Employment Form

* = Required Information

Last Name *

First Name *

Middle Initial *

Social Security Number *

Date Of Birth *

PRESENT ADDRESS

Address *

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number *

Other *

PERMANENT ADDRESS

Address *

Phone Number *

What other names have you worked under? *

Emergency Contact

Name *

Address *

Phone Number *

Are you 18 years of age or older? *

Yes

Are you a former employee? *

Yes

Can you after employment, submit verification of your legal right to work in the United States? *

Yes

Can you perform the job functions, tasks, duties, with or without reasonable accommodation, of the position(s) applied for? *

Yes

How did you hear about us? *

Job Interest Title *

Certified Nursing Assistant

Preventive Health Care Application

Licensed Practical Nurse

Registered Nurse

Position Desired *

Date Available *

Wage desired *

Other *

Education

Professional and Licenses Certifications

Type *

State Issued *

Date Issued *

Expires *

Number *

Type *

State Issued *

Date Issued *

Expires *

Number *

Employment History (start with the most recent employer first)

Employer Name *

From *

To *

Employment Address *

City *

State *

Zip Code *

Phone Number *

Position *

Supervisor's Name and Title *

Starting Wage *

Final Wage *

Reason For Termination *

Briefly Describe Duties *

Employer Name *

From *

To *

Employment Address *

City *

State *

Zip Code *

Phone Number *

Position *

Supervisor's Name and Title *

Starting Wage *

Final Wage *

Reason For Termination *

Briefly Describe Duties *

Employer Name *

From *

To *

Employment Address *

City *

State *

Zip Code *

Phone Number *

Position *

Supervisor's Name and Title *

Starting Wage *

Final Wage *

Reason For Termination *

Briefly Describe Duties *

Employer Name *

From *

To *

Employment Address *

City *

State *

Zip Code *

Phone Number *

Position *

Supervisor's Name and Title *

Starting Wage *

Final Wage *

Reason For Termination *

Briefly Describe Duties *

Employer Name *

From *

To *

Employment Address *

City *

State *

Zip Code *

Phone Number *

Position *

Supervisor's Name and Title *

Starting Wage *

Final Wage *

Reason For Termination *

Briefly Describe Duties *

Background Check

Disclosure of all Social Security Numbers (SSN) ever used and disclosure if on the Employee Disqualifying List (EDL)

Disclose all criminal convictions, findings of guilt, pleas of guilty and pleas of nolo contendere, except minor traffic violations

Have you ever pled guilty to, been convicted of, been released without imposition of sentence, and pleas of nolo-contendere, or received pretrial diversion for any crime, excluding minor traffic tickets? (please include expunged conviction) *

Yes

Describe all of these actions, including the nature of the criminal offense(s), the location(s), the dates, and their disposition. Conviction of crime is not an automatic bar for employment. Falsification of information will result in rejection of application or termination of employment.

I hereby, voluntarily give this agency the right to make a thorough investigation of my pre-employment criminal record checks, and closed records checks, and background & highway patrol checks as deemed necessary by law for this employment purposes.

Potential Employment must meet the basic requirement for hire which includes, but not limited to these check:

Must be registered with the State of Kansas
KBI Check
Two(2) credible Reference Checks

STATEMENT OF UNDERSTANDING

This agency does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, age, marital status, veteran status, or handicap. No question on this application is intended to secure information to be used for such discrimination.

I authorize investigation of all statements contained in this application if I am considered for employment. I also authorize previous employers named, or any other person to whom this agency may refer, to give any and all information regarding my employment or scholastic standing together with any other pertinent information.

I understand that misrepresentation or omission of facts requested in the application or other employment documents, unsatisfactory work references, or failure to pass the prescribed physical examination (if required for my position) will be sufficient cause for dismissal from the agency’s services . If it is discovered after I am hired.

To help ensure a safe and healthful working practices, the agency reserves the right to ask employees to provide body substance samples (such as urine /blood) to determine the illicit or illegal use drugs and alcohol.

Testing procedures can be initiated for post-accident situations. Situations where in the judgment of the agency that the employee demonstrates impairment from the use of drugs or alcohol, and situations concerning the suspected theft of controlled substances owned by the client. Refusal to submit to drug/alcohol testing will result in termination of employment

Since the agency operates 24 hours a day and may have priority consumers, I understand it may be necessary for me to be assigned consumers, work, shifts or days which do not coincide with my client/work preferences listed on this employment application. I also understand that management has the sole right to assign client/job duties, outside of my normal client/duties, In order to meet operational need or provide care to the consumers.

I also understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this agency is of an “Art Will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understand that this “At Will” employment relationship may not be charged by any written document or conduct unless such change is specifically acknowledged in writing by chief operating officer of the agency.

Signature *

Clear

Date *

Code of Ethics Statement

This code of ethics should allow for the use for bathroom and, with the client’s consent, eat lunch provided by the worker, in the client’s home.

