITY

STATE

ZIP

Phone

OTHER CONTACT INFORMATION:

RELATIONSHIP TO APPLICANT:

SUPERVISOR
CO-WORKER

DATES OF RELATIONSHIP:

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FROM:

TO:

PROFESSIONAL POSITION WHEN WORKING WITH APPLICANT:

Title:

Agency / Institution:

Address:

RECOMMENDATION:

Recommend
Do Not Recommend the Applicant for Enrollment

ADDITIONAL COMMENTS:

[Please write any comments that would assist the APO Enrollment Liaison in making a decision on this Applicant for enrollment.]

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Reference Signature

Date

PROVIDER APPLICANT REFERENCE FORM

INSTRUCTIONS:

Please type or print legibly.
Applicants must have references from two (2) supervisors or co-workers who are familiar with their work in a Developmental Disability setting.
APPLICANT - Complete Part I, provide this form to your references with a return self-addressed envelope. Provide the completed form from your reference with your application materials.
REFERCTCE - Complete Part II and return this farm to the applicant in the envelope provided to you.

PART I - APPLICANT

Name

PART II - REFERENCE

REFERENCE NAME:

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ADDRESS

CITY

STATE

ZIP

OTHER CONTACT INFORMATION:

RELATIONSHIP TO APPLICANT:

SUPERVISOR
CO-WORKER

DATES OF RELATIONSHIP:

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FROM:

TO:

PROFESSIONAL POSITION WHEN WORKING WITH APPLICANT:

Title:

Agency / Institution:

Address:

RECOMMENDATION:

Recommend
Do Not Recommend the Applicant for Enrollment

ADDITIONAL COMMENTS:

[Please write any comments that would assist the APO Enrollment Liaison in making a decision on this Applicant for enrollment.]

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Reference Signature

Date

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ATTESTATION OF COMPLIANCE with Background Screening Requirements

Employee/Contractor Name:

Health Care Provider/ Employer Name:

Address of Health Care Provider:

You must attest to meeting for employment and you may not have been arrested for and awaiting final disposition of, have been found guilty of, regardless of adjudication, or have adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under any of the following provisions of state law or similar law of another jurisdiction:
Criminal offenses found In section 435.04 P.S

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(b) Section 3ff4-4$93. relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.
(c) Section 4J §. 111, relating to adult abuse, neglect, jr exploitation of aged persons or disabled adults.
(d) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
(e) Section 782.04. relating to murder.

(g) Section 7.62-071. relating to vehicular homicide.
(h) Section ZB^OS. relating to killing of an unoom child by injury to the mother.
(i) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.
(j) Section 7SL.011, relating to assault, if the victim of the offense was a minor.
(k) Section 784,03. relating to battery, if the victim of the offense was a minor.
(I) Section 787.01. relating to kidnapping.

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(m) Section 797 Q2. relating to false imprisonment.
(n) Section ZS7.025, relating to luring or enticing a child.
(o) Section Z2LQ4(2), relating to taking, enticing or removing a child beyond the state limits with criminal intent pending custody proceedings.
(p) Section 787.04(3), relating to carrying a child beyond the state lines with cnminal intent to avoid producing a child at a custody heanng or delivering the child to the designated person.
(q) Section 790,115(1), relating to exhibiting firearms < weapons within 1,000 feet of a school. (r) Section 790115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.
(s) Section rn.O11, relating to sexual battery. (t) Former s.794,041. relating to prohibited acts of persons in familial or custodial authority.
(u) Section Z94-Q5, relating to unlawful sexual activity with certain minors.
(v) Chapter 796, relating to prostitution.
(w) Section Z98.02, relating to lewd and lascivious behavior.
(x) Chapter 800, relating to lewdness and indecent exposure.
(У) Section §06.01, relating to arson.
(z) Section 81Q.02. relating to burglary.
(aa) Section 810.14, relating to voyeurism, if the offense is a felony.
(bb) Section §.“10.14$. relating to video voyeurism, if the offense is a felony.
(cc) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.
(dd) Section §1_7.$83, relating to fraudulent sale of controlled substances, only if the offense was a felony.
(ее) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult
(ff) Section §25.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.
(gg) Section 825.103. relating to exploitation of an elderly person or disabled adult, if the offense was a felony.

(hh) Section 826.04. relating to incest.
(ii) Section 827-03, relating to child abuse,
aggravated child abuse, or neglect of a child (jj) Section 827-Q4, relating to contributing to the delinquency or dependency of a child.
(Kk) Former s. S27.Q$. relating to negligent treatment of children.
(ll) Seetion 827-071. relating to sexual performance by a child.
(mm) Section 843.01, relating to resisting arrest with violence.
(nn) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.
(oo) Section 843.12, relating to aiding in an escape.
(pp) Section £43.13, relating to aiding in the escape of juvenile inmates in correctional institutions.
(qq) Chapter 847, relating to obscene literature.
(rr) Section £74-05(1), relating to encouraging or recruitinq another to join a criminal gang.
(ss) Chapter 893, relating to drug abuse prevention and control only if the offense was a felony or if any other person involved in the offense was a minor.
(tt) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.
(uu) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.
(VV) Section 944.40. relating to escape.
(ww) Section 944.46. relating to harboring, concealing, or aiding an escaped prisoner.
(xx) Section 944.47, relating to introduction of contraband into a correctional facility.
(УУ) Section .996-701. relating to sexual misconduct in juvenile justice programs.
(zz) Section 295-711, relating to contraband introduced into detention facilities.
(3) The secunty background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741 28 whether such act was committed in this state or in another jurisdiction.

