APPLICATION FOR EMPLOYMENT___________________

EQUAL OPORTUNITY EMPLOYER

DATEPERSONAL INFORMATIONSOCIAL SECURITY NO-NAME (LAST NAME)

STATE

E-MAIL ADDRESSPHONE NO.

EMPLOYMENT DESIREDSALARY DESIREDDATE YOU CAN STARTPOSITION

IF SO, MAY WE INQUIREOF YOUR PRESENT EMPLOYER?

ARE YOU NOYESNOYESEMPLOYED? I

WHEN?WHERE?EVER APPLIED TO NOYESTHIS COMPANY BEFORE?

EDUCATION HISTORYYEARS DID YOUNAME & LOCATION OF SCHOOL SUBJECTS STUDIEDATTENDED GRADUATE?

GENERAL INFORMATION

U.S. MILITARY OR RANKNAVAL SERVICE

FORMER EMPLOYERS (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)

DATENAME & ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVINGMONTH AND YEAR

CONTINUED ON OTHER SIDE

NAME( FIRST NAME, MIDDLE)

PRESENT ADDRESS CITY STATE ZIP CODE

PERMANENTADDRESS CITY ZIP CODE

GRAMMAR SCHOOL

HIGH SCHOOL

COLLEGE

TRADE, BUSINESS ORCORRESPONDENCE

SCHOOL

SUBJECTS OF SPECIAL STUDY/RESEARCHWORK OR SPECIAL TRAINING/SKILLS

FROM

TO

FROM

TO

FROM

TO

FROM

TODAT

DATE OF BIRTH

GIVE BELOW THE NAMES OF PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.REFERENCES

AUTHORIZATIONI certify that the facts contained in this application are true and complete to the best of my knowledge and

understand that, if employed, falsified statements on this application shall be grounds for dismissal.I authorize investigation of all statements contained herein and the references and employers listed above

to give you any and all information concerning my previous employment and any pertinent information theymay have, personal or otherwise, and release the company from all liability for any damage that may resultfrom utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into anyagreement for employment for any specified period of time, or to make any agreement contrary to the forego-Ing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner pro-hibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.''

SIGNATUREDATE

DATEINTERVIEWED BY

DO NOT WRITE BELOW THIS LINE

REMARKS (IF APPLICABLE)

APPROVED: 1. 2.ADMINISTRATOR SUPERVISOR/DEPARTMENT HEAD DATE

KNOWN

LICENSE / CERTIFICATION TYPE NUMBER EXPIRATION DATE STATE ISSUED

NAME ADDRESS BUSINESS YEARS

HIRED DATE EMPLOYEE NUMBER

POSITION VERYFIED BY

...PERSONNEL CHECK LIST

EMPLOYEE NO:EMPLOYEE NAME:STREET ADDRESS: SOCIAL SEC NO:CITY/STATE/ZIP: TELEPHONE NO:

JOB TITLE: CELLULAR NO:DATE APPLIED: E-MAIL:

PERFORMANCE EVAL (90 DAYS) DATE OF HIRE:

CRIMINAL BACKGROUND CHECK (FDLE)/OIG/GSATAX EXEMPT FORM (IF APPLICABLE) (CONTRACTORS ONLY)

REFERENCES (2) EMERGENCY NOTIFICATION

EXP DATE EXP DATE EXP DATE

YEAR

____AUTOMOBILE INSURANCE - ____CAR REGISTRATION

____CPR CARD

_____PROOF OF CITIZENSHIP - _____SOCIAL SECURITY CARD

____INFECTION CONTROL

PROF LICENSE/ CNA CERTIFICATE

____DRIVER LICENSE

____PHYSICAL EXAMINATION FORM (2 Steps PPD)

COMPETENCY SKILL/ EVALUATION CHECKLIST( INITIAL & 3 YEARS)

____HHA 40 HOURS/ HOURS CERTIFICATION

____RESUME

PERFORMANCE EVALUATION ( 90 DAYS & ANNUALLY )

____FLU / INFLUENZA VACCINATION

DESCRIPTION YES CONFIDENTIAL ENVELOPE YESAPPLICATION FOR EMPLOYMENT/RESUME INS FORM 1-9 (ANOTHER FILE)

CONTRACTOR AGREEMENT (IF APPLICABLE) DRIVER LICENSE/'' S CARD/PROOF OF CITIZENSHIP

ACKNOWLEDGMENT OF POLICY & ALZHEIMER'S DIS. AFFIDAVIT OF COMPLIANCE WITH BACKGROUND

TRANSPORTATION RESPONSIBLY HEALTH QUESTIONNAIRE (SEPARATE FILE)

ACKNOWLEDGMENT OF PROBATIONARY PERIOD HEPATITIS DECLINATION FORM (SEPARATE FILE)

STATEMENT OF COMMITMENT PHYSICAL EXAMINATION FORM (SEPARATE FILE)

INFECTION CONTROL /STANDARD PRECAUTIONS IRS FORM W-4. OR W-9 (CONTRACTOR ONLY) (ANOTHER FILE)

JOB DESCRIPTION PROFESSIONAL LIABILITY INSURANCE

ORIENTATION CHECKLIST AUTOMOBILE INSURANCE

CONFIDENTIAL STATEMENT/PHI PLEDGE OF CONF. LICENSE VERIFICATION (Check before or on the DOH)

CODE OF CONDUCT COMPETENCY SKILLS/EVALUATION CHECKLIST (INITIAL)

STAFF SAFETY CHECKLIST GLUCOSE METER u / HAND HYGIENE COMPETENCY

INDIVIDUAL STATEMENT OF CONFLICT OF INTEREST COMPETENCY TEST or RN/LPN TEST

____PROFESSIONAL LIABILITY INSURANCE (1 & 3 MILLIONS)

HIV/AIDS: ____4 HOURS (one time) / ____1 HOUR

____OSHA / ____HIPPA / ____MEDICAL ERRORS:

____DOMESTIC VIOLENCE / ____ALZHEIMER'S DISEASE

____HHA MANDATORY 12 HOURS IN-SERVICE YEAR YEAR

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DOCUMENTS REQUIRED FOR PT/ST/OT APPLICATIONDOCUMENTOS REQUERIDO PARA LA APLICACION DEL PT I ST I OT

STATE OF FLORIDA LICENSELicencia de terapista del Estado de la Florida

1.

PROOF OF LIABILITY INSURANCE2.

3. CPR CARDTarjeta de CPR

4. HIV/AIDS update certificateCertificado de HIVIAIDS (renovacion)

5. OSHA update certificate(Certificado de OSHA (renovacion)

6. Domestic Violence CertificateCertificado de Violencia Domestica

Alzheimer's DiseaseCertificado de La E-nfen-nedad de Alzheimer

7.

