Phone No: CT: 860 840 3854 / MD: 240 660 0276 || Fax No: 18007841437 || Email: [email protected] || Address: 157 church street New haven CT 06510

PCA/HMKER/COMPANION JOB APPLICATION

INSTRUCTIONS: Complete all requested information. You may asked to provide additional information. Be sure to sign and date the application.

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    First name
    Middle name
    Last name
    Date of Birth
    Sex MaleFemalePrefer Not to Say
    Social Security Number
    Front Photo of your Social Security
    Front Photo of your Social Security

    Address

    Street Address Street Address Line 2
    City
    State / Province
    Postal / Zip Code
    Phone Number
    Email address
    Emergency Contact Name
    Emergency Contact Phone Number
    What Position are you applying for? Homemaker/Chore HelperPersonal Care AssistantCompanionIndependent Contractor (Client Recruiter)NursingAdministrative Assistant Years of Experience Less than 1 year1 to 5 yearsGreater than 5 years
    Education (mark only One) High SchoolAssociateBachelor's
    Degree
    Certificate/License Number
    Current Employment Status EmployedSelf - EmployedUnemployedStudent
    Are you legally authorized to work in the U.S.? YesNo
    If applicable, please detail any work restrictions
    Is selected for employment, are you willing to consent to a background check? YesNo
    Detail of Work Experience
    Have you ever been convicted of a crime? YesNo
    Language Spoken: EnglishSpanish
    Do you have current Cardiopulmonary Resuscitation (CPR) /Basic Life Support (BLS) certificate? YesNo
    If yes, explain the number of conviction(s), nature of offense commited, Sentence (s) imposed and type(s)of rehabilitations
    Do you have any work limitations? HearingSpeechLiftingHealthPhysicalEmotionalNo, I have no work limitations
    Indicates the Days available for work SundayMondayTuesdayWednesdayThursdayFridaySaturday
    Clients you are NOT willing/able to work with (check all that applies) Dementia/Alzheimer’sPhysical DisabilitiesSmokersPetsMental RetardationFemalesBehavioral DisordersMalesElderly (over 65)Clients uses marijuana for medicinal purposesChildrenHIV Positive/AIDSI am able to work with all clients
    Duties NOT willing/able to perform (check all that applies) BathingHousekeepingGroomingLaundryOral CareMeal PreparationDressingShoppingBowel CareTransportationBladder CareMedication remindingFeedingFriendly Reassurance Phone call/Home visitAmbulationI am able to perform all duties
    Indicate which the following you have experience in? Bathing/ShoweringHousekeepingGroomingLaundryPersonal HygieneMeal PreparationDressingShoppingBowel CareTransportationBladder CareMedication remindingFeedingFriendly Reassurance Phone call/Home visitAmbulationSocializationToiletingHome Care Nursing PracticeHospital Nursing Practice
    Are you restricted in the geographical location you are willing/able to work?: YesNo
    Mode of Transportation (Click all that applies): Private VehicleBusBikeTrainNone
    Do you have a driver's license? YesNo
    Are you willing to transport the client in your private vehicle? YesNo
    Do you have adequate vehicle insurance? YesNo
    Are you willing to drive a client's vehicle? YesNo
    Are you willing to escort a client to their own vehicle? YesNo
    Are you willing to escort a client on a public transportation? YesNo
    Have you ever been investigated for abuse, neglect or domestic violence? YesNo
    Have you ever been convicted of a crime, including any felony charges? -If Yes, specify.
    If YES, explain:
    Work-Related Reference #1: Last Position:
    Company Name
    Company Address
    Time Period: (Month/Year to Month/Year)
    Reason for Leaving
    Company Contact number
    Supervisor's Name
    Position in the Company
    Work-Related Reference #2: Last Position:
    Company Name
    Company Address
    Time Period: (Month/Year to Month/Year)
    Reason for Leaving
    Company Contact number
    Supervisor's Name
    Position in the Company