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(a) Any authorizing statutes, if the offense was a felony.
(b) This chapter, if the offense was a felony.
(c) Section 409-929. relating to Medicaid provider fraud.
(d) Section 409,9201, relating to Medicaid fraud.
(e) Section Z41.28, relating to domestic violence.
(f) Section 2ZL04. relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
(g) Section 817.034, relating to fraudulent acts through mail wire, radio, electromagnetic, photoelectronic or photooptical systems.
(h) Section §17.234, relating to false and fraudulent insurance claims.
(i) Section 817 481, relating to obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony.
(j) Section 817,50 relating to fraudulently obtaining goods or services from a health care provider.
(k) Section £17.505, relating to patient brokering.
(l) Section SI 7-559, relating to criminal use of personal identification information.

(m) Section 817.60. relating to obtaining a credit card through fraudulent means.
(n) Section 817,61 relating to fraudulent use of credit cards if the offense was a felony.
(o) Section 831.01. relating to forgery.
(p) Section S31-Q2. relating to uttering forged instruments.
(q) Section 831.07, relating to forging bank bills drafts, or promissory notes.
(r) Section 831,09 relating to uttering forged bank bills, cnecks, drafts, or promissory notes.
(s) Section 831-30, relating to fraud in obtaining medicinal drugs.
(t) Section 831,31. relating to the sale, manufacture delivery, or possession with the intent to sell, manufacture or deliver any counterfeit controlled substance, if the offense was a felony
(u) Section 895.03, relating to racketeering unlawful debts. and collection of unlawful debts.
(V) Section 336,1Q1, relating to the Florida Money Laundering Act.

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

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

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

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

Dote of Decision:

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

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

Purpose of Prior Screening:

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Screening conducted by:

Date of Prior Screening:

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Agency for Healthcare Administration

Agency for Healthcare Administration

Department of Health

Department of Health

Agency for Persons with Disabilities

Agency for Persons with Disabilities

Department of Elder Affairs

Department of Elder Affairs

Department of Financial Services

Department of Financial Services

Department of Children and Families

Department of Children and Families

Attestation

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Under penalty of perjury, I,

Name

, hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chaptre435 and section 408-809 F.S- ln addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.

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Employee/Contractor Signature

Title

Date

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Employee/Applicant/Contractor/Volunteer Name:

By signing this form, I affirm and attest that I meet the Moral Character requirements for employment as required pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes.

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EMPOWERED COMMUNITY LIVING LLC

Provider/Employer Name:

I have not been arrested with disposition pending or found guilty of regardless of adjudication, or entered a plea of nolo contendre (no contest) to or have been adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction for any of the offenses listed below.

Criminal Offenses listed in section 435.04, F.S.

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(a) Section 393.135, relating to sexual misconduct with certain developmental disabled clients and reporting of such sexual misconduct.
(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.
(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.
(d) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
(e) Section 782.04, relating to murder.
(f) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.
(g) Section 782.071, relating to vehicular homicide.
(h) Section 782.09, relating to killing of an unborn quick child by injury to the mother.
(i) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.
(j) Section 784.011, relating to assault, if the victim of the offense was a minor.
(k) Section 784.03, relating to battery, if the victim of the offense was a minor.
(l) Section 787.01, relating to kidnapping.
(m) Section 787.02, relating to false imprisonment.

(n) Section 787.025, relating to luring or enticing a child.
(o) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.
(p) Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person.
(q) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.
(r) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.
(s) Section 794.011. relating to sexual battery.
(t) Former s. 794.041. relating to prohibited acts of persons in familial or custodial authority.
(u) Section 794.05, relating to unlawful sexual activity with certain minors.
(v) Chapter 796, relating to prostitution.
(w) Section 798.02, relating to lewd and lascivious behavior.
(x) Chapter 800, relating to lewdness and indecent exposure.
(y) Section 806.01, relating to arson.
(z) Section 810.02, relating to burglary.

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(aa) Section 810.14, relating to voyeurism, if the offense is a felony.
(bb) Section 810.145. relating to video voyeurism, if the offense is a felony.
(cc) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.
(dd) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.
(ее) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.
(ff) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.
(gg) Section 825.103, relating to felony offenses for the exploitation of an elderly person or disabled adult.
(hh) Section 826.04. relating to incest.
(ii) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.
(jj) Section 827.04, relating to contributing to the delinquency or dependency of a child.
(kk) Former s. 827.05, relating to negligent treatment of children.
(II) Section 827.071, relating to sexual performance by a child.
(mm) Section 843.01, relating to resisting arrest with violence.
(nn) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.