Driver LicenseLicencia de Manejar

8.

Automobile InsuranceSeguro del Atitomovil (e/ que usa para trabajar)

9.

10. Proof of Citizenship/Residency (Voter Registration, Resident Card, etc.)Prueba de ciudadania / residencia

Social Security CardLa tarjeta de, Social Security

11.

Physical Examination ( 2 steps ) (Less than six (6) months )Examen fisico, por un medico (con fecha de menos de 6 meses)

12.

INDEPENDENT CONTRACTOR AGREEMENT

THIS AGREEMENT is effective as of and is by anda Florida corporation (''Company'') andbetween

(''Contractor'').

RECITALS:

WHEREAS, the Company is primarily involved in the business of providing HomeHealth Services to persons requiring these services; and

WHEREAS, the Company wishes to -engage the Contractor and the Contractor wishes tobe so engaged, to provide Home Health Services to persons designated by the Company, as anindependent contractor, upon the terms and conditions contained below;

NOW, THEREFORE, in consideration of these premises, mutual promises, covenants,terms and conditions contained herein, and other good and valuable considerations, the receiptand sufficiency of which are acknowledged by the parties, the parties agree as follows:

Services. Contractor shall provide, directly to Home Health Services personsI .designated by the Company, services at such times and at such places as shall be agreed tobetween the Company and the Contractor. Contractor agrees that all patients are accepted forservices only by the Company.

Compensation. The contractor shall be entitle to receive from the Company a2.provided by the Contractorpayment with respect to each service of

to persons designated by the Company, which compensation is (and shall be paid) as set forunder Ext-jibit ''A'' labeled and attached hereto and initialed by the parties hereto. Contractorshall not be entitled to any other compensation, and Contractor shall not be entitled to receive&-iy reimbursement for any costs or expenses incurred by the Contractor. In connection withservices provided by the Contractor, the Contractor shall prepare and provide to the Company, asmay be reasonably requested, all reasonable documentation of such services in order that theCompany, or any other entity designated by the Company, may comply with appropriate Federaland state laws with respect to the reimbursement by the Company, or such other entity, of thepayments by the Company to the Contractor as compensation herein.

Contractor's Representations. Contractor represents to the Company that3.Contractor is, and will continue to be during the term of this Agreement, duly licensed asnecessary in the State of Florida to provide the services hereunder. and the execution of thisAgreement by the Contractor does not conflict with any other agreement to which the Contractoris a party. Contractor also represents that Contractor will perform hereunder without negligenceand in compliance with all applicable laws including, without limitation, professionalregulations. Contractor will dress appropriately while providing services.

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4. Insurance. Contractor shall be responsible for obtaining and maintaining appropriatelevels of professional liability insurance to cover the Contractor's performance hereunder.Contractor is required to provide Company a valid Certificate of Insurance reflecting professionalliability insurance coverage immediately upon the request of Company.

In addition, Contractor is required to maintain automobile liability and personal injuryprotection insurance and shall provide proof of such insurance to the Company wheneverrequested.

Contractor must immediately notify Company if the Contractor's professional liability,automobile or PIP insurance is terminated, expires or is reduced, whether such action wasinitiated by the insurance Company or the Contractor.

Term. This Agreement shall commence as of the date first written above and shall5.continue for successive one (1) year terms, unless sooner terminated as follows: (1) thisAgreement can be terminated by either party hereto upon thirty (30) days' written notice prior tothe commencement of the successive one (1) year period; (ii) this Agreement may be paycompensated due to the Contractor hereunder within forty-five (45) days of the receipt by theCompany of wTitten notice of demand of same by the Contractor to the Company; (iii) thisAgreement may be terminated by the Company at any time without notice in the event theContractor breaches any covenant or representation under this Agreement, or (iv) this Agreementmay be terminated at any time upon mutual written consent of the parties.

Independent Operation and Indemnity. This parties acknowledge that neither (1) theContractor, nor (ii) the Company, or any of their affiliates (including, without limitation,principals, employees, agents and executive officers. if any), shall be deemed hereunder jointventurers, principals, partners, employees or agents of the other party hereto; provided all of theduties, obligations and responsibilities of the Contractor, and all activities with respect to thesatisfaction of the foregoing, shall be conducted by the Contractor of the foregoing, shall beconducted by the Contractor independent of the Company as an independent contractor. TheContractor shall inderrmify and hold the Company harmless from any and all claims of everykind and description whatsoever asserted against the Company arising out of the performance by

6

the Contractor of Contractor's duties, obligations and responsibilities hereunder.Notwithstanding anything contained herein, the Contractor shall not be permitted to delegate anyof the Contractor's duties hereunder to any employee, not employed by the contractor, and forwhich the company has not received a completed and updated personnel file. Notwithstandinganything contained herein, the Contractor shall not be permitted to delegate any of theContractor's duties hereunder to any agent or other person without the written consent of theCompany. The Contractor is not entitled to participate in any plans, arrangements ordistributions of the Company in connection with any pension, stock. bonus, profit sharing or anyother plans or benefits paid or made available to regular employees of the Company. Contractorshall have general control of Contractor's activities with the right to exercise independent goodjudgment as to the manner (but only as permitted hereunder) of servicing patients, customersand otherwise carrying out the provisions of this Agreement. In acting as an independentcontractor

2

hereunder Contractor shall be required to make arrangements for insurance, licenses and permitsI

and for the payment of income taxes and social security taxes with regard to any paymentsreceived by Contractor and Contractor's services.

Restrictive Covenant and Confidentiality. All. Statistical, financial and personaldata relating to the patient which is confidential and which is clearly designated a s such, will bekept in the strictest of confidence by Contractor and Company. Accordingly, Contractor agreesnot to compete with Company for those patients and legal entities Contractor has serviced underthis Agreement,

The Contractor acknowledges and agrees that information concerning the patients.suppliers, office files, procedures and policies, and other aspects of the business of the Company,is confidential, and in connection therewith, the contractor agrees not to use or disclose any suchinformation at any time except as permitted under or as otherwise permitted in writing by theCompany. The Contractor agrees to immediately surrender all such information in thepossession or control of the Contractor, including all reproductions thereof, upon any terminationof this Agreement.