    Personal Reference #1

    Name
    Phone
    Email
    Address
    Relationship

    Personal Reference #2

    Name
    Phone
    Email
    Address
    Relationship
    I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misinterpretation may result in rejection of my application. I authorized investigation of all statements contained in this application, as required. Additionally, I authorized former employers, references and any other individual/organizations to provide information to Macas Home Care LLC and I hereby release and discharge any of the above and Macas Home Care LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary. I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check. I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States
    Signature
    Date

    POLICIES AND PROCEDURES COMPLIANCY AGREEMENT

    I have been oriented to Macas Home Care LLC‘s Policies and Procedures. I understand the Agency’s policies and procedures and hereby agree to abide by them. I understand that revisions to these policies & procedures may occur and it is my responsibility to adhere to all revisions, as stated

    Employee Name

    First Name
    Last Name
    Signature
    Date
    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
    Date

    JOB DESCRIPTION

    Home Care Companion

    Description

    Home Care Companions provide service to individuals in their own homes and communities who need assistance caring for themselves because of old age, sickness, disability and/or other infliction. Home care may include light housecleaning, laundry, meal preparation, transportation, companionship, respite and advice on such things as nutrition, cleanliness and household activities.Home Care Companions are responsible for ensuring that service is delivered in a caring and respectful manner, in accordance with relevant Agency policies and industry standards.

    Reporting Relationship

    Reports to Supervisor

    Responsibilities/Activities:

    Provide companionship, friendship and emotional support. Talk, listen, share experiences, play games/cards, read to client etc. Help keep clients in contact with family, friends and the outside world. Provide transportation to medical appointments, grocery store and errands. Accompany clients to recreational and/or social events. Assist with plans for visits and outings. Write or type letters/correspondence. Organize and read mail. Plan trips and outings and possibly travel with clients. Teach/perform meal planning and preparation. Perform light housekeeping. Participate on the Care Team by providing input and making suggestions. Ensure service is delivered in accordance with Agency policies, procedures and industry standards. Monitor supplies and resources. Evaluate the program and make recommendations, as indicated. Follow the written care plan. Assist in basic client transfers providing the client has been assessed as being capable of ambulating without assistance; and/or, providing another trained caregiver (including family) is involved in the transfer. Carry out duties as assigned by the Supervisor. Observe the client’s functioning and report to Supervisor. Complete and maintain records of daily activities, observations, and direct hours of service. Develop and maintain constructive and cooperative working relationships with others. Make decisions and solve problems.Assist with pet care. Communicate with Supervisor and co-workers. Attend orientation, in-service training sessions and staff meetings.

    Required Knowledge

    Knowledge of home management skills. Knowledge of principles and processes for providing client services, including needs determinants, meeting quality standards and evaluation of client satisfaction. Knowledge of the English language. Knowledge of information and techniques needed to diagnose and treat injuries including emergency first aid and CPR. Knowledge of clerical procedures such as maintaining records and completing forms.Required Skills/Abilities Ability to be aware of other people’s reactions and understand why they react as they do. Ability to establishing and maintain relationships.Ability to teach others. Ability to identify problems and determine effective solutions. Ability to apply reason and logic to identify strengths and weaknesses of possible solutions. Ability to understand written and oral instructions.Ability to communicate information orally and in writing. Ability to listen and understand the spoken word.Ability to work independently and in cooperation with others. Ability to determine or recognize when something is likely to go wrong. Ability to suggest ideas on a subject.Ability to provide advice and consultation to others. Ability to observe and recognize changes in clients.Ability to establish and maintain harmonious relations with clients/families/co-workers.

    Physical and Mental Demands:

    Good physical and mental health. Physical ability to stand, walk, use hands and fingers, reach, stoop, kneel, crouch, talk, hear and see. Mental fortitude and stability to handle stress. Physical and mental ability to drive a vehicle.

    Qualifications/Education

    HHA or CNA Certificate Current driver’s license. Proper Vehicle Insurance Coverage.

    Training/Experience:

    May require related experience. May required similar social and cultural backgrounds with some clients.