(oo) Section 843.12, relating to aiding in an escape.
(pp) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institution.
(qq) Chapter 847, relating to obscene literature.
(rr) Section 874.05, relating to encouraging or recruiting another to join a criminal gang.
(ss) Chapter 893, relating to drug abuse prevention and control if the offense was a felony or if any other person involved in the offense was a minor.
(tt) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting requirements for such sexual misconduct.
(uu) Section 944.35(3). relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.
(vv) Section 944.40, relating to escape.
(ww) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.
(xx) Section 944.47, relating to introduction of contraband into a state correctional facility.
(yy) Section 985.701, relating to sexual misconduct in juvenile justice programs.
(zz) Section 985.711, relating to contraband introduced into detention facilities

435.04(3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction.

Section 393.0674(2). felony offenses for the release or use of information from juvenile records of the Agency for Persons with Disabilities for any purpose other than screening for employment

Criminal Offenses listed in section 393.0655 (5), F.S.

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(a) Any authorizing statutes, if the offense was a felony.
(b) This chapter, if the offense was a felony.
(c) Section 409.920, relating to Medicaid provider fraud.
(d) Section 409.9201, relating to Medicaid fraud.
(e) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.
(f) Section 817.234, relating to false and fraudulent insurance claims.
(g) Section 817.505, relating to patient brokering.
(h) Section 817.568. relating to criminal use of personal identification information.

(i) Section 817.60. relating to obtaining a credit card through fraudulent means.
(j) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
(k) Section 831.01, relating to forgery.
(l) Section 831.02, relating to uttering forged instruments.
(m) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
(n) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.

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

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

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

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

ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED:

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

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Signature of Affiant:

Date:

My record contains one or more of the applicable disqualifying acts or offenses listed above.

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Signature of Affiant:

Date:

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

I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be holding a position that is within the scope of mv licensed practice, and I am not subject to the screening provisions of section 393.0655, Florida Statutes.

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Signature of Affiant:

Position for Provider/Employer listed on pg. 1

Date:

PERSONAL HEALTH INFORMATION PLEDGE OF CONFIDENTIALITY

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Name

the undersigned, have read and understood EMPOWERED

COMMUNITY LIVING (hereinafter EMPOWERED COMMUNITY LIVING policy on confidentiality of personal health information (PHI) as described in the Confidentiality Policy which is in accordance with relevant state and federal legislation.

I also acknowledge that I am aware of and understand the Policies regarding the security of personal health information including the policies relating to the use, collection, disclosure, storage and destruction of personal health information. In consideration of my employment or independent contractor status with EMPOWERED COMMUNITY LIVING and as an integral part of the terms and conditions of my employment or contractor status, I hereby agree, pledge and undertake that I will not at any time, during my employment or association EMPOWERED COMMUNITY LIVING Or after my employment or association ends, access or use personal health information, or reveal or disclose to any persons within or outside, any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicable Legislation, and policies governing proper release of information.

I understand that my obligations outlined above will continue after my employment/contract/ association/appointment with EMPOWERED COMMUNITY LIVING ends.

I further understand that my obligations concerning the protection of the confidentiality of PHI relate to all personal health information whether I acquired the information through my employment or contract or association or appointment with EMPOWERED COMMUNITY LIVING or with any of the entities, which have an association with this organization. I also understand that unauthorized use or disclosure of such information will result in a disciplinary action up to and including termination of employment or contract or association or appointment, the imposition of fines pursuant to relevant state and federal legislation, and a report to my professional regulatory body.

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Signature

Date

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Witness

Date

HOME HEALTH AIDE REGISTRATION AGREEMENT

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HOME HEALTH AIDE CONTRACTOR

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Upload Your Filled PRIVACY STATEMENT Form Here......

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acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchanqe of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse.

Employee/Contractor Name (Printed)

Employee/Contractor Signature

Date

EMPOWERD COMMUNITY LIVING, LLC

Signed Policy and Procedures

In effect: (Date) until further notice

I have read and been informed about the content, requirements, and expectations of the policy and procedures for employees at Empowered Community Living, LLC. I have received a copy of the policy and agree to abide by the policy guidelines as a condition of my employment and my continuing employment at Empowered Community Living, LLC.

I understand that if I have questions, at any time, regarding the policies, I will consult with my immediate supervisor or my Human Resources staff members.

Please read the handbook carefully to ensure that you understand the policies and procedures before signing this document.

Employee Signature:

Employee Printed Name:

Receipt By:

Date:

WAIVER OF LIABILITY INSURANCE

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Name

, am operating as an

Contractor

Address

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Phone

Tax ID / SS #

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Signature

Date

W-9

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USCIS Form

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