The Contractor hereby agrees and acknowledges that (1) this Section and eaen of itsprovisions are reasonable as they relate to restrictions and limitations upon the Contractor, (ii)neither this Agreement nor this Section will operate as a bar to the Contractor's sole means ofsupport, (iii) this Section may be enforced by the Company through use of an injunction or anyother equitable remedy given the of the amount of damages to the Company for a breach of thisSection. in addition to any other remedies the Company may have hereunder or under law, (iv)the Company shall be entitled to reimbursement from the Contractor for legal fees, costs andexpenses incurred by the Company through all appeals, if any, to enforce this Section (v) thisSection shall survive any termination of this Agreement; and (vi) if any provision of this Sectionis deemed unenforceable by a court of competent jurisdiction for whatever reason, such termshall be substituted with such ten-n of immediately lesser duration or effect which shall bedeemed enforceable,

Disclosure and Access. Contractor agrees and acknowledges that it will promptly8.notify Company, in writing, of any inquires, investigations, complaints, and any disciplinaryactions taken by any entity based on the Contractor's actions or inactions. Contractor herebyauthorizes any entity regulating or supervising the Contractor to release to Company allin-formation relating to such complaint or disciplinary action.

Contractor also agrees to provide Company access, upon request, to the Contractor',,books, documents, and records. Contractor also agrees to allow federal and state agents accessto books and records to verify the costs and reasonableness of the services furnished.

Third Party Beneficiaries. this agreement has been entered into solely for the9.benefit of the parties hereto and in no event whatsoever shall any other party or parties bedeemed a third part- beneficiary or beneficiaries of this Agreement.

3

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10. COMPANY RESPONSIBILITIES UNDER THIS CONTRACTBoth Company and Contractor agree that the Company has the following responsibilities underthis contract:

a) admitting clients for services and maintains all records of visits within thecompany patient recordscheduling of delivery/visitsb)specifying types and time frames for Company required documentation to be

c) completed and submitted to Companyd) providing Contractor review and agree to comply with the policies and procedures

including personnel, specifically addressing Contractor's qualifications and jobduties/responsibilities

e) client assessments. reassessments, formulation and revision of service plans anddischarge planning, visit schedule for Home Health Services visits. Contractorshall participate with Company in these activities as qualified and stipulated inContractor's agreement.

f) The company will make all payments to the contractor on a biweekly basis,Friday, if all documentation is in for those services specified and completed toagency policies and procedures, as per contract.The company will perform first on-site evaluation, 90 day and annualevaluations/competency of the contractors staff performing services, in the home.for the company. This will be done with a professional of the same discipline andthe DON/designee provided by the company and arranged with the contractor tobe done at the time of the home visit of the contractor staff. The company mayalso make unannounced visit to ensure that the agency care/services are beingperformed as per agency policies and procedures.

g)

CONTRACTOR RESPONSIBILITIES UNDER THIS CONTRACT

Both the Company and the Contractor agree that the Contractor has the following responsibilitiesunder this contract:

a) contractor will provide to the agency all documentation of services performed no laterthan Tuesday of the following week

b) follow scheduled visits and notify agency pf any changes immediatelyc) maintain and comply with all agency policy and procedures including, but not limited

to Medicare conditions of participation when applicable.A

d) under (e) in Company responsibilities Contractor shall; participate with the Company inthese activities as qualified and stipulated in Contractor's a,greement

c) Contractor will assist as per Company with evaluations/competencyf) Contractor will provide agency with all specified personnel files as per agency policies

and procedures. These must be reviewed and approved for completeness by theCompany- Contractor must have completed agency orientation with agency policies andprocedures before date of hire can be established and first case to be assigned

4

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11. Miscellaneous. This Agreement shall be governed by Florida law, with the solevenue for any action, suit or preceding arising hereunder to be County, Florida. Noamendment to or assignment of this Agreement will be valid unless in writing and signed by theparties signing below. This Agreement may not be waived unless such waiver is in writing andsigned by the waiving party. Each party acknowledges having been represented by independentlegal counsel in connection with this Agreement or having waived such right. This Agreementsets forth the entire agreement of the parties as to the subject hereto and supersedes any prioragreement. Each party will execute such reasonable documents and take such reasonable actionas may be reasonably requested to give effect to this Agreement. All costs and expenses of theparties in connection with this Agreement shall be borne by each such party incurring such costsand expenses. This Agreement may be executed in any number of counterparts.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the dayand year first above written.Witnesses: Company

By:

Contractor:

By:

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POSITION:NAME:

ACKNOWLEDGMENT OF POLICIES AND PROCEDURESAND

ALZHEIMER'S DISEASE

I, I hereby acknowledge that I have read, understood, andaccept the Policies and Procedures as true and that I shall abide by the, same while affiliated with theAgency also acknowledge that I received a copy of the ''Alzheimer's disease and Related Dementias"Handout on the date of hire

Initial

TAX EXEMPT FORM

, hereby acknowledge that I am an independent contractor,I,Therefore, I am responsible for my social security and taxes and I will receive an IRS 1099 form for thepreceding year by February 1, of each year which is also sent to the Internal Revenue Service.

As an independent contractor, I am not eligible for any benefit such as vacation, disability orunemployment and will not be covered by Workmen's Compensation.

Initial

TRANSPORTATION RESPONSIBILITY CONTRACT

It has been explained to me that I am being offered employment by the Agency with the understandingthat I have personal transportation at my disposal to be used for, travel to and from the patientassignments I further understand that I am responsible for auto liability for bodily injury and propertydamage insurance.

Initial

ACKNOWLEDGMENT OF PROBATIONARY PERIOD

in accepting employment with the Agency acceptI,and understand that the first 90 days of employment will be considered my probationary period, If for anyreason my employment is terminated during this period, I understand and accept that this account will notbe charged with any unemployment benefits that I may be eligible to receive under the State of Floridaunemployment compensation law.

I also understand and accept that at the end of the 90 days period, I will receive a written evaluation of mywork performance. Should the agency fail to provide this written evaluation, it shall be understood andaccepted by all involved that the probationary period will have been completed satisfactorily,

Initial

1I

(Independent Contractors)

CONFIDENTIALITY STATEMENT

I have been formally instructed regarding the agency's policy and procedures for maintaining the confidentiality andprivacy of all information contained in patient/client/personnel files and records, as well as any information that isobtained verbally.

I understand that, except as needed to conduct business, patient/client and/or personnel information may riot bediscussed with anyone either inside or outside the agency,

I understand that no medical records are to be removed from the home health agency unless a ''Release ofInformation'' form has been completed and signed by the patient/client,

I understand that any breach of confidentiality may be grounds for immediate termination of employment,

I have been formally instructed in the policies and procedures of the Agency regarding full compliance with all HIPAAregulations,

Signature: Date:

PROTECTED HEALTH INFORMATION PLEDGE OF CONFIDENTIALITY

I, the undersigned, have read and understand the Agency (hereinafter "the Agency'') policy on confidentiality ofprotected health information ("PHI'') as described in the Confidentiality Policy which is in accordance with relevantstate and federal legislation,

I also acknowledge that I am aware of and understand the Policies of the Agency regarding the security of PHIincluding the policies relating to the use, collection. disclosure, storage and destruction of PHI.