    Name

    First Name
    Last Name
    Signature
    Date
    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
    Date

    JOB DESCRIPTION

    Homemaker

    Description

    Homemakers provide service to individuals in their own homes and communities, who need assistance caring for themselves as a result of old age, sickness, disability, and/or other infliction. Home care may include housecleaning, laundry, meal preparation, transportation, companionship, and respite, Homemakers are responsible for ensuring that service is delivered in a caring and respectful manner, in accordance with relevant Agency policies and industry standards.

    Reporting Relationship

    Reports to Supervisor

    Responsibilities/Activities:

    o Teach/perform meal planning and preparation, routine housekeeping activities such as making/changing beds, dusting, vacuuming, washing floors, cleaning kitchen and bathroom, and laundry. o Perform/assist with essential shopping/errands, which may include handling the client’s money, in accordance with the care plan and under the observation of the Supervisor. o Assist with following a written, special diet plan and reinforcement of diet maintenance, which is provided under the direction of a Physician and as identified in the care plan.oEscort to medical facilities, errands, shopping, and outings as specified in the care plan. o Provide companionship, friendship, and emotional support. o Assist clients with communication by writing or typing correspondence for them or researching information for them. o Participate on the Care Team by providing input and making suggestions. o Ensure service is delivered in accordance with all relevant policies, procedures, and practices. o Monitor supplies and resources. o Evaluate the program and make recommendations to it, as indicated.oFollow the written care plan. o Carry out duties as assigned by the Supervisor. o Observe the client’s functioning and report to Supervisor.oComplete and maintain records of daily activities, observations, and direct hours of service.oAttend orientation, in-service training sessions and staff meetings. o Develop and maintain constructive and cooperative working relationships with others. o Make decisions and solve problems.oCommunicate with Supervisor and co-workers. o Observe, receive, and obtain information from relevant sources.

    Required Knowledge

    o Knowledge of home management skills. o Knowledge of principles and processes for providing client and personal services, including needs determinants, meeting quality standards and evaluation of client satisfaction. o Knowledge of the English language. o Knowledge of information and techniques needed to diagnose and treat injuries including emergency first aid and CPR. o Knowledge of clerical procedures such as maintaining records and completing forms.

    Required Skills/Abilities

    o The ability to be aware of other people’s reactions and understand why they react as they do. o The ability to establishing and maintain relationships. o The ability to teach others. o The ability to apply reason and logic to identify strengths and weaknesses of possible solutions. o The ability to identify problems and determine effective solutions. o The ability to understand written and oral instructions. o The ability to communicate information orally so others understand. o The ability to communicate in writing so others understand. o The ability to listen and understand the spoken word. o The ability to work independently and in cooperation with others. o The ability to determine or recognize when something is likely to go wrong. o The ability to suggest several ideas on a subject. o The ability to perform activities that use the whole body. o The ability to handle and move objects and people. o The ability to provide advice and consultation to others. o The ability to observe and recognize changes in clients. o The ability to establish and maintain harmonious relations with clients/families/co-workers.

    Physical and Mental Demands:

    o Good physical and mental health. o Physical ability to stand, walk, use hands and fingers, reach, stoop, kneel, crouch, talk, hear, and see. o Mental fortitude and stability to handle stress. o Physical and mental ability to drive a vehicle.

    Qualifications/Education

    o HHA or CNA Certificate o Current driver’s license. o Proper Vehicle Insurance Coverage.

    Training/Experience:

    o May require related experience.

    Name

    First Name
    Last Name
    Signature
    Date
    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
    Date

    COMPLIANCY AGREEMENT

    I agree to comply with the policies, regulations, and standards of: o Federal, States and Local Laws o The Health Insurance Portability & Accountability Act of 1996 (HIPAA) o Professional Standards o Relevant, Federally-Funded Healthcare Programs I understand my responsibility to report: o Any suspicions or observations of fraud or abuse in accordance with the Federal Deficit Reduction and False Claims Acts; and, any known or suspected HIPAA security incidents or violations. I understand that revisions to these policies, procedures, laws, regulations, and standards may occur over time, and it is my responsibility to adhere to all revisions, as stated. I understand that adhering to these policies , procedures, laws, regulations, and standards is a condition of employment and/or continued employment. Furthermore, I understand that if I do not comply with these security policies and procedures, appropriate sanctions will be applies against me.