The following are prohibited:

Use of client car
Consume client’s foods or drink except water
Use client’s telephone for personal calls
Discuss own or other’s personal problems, religious or political beliefs
Accept gifts or tips
Bring other persons to the client’s home
Consume alcoholic beverages, or use of medicines or drugs for any purpose, other than medical, in the client’s home or prior to service delivery
Smoke in the client’s home
Solicit or accept money or goods for personal gain from the client
Breach the client’s privacy and confidentially of information and records
Purchase any items from the client even at fair market value
Assume control of the financial or personal affairs, or both, of the client or of his/her estate including power of attorney, conservatorship or guardianship
Take anything from the client’s home
Commit any act of abuse, neglect or exploitation
Assign family members to provide care to client’s
Taking or Handle client’s Credit Cards, ATM Cards, Bank Cards ask for a loan of money from client’s or client’s family members.

Signature *

Clear

Date *

Acknowledgement

CONFIDENTIALITY STATEMENT:

I understand that I must maintain the confidentiality of all verbal, written or electronic information obtained about a client while caring for the client. Client information is to be discussed only with your supervisor, it is illegal to discuss one client’s care with another client. It is illegal to discuss one client’s care with another staff person not involved in the care of the patient. All information regarding clients and their families will not be discussed except in the line of duty; no discussion of that is involved in caring for the client. Persons requiring information about a client or a client’s family must be directed to the “LOCAMP HOME HEALTHCARE LLC.” Manager.

I have received Code of Ethics, Clients Bill of Rights, and Confidentiality Statement.

I agree to follow this Agency’s Policy & procedure on maintaining confidentiality.

Employee Name *

Employee Signature *

Clear

Date *

Agency Representative *

Employee Signature *

Clear

Date *

Employee Reference

BELOW GIVE THE NAMES OF THEREE PERSONS YOU ARE NOT RELATED TO WHO HAVE KNOW YOU AT LEAST A YEAR.

Name *

Address *

Telephone *

Name *

Address *

Telephone *

Name *

Address *

Telephone *

Crimes and Punishment on Abuse and Neglect

1. A person commits the crime of elder abuse in the first degree if he attempts to kill, knowingly causes or attempts to cause serious physical injury, and or disability, to any person sixty years of age or older.
Elder abuse in the First Degree is a Class A Felony

2. Elder abuse in the second degree occurs when a person commits the crime of elder abuse by means of a deadly weapon or dangerous instrument or recklessly and purposely causes physical injury.
Elder abuse in the Second Degree is a Class B Felony.

3. Elder abuse in the third degree results from knowing that another person abuses or neglects a patient and failing to make a report regarding your finding, or ,intentionally failing to provide quality care goods or services, which may result in stress, physical emotional distress, and risk to life, body or health.
Elder abuse in the Third Degree is a Class A Felony

Employee Signature *

Clear

Date *

No Call / No Show Termination

Employees of Locamp Home Health Care,

We value all of our clients and strive to provide the best home care possible in the most comfortable setting.
Please understand that when we schedule you with a client, we are reserving time for your client particular needs with you. When you’re assigned to a client we except you to show up on time and be ready to assist the client.
Therefore a NO CALL / NO SHOW for your scheduled time with a client will result in TERMINATION of employment with Locamp Home Health Care.

Sincerely, Management of Locamp Home Health Care

Employees Name *

Date *

Patient Bill of Rights

Patient Rights and Responsibilities and Consent for Treatments / Advanced Directives