In consideration of my employment or association with the Agency, and as an integral part of the terms andconditions of my employment or association, I hereby agree, pledge and undertake that I will not at any time, duringmy employment or association with the Agency, or after my employment or association ends, access or use PHI, orreveal or disclose to any persons within or outside the Agency, any PHI except as may be required in the course ofmy duties and responsibilities and in accordance with applicable Legislation, and the Agency policies governingproper release of information.

I understand that my obligations concerning the protection of the confidentiality of PHI relate to all PHI whether Iacquired the information through my employment or contract or association or appointment with the Agency or withany of the entities, which have an association with the Agency

I also understand that unauthorized use or disclosure of such information will result in a disciplinary action up to andincluding termination of employment or contract or association or appointment, the imposition of fines pursuant toorelevant state and federal legislation, and a report to my professional regulatory body.

I have been informed of the contents of the Agency's PHI Confidential Policy and the consequences of a breach.

DateSignature of Individual making pledge

I have discussed the PHI Confidential Policy and the consequences of a breach with the above named.

DateSignature of individual administering pledge

I understand that, except as needed to conduct business, patient/client and/or personnel information may riot bediscussed with anyone either inside or outside the agency,

CODE OF CONDUCT

It is the objective of the Agency, to provide equipment, supplies and related service inaccordance with all applicable laws, regulations and statutes. The agency believes thatits employees and subcontractors share this objective and wish to perform their jobs ina competent, legal and ethical manner and thus, have established a Code of Conductas a demonstration of that commitment.

I agree to:

Always perform my duties and responsibilities to the best of my ability.1 .

Treat all patients/clients with care, courtesy and respect and maintainpatient/client confidentiality at all times,

2.

3. Protect all patient/client rights and report any failure to observe patient/clientrights by any person promptly.

4. Always speak truthfully to all persons with whom I have contact in the course ofmy duties, including patients/clients, family members, other employees andgovernment officials.

5. Obey all laws which may apply to the performance of my duties.

6. Make sure all documents or records which I prepare contain only accurate andtruthful information.

7. Observe all other standards of conduct which apply to my position.

Report any activities that may violate this Code of Conduct to the agency'sAdministrator.

8.

I hereby certify that I have received, read and agree to abide by this Code of Conduct.

Employee/Subcontractor Signature

Date

a

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST

I have read and am fully familiar with the Agency's policy statement regarding conflictof interest, I am not presently involved in any transaction, investment or other matter inwhich I would profit or gain directly or indirectly as a result of my membership on theAgency Board of Directors or its committees or my employment. Furthermore, I agreeto disclose any such interest which may occur in accordance with the requirements ofthe policy and agree to abstain from any vote or action regarding the Agency's businessthat might result in any profit or gain, directly or indirectly, for myself,

DateSignature

Print Name

HEPATITIS B DECLINATION FORM

Discipline:Name:

Hepatitis B is a major infectious occupational health hazard in the health-care industry,The critical risk for health personnel is contact with blood and other body fluidsPersons previously infected with Hepatitis B virus (HBV) are immune to the disease,For persons who have riot had the disease, Hepatitis B vaccine will provide immunity.The vaccine is given in three separate doses and failure to receive all doses may causethe vaccine to be ineffective and not result in immunity. Clinical studies have shownthat 85% to 96% percent of these vaccinated evidence immunity. Periodic testing ofvaccinated persons for antibody to Hepatitis B will confirm immune status.

I understand that due to my risk of occupational exposure to blood or other potentiallyinfectious material I may be at risk of acquiring Hepatitis B virus (HBV) infections. Ihave been given the opportunity to be vaccinated with Hepatitis B vaccine, at no chargeto myself,

I have read the above information and have received verbal and written instructionsregarding the efficacy, risk and complications of receiving the vaccine. Any questions Ihad have been answered. I acknowledge that I am aware of the availability of theHepatitis B vaccine and the benefit that such vaccination provides in the prevention ofinfection with Hepatitis B virus.

[ ] I decline Hepatitis B vaccination at this time because I have completelythe three 3 doses of the Hepatitis B vaccine. I have attached a copy ofHepatitis B Vaccination Record.

I decline Hepatitis B vaccination at this time, I understand that bydeclining this vaccine, I continue to be at risk of acquiring Hepatitis B. If inthe future I continue to have occupational exposure to blood or otherpotentially infectious material, I will want to be vaccinated with Hepatitis Bvaccine. I can receive the vaccination series at no charge to me.

I accept vaccination with the Hepatitis B vaccine. I have read the aboveinformation concerning the Hepatitis B vaccine. I understand I mustcomplete the three (3) doses series for full immunization. I can receivethe vaccination series at no charge to me.

WitnessSignature of Applicant

Date

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EMPLOYEE SAFETY CHECKLIST

Date:

Employee:

On I reviewed the above checked items relating to the safetyrules and safe work procedures for the Agency.

Employee Signature:

Administrator/Safety officer Signature:

________________________________________________

Employee will initial each box when instruction is completed and allquestions/concerns have been answered.

1- General safety policy and program

2- Safety rules- general

3- Safety rules-specific to job

4- Employee counseling (discipline for safety policy violation)

5- Fire prevention, location of fire fighting equipment, and location of exits

6- Disaster Planning Emergency Preparedness

7- How, when, and where to report injuries

8- Housekeeping and cleaning up spills

9- When and where to report unsafe conditions

10- Proper body mechanic procedures

[ ]

[ ]

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EMERGENCY CONTACT INFORMATION

Position:Employee Name:

Telephone: Bp: Cell:

1. Emergency Contact

Name:

Relationship:

Phones: Cell: (Bp: ( ) ( ) )

Work ( )

Address

2. Emergency Contact

Name:

Relationship:

Phones: Cell: (Bp: ( ) ( ) )

Work ( )

Address

HEALTH QUESTIONNAIRE

Name Social Security #

This questionnaire must be filled out completely by all staffs.

Do you have, have you ever had, or have you been told you might have any of the followingphysical condition, ailments or diseases? Please check the appropriate box if the answer is

11 If a box is checked, give details as to time, duration, treatment and names of doctors on''YES.reverse side of this form.