    Name

    First Name
    Last Name
    Signature
    Date
    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
    Date

    CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT

    It is the responsibility of all Agency employees to preserve and protect confidential Agency, client and employee medical, personal and business information and, thus, shall not disclose such information except as authorized by law, client or individual. Confidential Client Information includes, but is not limited to any identifiable information about a client’s and/or his/her family including, but not limited to: A.medical history; B.mental, or physical condition; C.treatments and medications; D.test results; E.conversations; F.financial information; and, G.household possessions. Confidential Employee information includes, but is not limited to: o contact information i.e. telephone number(s); address, email address o names of spouse and/or other relatives; o Social Security Number; o performance appraisal information; o health status and treatments; and, o other information obtained from their personnel files which would be an invasion of privacy e.g.:  Date of Birth;  Place of Birth  Traditional password identifiers  Bank account numbersIncome tax records  Driver’s license numbers  Credit card numbers  Passport numbers  Confidential Business Information Confidential business information includes, but is not limited to: W.client lists; X.security data and credentials such as passwords, Y.any information that, if released, could be harmful to the Agency; and, Z.any financial information including accounts receivable, accounts payable and payroll. I acknowledge that: 27.I understand that it is my legal and ethical responsibility to protect the security, privacy, and confidentiality of all client records, Agency information and other confidential information relating to the Agency, including business, employment and medical information pertaining to clients, their families and employees. 28.I will only discuss confidential information during the performance of my duties and only for job related purposes and shall take caution to ensure such conversations are not within hearing range of anyone who is not entitled to have this information 29.I shall respect and maintain the confidentiality of all discussions, conversations, and any other information generated while providing service to clients in connection with individual client service, risk management and/or peer review activities. 30.I shall not disclose the content of any discussions, deliberations, client records, peer reviews or risk management information, except to persons authorized to receive such information, while conducting Agency business. 31.I shall only access or distribute client care information when executing my job duties or when required to do so by law. 32.I will only access records on a “need-to-know” basis in the performance of my duties. 33.I will not share my Login or User ID and password for accessing electronic records with anybody. If I believe someone else has used my Login or User ID and/or password, I will immediately notify the Supervisor. 34.I will only use mobile computing devices, with Agency approval, AND providing they are encrypted with an approved data encryption solution before using them for any Agency-related business. I understand that I may be personally responsible for any breach of confidentiality resulting from unauthorized access due to hacking or other means to Agency information stored on my unencrypted device 35.I understand that the Agency will undertake measures to determine if client and employee records have been accessed without authorization. 36.I understand that state and federal laws/regulations governing a client’s right to privacy, the illegal or unauthorized access or disclosure of client’s confidential information may result in disciplinary action up to and including immediate termination from my employment and possible civil fines and criminal sanctions. 37.I understand that I am obligated to maintain these confidentiality after my employment with this Agency ceases. I hereby acknowledge that I have read and understand the above-mentioned information and that my signature below indicates my agreement to comply with these terms.

    Name

    First Name
    Last Name
    Signature
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    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
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    PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

    Please be advised that you are responsible for your background check fee. A total amount of thirty U.S dollars($30.00) for background check will be deducted from your first paycheck. Please note that endorsing this section of the application form with your signature gives Macas Home Care LLC the consent to deduct the background check fee($30.00) from your first paycheck. I understand that as part of the employment process, Macas Home Care LLC needs to complete a background check on me regarding: 1.Criminal record; 2.Sex and Violent Offenders Record; 3.Employment Verification; 4.Education Verification; 5.License Verification; 6.Motor Vehicle Records, 7.Personal/Professional Reference Verification; 8.Medical Suitability; 9.Drugs/Alcohol; 10.Child Abuse Clearance (if indicated) o I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to Macas Home Care LLC or its authorized agent(s). o I understand that this authorization is to be part of the written and signed employment application.oI also understand that I do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further. o I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law. o I further authorize that a photocopy of this authorization may be considered as valid as the original o I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with Macas Home Care LLC is contingent upon successful completion of a background check.