THE PATIENT HAS THE RIGHT:
1.To competent , individualized health care that is given without discrimination to raced, creed, color, age, sex, national origin, disability, marital status, source of payment, or political beliefs.
2.To expect a written care plan which is in accordance with physicians’ orders and participate in all decisions affecting his/her care and plan of treatment.
3.To be informed in advance about the care to be furnished, the disciplines that will furnish the care and the proposed visit frequency.
4.To know the identity and responsibilities of those for coordinating, rendering, and supervising the care, including health care providers under contractual relationships.
5.To have his/her privacy respected and all health, social, and financial information treated as confidential. The patient may approve or refuse to release medical information to any individual outside of the agency, except in the case of transfer to another agency or health facility, or as required by law, accrediting bodies or third-party payment contract.
6.To a complete explanation of all services provided, initially and on a continuous basis. To health teaching and educating in a language or form the patient can reasonably be expected to understand.
7.To expect recommendations for services, evaluations, and referrals, appropriate to the nature of his/her illness and rehabilitation, to other community agencies or health care agencies that can assist or enhance the provision of health care regardless of ability to pay.
8.To be fully informed as to the nature and method of experimental treatment or research and either give documented voluntary informed consent or refuse such treatment.
9.To be assured that transfer or discharge from the agency is only for medical reasons, self-welfare, or the welfare of others and participate in the transfer process, to another agency or level of care, if the agency can no longer meet the care or need of the patience cause of the agency’s mission, philosophy, or limitations in its scope of care or services.
10.To be involved in resolving ethical issues or conflicts about care service.
11.To have his/her property and person treated with respect.
12.To voice complaints or grievances, or ask questions about care or services and recommend changes in policies and services without being subject to coercion, discrimination, reprisal or unreasonable interruption of service for doing so. All complaints will be investigated and documented, including resolution, within five (5) working days after their receipt.
13.To know that his/her family or guardian may exercise the patient’s rights if the patient has been judged incompetent by a court of law.
14.To know that Medicate/Medicaid are accepted as payment in full. If you enroll with HMO during our period of care, then you may be liable and may be billed for services rendered.
15.To be advised, orally and in writing, of any changes in the payment expectations, as soon as possible, but no later than 30 calendar days from the date the agency becomes aware of the change.
16.To be informed of the financial responsibilities under private insurance arrangements.
17.To continuity of services.
18.To select or change his/her own physician, treatment or agency.
19.To refuse treatments and to be informed about the consequences of such action.
20.To have Advance Directives honored as permitted by local, state, and federal law.
21.To choose or reject ancillary services and to be fully informed of any financial gain or relationship to the agency of such services.

THE PATIENT HAS THE RESPONSIBILITY:
1.To cooperate with your physician and the agency in your treatment program.
2.To notify the agency of changes in your address, health status, medications, physician or admission to health care facility.
3.To inform the agency of your inability to keep a scheduled appointment.
4.To notify the agency when you feel your rights are not being respected.
5.To sign a release when refusing medications, treatments, the recommended plan of care, or when refusing home health services.
6.To notify the agency if you are no longer homebound.
7.To notify the agency if you join or are enrolled in an HMO.
8.To provide a safe home environment in which your care can be given.
9.To provide the agency with a current copy of your Advance Directives.
10.To express any concerns regarding the course of treatment or your ability to comply with instructions.
11.Each patient shall have the right to choose care providers and the right to communicate with those providers.
12.Each patient shall have the right to request information about the patients’ diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms that the patient and the patient’s family can readily understand so that they can give their informed consent.
13.Each patient shall be admitted for service only if the agency has the ability to provide sage, professional care at the level of intensity needed.
14.Each patient shall have the right to review all health records pertaining to them unless it is medically contraindicated in the clinical record by the physician.
15.Each patient denied service for any reason shall have the right to be referred elsewhere
16.Each patient has had the right to be free from verbal, physical, and psychological abuse and to be treated with dignity.
17.Each patient shall have the right to be advised in writing go he availability of licensing agency’s toll-free complaint telephone number
Any suspected abuse, neglect, or exploitation identified by any agency employee, or reported to the agency regarding any agency employee, shall be reported to the appropriate authority as listed below.

1.Local Law enforcement –Kansas 911
2.Kansas Home Health Hotline 1-800-842-0078
3.Kansas Department of Health and environment 1-785-296-1259

Employee Signature *

Clear

Date *

Client Signature *

Clear

Date *

Certified Nurse Aid Job Description

Position Summary:
Under the supervision of the Locamp Home Health Care R.N. Manager. The Locamp Home Health Aide is responsible for the care of a client 24 hours per day in their private setting. Caregiver will report to work as scheduled to stay in the client’s home until the shift is over. All meals will be provided for the client, prepared by the caregiver and will assist the client with the activities of daily living.

Duties
Your exact duties may vary depending on the type of setting, but could include:

getting to know individual clients and being aware of their special interests and social needs

supporting clients with daily personal care such as washing, dressing, using the toilet and feeding themselves

carrying out general tasks such as housework, laundry and shopping

helping clients organize their budget, pay bills and write letters

helping families adjust to new caring responsibilities

working with other health and social care professionals to deliver individual care and development plans

helping to organize recreational activities

escort clients to and from the residential home

implements and support patient care-plan

provides routine care, such as bathing, dressing and feeding

provides patient transportation to doctor’s dressing and feeding

must have a valid Kansas driver’s license and proof of auto insurance

grocery shopping will be done by caregiver, receipts must be provided to patient

light housekeeping

provides client with laundry and linen changes

provides medication reminds

meal preparation and clean-up, meals are provided for caregiver

provides for a safe living environment for client without infringing on the clients rights

caregiver understands that no assistance is to be offered regarding any financial matters of clients

report any

Qualifications

It would be useful to have:
Experience in a caring role, perhaps through volunteering or with your own family.

Previous experience is likely to be essential if you plan to work with people who have mental health issues or learning disabilities.

PSome employers will expect you to have a driver’s license because you are likely to have Clients in a number of different locations.

Employee Signature *

Clear

Date *

Employer Signature *

Clear

Date *