Hypoglycemia EmphysemaMarie-Strumpet Disease OsteomyelitisMultiple Sclerosis DermatitisRupture or Hernia AllergyBack Trouble or Injury Hemophilia (Bleeder)Tuberculosis High Blood PressureLung or Bronchial Trouble Heart TroubleLead Poisoning Varicose VeinsDiabetes ArteriosclerosisEpilepsy Mental TroublesVenereal Disease Hearing DefectsRheumatic or Gout Eye TroublePolio Thrombophlebitis

Have you been in the armed forces? NoYesAre you receiving disability? NoYes

NoYesHave you ever had a job-connected disease or injury?N oIf yes? Did you receive compensation? Yes

Medical Benefits? Yes No If so, How long?Have you been given a disability rating as a result of any type of injury or illness?

Yes NoN oDo you wear a truss or brace of any kind? Yes

N oYesHave you been told by a physician to wear a truss or brace or any kind?Do you have or have you had any other injury or disability not mentioned above?

Yes No

I understand this record is submitted as an inducement to gain employment and is to becomepart of my employment record. I swear/or affirm that any answers and/or information given onboth sides of this form are true and correct and authorize you to consult previous employers.

DateSignature of Applicant

STATEMENT OF COMMITMENT

I have read and understand_______________________________________________________ (''the Agency') personnel Policy Manual. In compliance with those policies I agree to conform to the following:

I will always maintain professionalism in the home to which I am assigned.

I will IMMEDIATELY contact the Agency regarding any areas of discrepancy between theclient's/patient's assessment of the assignment requirements and my understanding of myspecific performance level as designated by the Agency

I have read and understand the Agency job description which is appropriate to my level ofperformance. I will not accept assignments beyond my designated performance level asdetermined by the Agency.

I will abide with the Agency Standard Code of Dress as described in the Personnel Policy Manual.

I will not accept any money or gifts from the Agency's client/patient/caregiver. I will receivepayment for services rendered directly from the Agency.

I will arrive on time for the assignments I have accepted. In the event of an emergency which maycause me to be late or if I am unable to meet my assignment commitment, I will notify theAgency's office of the situation and expected arrival time. I also understand that not calling theAgency will be grounds for termination immediately.

I will not make or accept personal telephone calls on the ciient's/patient's telephone.

I will not smoke in a client's/patient's home.

I will not transport a client/patient or family member in my personal vehicle.

Initial

INFECTION CONTROL/STANDARD PRECAUTIONSBIOMEDICAL WASTE PROTOCOL

ANDSAFETY AND RISK MANAGEMENT

I hereby acknowledge that I have read and understood the Infection Control/Standard Precautions Policy,Bio-Medical Waste Protocol and Safety/Risk Management contained in the field staff procedures manual.I am familiar with the procedures appropriate to my position as a field employee/contractor.

Initial

I have read, understood and will abides to the policy and procedures. Failure to comply with thesepolicies may result of being placed under suspension or termination from work.

Date:Signature:

Reference/Facility Name: /Address:

Your name has been given as a reference by the applicant listed below. Your assistance is important in the thoroughscreening of our applicant. This information is confidential.

Sincerely,

Applicant's Signature

I hereby authorize the following information to be released to ____________________________________________

Date of employment: From T o

Name of Applicant: Social Security No.

RN L P N HHA PT RT OT MSW Other

Evaluation Check: FAIR POOREXCELLENT GOODJob Knowledge

Quality of Work

Quantity of Work

Attitude

Dependability

Punctuality

Personal Appearance

Eligible for re-employment:YES NO If no, please explain:To your knowledge does this applicant have any disability that would adversely affect the performance of his/herduties: YES NO If yes please explainDo you recommend this applicant: YES NO I If no please explain:In your opinion will this candidate be suitable for independent assignment. YES NOIf no please explain

GOOD EXCELLENTHow would you rate this employee's technical skills: POOR FAIR

Signature ( Reference ):________________________________ Tiltle: ___________________________ Date: ______________

Reference Information Request___________________________

X

Reference/Facility Name: /Address:

Your name has been given as a reference by the applicant listed below. Your assistance is important in the thoroughscreening of our applicant. This information is confidential.

Sincerely,

Applicant's Signature

I hereby authorize the following information to be released to ____________________________________________

Date of employment: From T o

Name of Applicant: Social Security No.

RN L P N HHA PT RT OT MSW Other

Evaluation Check: FAIR POOREXCELLENT GOODJob Knowledge

Quality of Work

Quantity of Work

Attitude

Dependability

Punctuality

Personal Appearance

Eligible for re-employment:YES NO If no, please explain:To your knowledge does this applicant have any disability that would adversely affect the performance of his/herduties: YES NO If yes please explainDo you recommend this applicant: YES NO I If no please explain:In your opinion will this candidate be suitable for independent assignment. YES NOIf no please explain

GOOD EXCELLENTHow would you rate this employee's technical skills: POOR FAIR

Signature ( Reference ):________________________________ Tiltle: ___________________________ Date: ______________

Reference Information Request___________________________

X

INSTRUCTIONS TO PRINTERSFORM W-9, PAGE 1 of 4MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD to HEADPAPER: WHITE WRITING, SUB. 20. INK: BLACKFLAT SIZE: 216mm (81⁄ 2 ") 3 279mm (11")PERFORATE: (NONE)

Give form to therequester. Do notsend to the IRS.

Form W-9 Request for TaxpayerIdentification Number and Certification

(Rev. October 2007) Department of the TreasuryInternal Revenue Service Name (as shown on your income tax return)

List account number(s) here (optional)

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

City, state, and ZIP code

Pri

nt o

r ty

pe

See

Sp

ecifi

c In

stru

ctio

ns o

n p

age

2.

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoidbackup withholding. For individuals, this is your social security number (SSN). However, for a residentalien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it isyour employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Social security number

or

Requester’s name and address (optional)

Employer identification number Note. If the account is in more than one name, see the chart on page 4 for guidelines on whosenumber to enter. Certification

1. 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 InternalRevenue 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 hasnotified me that I am no longer subject to backup withholding, and

2.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding 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 retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you mustprovide your correct TIN. See the instructions on page 4. SignHere

Signature ofU.S. person ©

Date ©

General Instructions

Form W-9 (Rev. 10-2007)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

13 I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

TLS, have youtransmitted all R text files for this cycle update?

Date

Action

Revised proofsrequested

Date

Signature

O.K. to print

Use Form W-9 only if you are a U.S. person (including aresident alien), to provide your correct TIN to the personrequesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you arewaiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S.exempt payee. If applicable, you are also certifying that as aU.S. person, your allocable share of any partnership income froma U.S. trade or business is not subject to the withholding tax onforeign partners’ share of effectively connected income.