    Name

    First Name
    Last Name
    Date of Birth
    Social Security Number
    Address
    City
    State / Province
    Postal / Zip Code
    Phone Number Former names and Dates used: Current Driver's License, passport Driver's License (Back) State any other Cities, States, and Dates of residency during the last 10 years:
    1. City, State:
    From (mm/yy):
    To (mm/yy):
    2. City, State:
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    3. City, State:
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    Signature
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    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
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    DECLINE/ACCEPT INFLUENZA VACCINATION

    Macas Home Care LLC has recommended that I receive an influenza vaccination to protect myself and the clients I serve. I acknowledge that I am aware of the following facts: o Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year. o Influenza vaccination is recommended for me and all other healthcare workers to prevent influenza disease and its complications, including death. o If I contract influenza, I will shed the virus for 24-48 hours before influenza symptoms appear. My shedding the virus can spread influenza infections to clients o If I become infected with influenza, even when my symptoms are mild, I can spread severe illness to others. o I understand that that the strains of virus that cause influenza infection change almost every year, which is why a different influenza vaccine is recommended each year. o I cannot get the influenza disease from the influenza vaccine. o The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including; o Clients; o my co-workers o my family o my community I have read and fully understand the information on this declination form. I have read and fully understand the information on this declination form.Despite these facts, I am choosing to decline influenza vaccination right now. I understand that I may change my mind at any time and accept influenza vaccination, if vaccine is available. I will provide proof of influenza vaccination.

    Name

    First Name
    Last Name
    Signature
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    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
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    REQUEST or DECLINE HEPATITIS B VACCINE

    I hereby request the series of Hepatitis B vaccine injections: I hereby decline the series of Hepatitis B vaccine injections because: 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 the Hepatitis B vaccine, at no charge to me; however, I decline the 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 the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

    Name

    First Name
    Last Name
    Signature
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    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
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    REQUEST/DECLINE OF COVID - 19 VACCINE

    Macas Home Care LLC has recommended that I receive a Covid-19 vaccination to protect myself and the clients I serve. I acknowledge that I am aware of the following facts: o Covid-19 is a serious respiratory disease that killed an average of 1,011,013 persons and hospitalized more than 25,621 persons in the United States as of June of 2022. o Covid-19 vaccination is recommended for me and all other healthcare workers to prevent Covid-19 disease and its complications, including death. o If I contract Covid-19, I will shed the virus for 24-48 hours before Covid-19 symptoms appear. My shedding the virus can spread Covid-19 infections to clients. o If I become infected with Covid-19, I can spread severe illness to others even when my symptoms are mild. o I understand that the strains of the SARS-COV-2 virus that cause Covid-19 infection change almost every year, which is why a booster of Covid-19 vaccine is recommended after the first shot. o I cannot get the Covid-19 disease from the Covid-19 vaccine. o The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including: o Clients o my co-workers o my family o my community I have read and fully understand the information on this declination form.

    Name

    First Name
    Last Name
    Signature
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    Agency Representative Name (OFFICE USE ONLY!!! DO NOT Fill if you are an applicant): Name and Position
    Signature
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    Please upload other forms of photo ID ( Passport, Permanent Resident Card, Work Authorization, Driver's License)(Front) Please upload other forms of photo ID ( Passport, Permanent Resident Card, Work Authorization, Driver's License) (Back) Vehicle Insurance (Front) Vehicle Insurance (Back) Certifications (BLS, CPR, CNA, PCA)

    Phone No:

    CT: 860 840 3854 / MD: 240 660 0276

    Email:

    [email protected]

    Address:

    157 church street New haven CT 06510

    © Macas Home Care LLC