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

A person who is required to file an information return with theIRS must obtain your correct taxpayer identification number (TIN)to report, for example, income paid to you, real estatetransactions, mortgage interest you paid, acquisition orabandonment of secured property, cancellation of debt, orcontributions you made to an IRA.

Individual/Sole proprietor

Corporation

Partnership

Other (see instructions) ©

Note. If a requester gives you a form other than Form W-9 torequest your TIN, you must use the requester’s form if it issubstantially similar to this Form W-9.

● An individual who is a U.S. citizen or U.S. resident alien, ● A partnership, corporation, company, or association created or

organized in the United States or under the laws of the UnitedStates, ● An estate (other than a foreign estate), or

Definition of a U.S. person. For federal tax purposes, you areconsidered a U.S. person if you are:

Special rules for partnerships. Partnerships that conduct atrade or business in the United States are generally required topay a withholding tax on any foreign partners’ share of incomefrom such business. Further, in certain cases where a Form W-9has not been received, a partnership is required to presume thata partner is a foreign person, and pay the withholding tax.Therefore, if you are a U.S. person that is a partner in apartnership conducting a trade or business in the United States,provide Form W-9 to the partnership to establish your U.S.status and avoid withholding on your share of partnershipincome. The person who gives Form W-9 to the partnership forpurposes of establishing its U.S. status and avoiding withholdingon its allocable share of net income from the partnershipconducting a trade or business in the United States is in thefollowing cases: ● The U.S. owner of a disregarded entity and not the entity,

Section references are to the Internal Revenue Code unlessotherwise noted.

● A domestic trust (as defined in Regulations section301.7701-7).

Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ©

Exempt payee

Purpose of Form

AlzheimerResource Center

Prepared by the Florida Health Care Association with the assistance of the Alzheimer ResourceCenter of Tallahassee, Florida to meet the statutory requirement of 400.4785(l) (a) F.S.

ALZHEIMER'S DISEASE (AD) AND RELATED DEMENTIASHistoryAlzheimer's disease (AD) was first discovered in 1906 by a German doctor named Alois Alzheimer. It is adisorder of the brain, causing damage to brain tissue over a period of time. The disease can linger from 2 to25 years before death results. AD is a progressive, debilitating and eventually fatal neurological illnessaffecting an estimated 4-5 million Americans. It is the most common form of dementing illness.Alzheimer's disease is characterized clinically by early memory impairment followed by language andperceptual problems. This disease can affect anyone - it has no economic, social, racial or national barriers.CausesThere is no one cause for Alzheimer's disease. AD may be sporadic or passed through the genetic make-up.The disease causes gradual death of brain tissue due to biochemical problems inside individual brain cells.The symptoms are progressive, but there is great variation in the rate of change from one person to another.Although in the early stages of Alzheimer's the victim may appear completely healthy, the damage is slowlydestroying the brain cells. The hidden process damages the brain in several ways:

Patches of brain cells degenerate (neuritic plaques). Nerve endings that transmit messages become tangled (neurofibrillary tangles)

There is a reduction in acetylcholine, an important brain chemical (neurotransmitter)Spaces in the brain (ventricles become larger and filled with granular fluid)

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. The size and shape of the brain alters - the cortex appears to shrink and decayUnderstandably, as the brain continues to degenerate, there is a comparable loss in mental functioning. Sincethe brain controls all of our bodily functions, an Alzheimer victim in the later stages will have difficultywalking, talking, swallowing and controlling bladder and bowel functions. They become quite frail andprone to infections such as pneumonia.

Dementia vs. Normal AgingAs a person grows older, he/she worries that forgetting the phone number of a best friend must mean he/sheis becoming demented or getting Alzheimer's disease. Forgetfulness due to aging or increased stress is notnormal aging and is not dementia."Dementia'' is an encompassing term for numerous forms of memory loss. There are many types of dementiasuch as Alzheimer's disease, Multi-Infarct dementia or Parkinson's disease. When a person has dementia,he/she will lose the ability to think, reason and remember and will inevitable need assistance with everydayactivities such as dressing and bathing. Changes in personality, mood are also symptoms of dementia. Manydementias are treatable and reversible. Alzheimer's disease is the most common form of untreatable,irreversible dementia.

Alzheimer's Disease - Stages of ProgressionAlzheimer's Disease can be characterized as having early, middle, and late stages through which the patientgradually progresses, but not at a predictable rate. The range of the course of the disease is 2-25 years.NOTE: Stages very often overlap. Everyone progresses through these stages differently.

First Stage: This is a very subtle stage usually not identified by either the impaired person or the family asthe beginning signs of the disease. Subtle changes in memory and language along with some confusion occurat this time. The family usually denies or excuses the performance deficiencies at this stage.

Forgetfulness/memory lossimpaired judgmentTrouble with routinesLessening of initiativeDisorientation of time and places

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DepressionFearfulnessPersonality changeApraxia (forgetting how to use tools and equipment)Anomia (forgetting the right word or name of a person)

Second Stage: As Stage 1 moves onto Stage 2, there is usually a particular significant event which forces thefamily (and impaired person) to consider that something is really wrong. At this time, they usually go to adoctor to diagnose the problem.

Poor short-term memoryWandering (searching for home)Language difficultiesIncreased disorientationSocial withdrawalMore spontaneity, fewer inhibitionsAgitation and restlessness, fidgeting, pacingDeveloping inability to attach meaning to sensory perceptions: (taste, touch, smell, sight, hearing)inability to think abstractlySevere sleep disturbances and/or sleepinessConvulsive seizures may developRepetitive actions and speechHallucinationsDelusions

Third (Final Stage): This stage is the terminal stage and may last for months or years. The individual willeventually need total personal care. They may no longer be able to speak or recognize their closest relatives.

Little or no memoryinability to recognize themselves in a mirrorNo recognition of family or friendsGreat difficulty communicatingDifficulty with coordinated movementsBecoming emaciated in spite of adequate dietComplete loss of control of all body functionsincreased frailtyComplete dependence

COMMON PROBLEMS WITH DEMENTIADelusions

Suspiciousness: accusing others of stealing their belongingsPeople are "out to get them"Fear that caregiver is going to abandon (results in AD person never leaving caregiver's side)Current living space is not ''home''

HallucinationsSeeing or hearing people who are not present

Repetitive actions or questionsThey forget they asked the questionRepetitive action such as wringing a towel

WanderingPacingSundowning: trying to get ''home"Generally feeling uncomfortable or restlessIncreased agitation at night

Losing thing/Hiding thingsSimply do not remember where items areMight hide things so that people don't ''steal" them

Inappropriate sexual behaviorPerson with AD loses social graces and is only doing what feels good

Agnosia: inability to recognize common people or objectsA wife of forty years will become a stranger to the person with AD, he might even think she is thehired helpMight not recognize a spatula or the purpose of the spatula and/or cannot verbalize the name orpurpose of the object

Apraxia: loss of ability to perform purposeful motor movementsCannot tie a shoe or manipulate buttons on a shirt

Catastrophic reactions(Causes) AD person often becomes excessively upset and can experience rapidly changing moods. The personbecomes overwhelmed due to factors such as too much noise, too many people around, unfamiliarenvironment, routine change, being asked to many questions, being approached from behind.(Reactions) AD person may become angry, agitated, weepy, stubborn or physically violent. It is best toattempt to avoid catastrophic reactions rather than dwell on how to handle them.

HANDLING DISTURBING BEHAVIORSOne of the most difficult challenges for caregivers is how to handle some of the disturbing behaviors thatAlzheimer's can cause. Symptoms such as delusion, hallucinations, angry outbursts, suspiciousness, failureto recognize familiar people and places are often the most upsetting behaviors for families. The followingpoints may help in responding to disturbing symptoms.First, try to understand if there is a precipitating factor causing the behavior. Were there household changes,too much noise or activity, was the daily routine upset? Time of day can also affect behavior (Sundowning).Being aware of these factors can help to better plan activities or anticipate problems.1.2.3.4.5.6.7.

Keep tasks, directions and routine simple without being condescendingAlways give the person plenty of time to respondAttempt to remain calm and remind yourself that the behavior is due to the diseaseAvoid arguingWrite down the answers to frequently asked questions, then remind them to look at the messageReduce environmental noise: television, radio, too many people talkingUse distraction when unacceptable behavior starts: bring them into a different room, start talkingabout childhood or another favorite topic, show them magazines, ask them to help you do somethinglike dusting or sweepingDo not overreact or scold for problem behavior: redirect or distractBe reassuring with touch, eye contact and tone of voice

8.9.

Find the familiar: old pipe, favorite chair, family pictures10.Avoid denying hallucinations: try non-committal comments like, ''You spoke with your mother, I11.miss my mother too''Be sure to inform physician of hallucinations, no matter how tameRestless behavior or pacing is usually unavoidable, however you can make the environment safe byinstalling locks that are above reach, remove unnecessary obstacles, make sure the person is wearingsome kind of identification

12.13.

Alzheimer Resource Center of Tallahassee: (850) 561-6869 Website: www.arc-tallahassee.org

Alzheimer's Foundation of America Website: http://www.alzfdn.org

Employee Name: ______________________________

Date Signature ________________________

Employee Name: ______________________________

Alzheimer's disease is a progressive, degenerative disorder that attacks the brain's nerve cells, orneurons, resulting in loss of memory, thinking and language skills, and behavioral changes. Alzheimer'sdisease is the most common cause of dementia, or loss of intellectual function, among people aged 65and older.Home care is a very helpful choice for both the person with Alzheimer's disease and their familiesbecause it provides the very kind of care that is most important - service in the comfort and familiarity ofthe patient's own place of residence. Criteria for home care admission, for persons with end stagedementia, may not always be well known - the issues of mobility, nutrition and weight, verbalcommunication, problems with infection and overall decline are evaluated. The psychological and physicalsupport provided by home care teaching and supportive equipment can greatly relieve the familycaregiver. Caring for a person with Alzheimer's Disease (AD) is a challenge that calls upon the patience,creativity, knowledge, and skills of each caregiver.Our home heath agency treats patients with every kind of terminal condition and many different forms ofdementia, including persons with ADRDs. A proper assessment of a patient addresses the needs of theperson and his or her caregivers and family in a comprehensive fashion. This is especially important tothe family of a person suffering from ADRDs, since this person may have difficulty communicating his orher needs to family members. More than those with other diseases, these patients spend a long period atthe end of their lives bed bound, mostly unresponsive, and in need of total care. As with all of our patients,it is the goal of our home care program to care for the ADRD patient while supporting and comfortingfamily and loved ones regardless of the setting or the patient's daily abilities. These communicationchallenges become part of the task of you, the caregiver.It's common for people with Alzheimer's disease to have trouble with language. Perhaps the individualmay try describing an object rather than using its name because of difficulty thinking of the correct word.For example, the person might refer to the telephone as ''the ringer'', or ''that thing I call people with''. Ittakes much patience to communicate with individuals who forget names, struggle for the words they wantto use, never finish a sentence, or repeat the same phrase over and over--all problems that may beexperienced by people with Alzheimer's disease. To facilitate communication, try these strategies:* Relax. People with Alzheimer's communicate better when they do not feel pressured.* Keep distractions to a minimum. Turn off the radio and television. If others are in the room, find a quietspot.* When the person has trouble expressing a thought, guess what may be meant by asking questions they can answer with a yes or no. For example, " Do you mean ?" or ''Do you want to go ?* Sometimes people forget what they are saying and stop in the middle of a sentence. To help them startagain, calmly repeat the last few words they said. If they can't continue, ask a question that relates to whatthey had been saying.* Make sure you understand what they have said. Questions like, " You want to leave now, is that right?''or " You want some milk, don't you''? will verify what's been said.* You may have to decipher a meaning from a few words. The person's tone of voice and body languagemay also help you figure out what they mean. For example, a shaky voice and fidgeting behavior mayconvey fear more than their words can. Many people have limited access to the words they want to use.''Walk now'' may mean a person is uncomfortable and Wants to leave the room.

Date Signature

HOME CARE AND ALZHEIMER'S

AHCA Form # 3100-0008, August 2010 Section 59A-35.090(3)(b)2, Florida Administrative Code Page 1 of 3 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

Authority: This form may be used by all employees to comply with: • the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee

required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND

• the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which requires

proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the Agency, the Department of Health, the Agency for Persons with Disabilities, the Department of Children and Family Services, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651 if the person has not been unemployed for more than 90 days.

This form must be maintained in the employee’s personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application.

Employee/Contractor Name:

Health Care Provider/ Employer Name:

Address of Health Care Provider: I hereby attest to meeting the requirements for employment and that I have not been arrested for or been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:

Criminal offenses found in section 435.04, F.S

a) Section 393.135, relating to sexual misconduct with certain developmentally 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 782.04, relating to murder.

(e) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.

(f) Section 782.071, relating to vehicular homicide.

(g) Section 782.09, relating to killing of an unborn quick child by injury to the mother.

(h) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.

(i) Section 784.011, relating to assault, if the victim of the offense was a minor.

(j) Section 784.03, relating to battery, if the victim of the offense was a minor.

(k) Section 787.01, relating to kidnapping.

(l) Section 787.02, relating to false imprisonment.

(m) Section 787.025, relating to luring or enticing a child.

AFFIDAVIT OF COMPLIANCE WITH Background Screening

Requirements

AHCA Form # 3100-0008, August 2010 Section 59A-35.090(3)(b)2, Florida Administrative Code Page 2 of 3 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

(n) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.

(o) 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.

(p) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.

(q) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.

(r) Section 794.011, relating to sexual battery.

(s) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority.

(t) Section 794.05, relating to unlawful sexual activity with certain minors.

(u) Chapter 796, relating to prostitution.

(v) Section 798.02, relating to lewd and lascivious behavior.

(w) Chapter 800, relating to lewdness and indecent exposure.

(x) Section 806.01, relating to arson.

(y) Section 810.02, relating to burglary.

(z) Section 810.14, relating to voyeurism, if the offense is a felony.

(aa) Section 810.145, relating to video voyeurism, if the offense is a felony.

(bb) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.

(cc) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.

(dd) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.

(ee) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.

(ff) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.

(gg) Section 826.04, relating to incest.

(hh) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.

(ii) Section 827.04, relating to contributing to the delinquency or dependency of a child.

(jj) Former s. 827.05, relating to negligent treatment of children.

(kk) Section 827.071, relating to sexual performance by a child.

(ll) Section 843.01, relating to resisting arrest with violence.

(mm) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.

(nn) Section 843.12, relating to aiding in an escape.

(oo) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.

(pp) Chapter 847, relating to obscene literature.

(qq) Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang.

(rr) 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.

(ss) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.

(tt) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.

(uu) Section 944.40, relating to escape.

(vv) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.

(ww) Section 944.47, relating to introduction of contraband into a correctional facility.

(xx) Section 985.701, relating to sexual misconduct in juvenile justice programs.

(yy) Section 985.711, relating to contraband introduced into detention facilities.

(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.

Criminal offenses found in section 408.809(4), F.S

(a) Any authorizing statutes, if the offense was a felony.

AHCA Form # 3100-0008, August 2010 Section 59A-35.090(3)(b)2, Florida Administrative Code Page 3 of 3 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

(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 741.28, relating to domestic violence.

(f) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.

(g) Section 817.234, relating to false and fraudulent insurance claims.

(h) Section 817.505, relating to patient brokering.

(i) Section 817.568, relating to criminal use of personal identification information.

(j) Section 817.60, relating to obtaining a credit card through fraudulent means.

(k) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.

(l) Section 831.01, relating to forgery.

(m) Section 831.02, relating to uttering forged instruments.

(n) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.

(o) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.

(p) Section 831.30, relating to fraud in obtaining medicinal drugs.

(q) 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.

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: Screened conducted by: Date of Prior Screening:

Agency for Health Care Administration Department of Health Agency for Persons with Disabilities Department of Children and Family Services Department of Financial Services

Affidavit Under penalty of perjury, I, , hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In 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. Employee/Contractor Signature Title Date

HAND HYGIENE COMPETENCY TESTING

Discipline:Staff Name:

V = VerballyMethod Keys: 0 = Observed

METHODDATE PERFORMANCE CRITERIA Standard Met

Yes No V0

PROCEDURE

1. Line a clean area by the sink with paper towel.

2. Place the soap and paper towel roll on the lined paper towel.

3. Turn on water.

4. Regulate temperature to warm water.

5. Wet hands, with fingers pointed downwards.

6. Get soap.

7. Apply soap to hands and wrists.

8. Rub hands in circular motion.

9. Interlace fingers, rub back and forth, rub fingernails.

10. Count up to 15 seconds doing # 8 and #9.

1 1. Rinse hands with water with fingers pointing down.

12. Dry hands with paper towel.

13. Turn off faucet with paper towel.

14. Leave area clean and neat,

COUGH ETIQUETTE

Cover your mouth and nose with a tissue when you cough orsneeze, or cough or sneeze into your upper sleeve, not in yourhands.

ALCOHOL-BASED HAND RUB

Clean both hands with alcohol-based hand rub in place of handwashing with soap and water if your hands are notcontaminated with blood or body fluids.

Signature of Person Determining Competency/Title Date

DateSignature of Employee/Subcontractor

ORIENTATION CHECKLIST

Name: Position:

Please put a check mark:

Agency's Mission and VisionAgency's philosophy, goals and objectivesOrganizational Structure

Agency policies and procedures including, but not limited to:OSHANon-discriminationGrievance ProceduresPatient's Bill of Rights and ResponsibilitiesAdmission CriteriaHIV Training Update

Requirements of employmentJob DescriptionContract Agreement (if applicable)Evaluation (Probationary Period/Annually)Assignments/Proper DocumentationVisit Note / Missed VisitSupervisory VisitsPatient Privacy Rights / HIPAA ComplianceInfection Control/Standard PrecautionsEmergency PreparednessHours of Operations / Office staff and 24 Hours Answering ServiceAccident and Incident Reporting (Patients and Staffs)Abuse Hotline and AHCA Consumer HotlineNon-Retaliation Policy How to report concerns to The Joint Commission, State and/or FederalAgenciesScreening abuse, neglect and exploitationAdvance DirectiveConfidentiality of patient informationPayment Schedule/PayrollSafety & Risk Management including the Fall Prevention Program, Oxygen SafetyEthical issuesHazardous Materials/Waste ManagementQuality ImprovementUnanticipated adverse events

Registered Nurses l Qualified Therapist OnlyAdmission/Discharge/OASISCoordination of ServicesIV Administration (if applicable)

I hereby verify that I have had all my questions answered to my satisfaction and that Iunderstand all of the material covered.

Date-Signature:

Date:Supervisor/DON Signature:

PHYSICAL THERAPISTJOB DESCRIPTION

JOB SUMMARY

Professional member of patient's treatment team who evaluates, assesses, anddelivers services according to a written plan of treatment approved by a physician.Provides supervision for all services rendered by Physical Therapist Assistants.Supervises certified nursing assistant/home health aide (CNA/HHA) when appropriate.The physical therapist shall be accessible at all times by two way communication, whichenable the physical therapist to be readily available for consultation during the deliveryof care.

DUTIES AND RESPONSIBILITIES

Provides physical therapy services as prescribed by a physician which can besafely provided in the home and assisting the physician in evaluating patients byapplying diagnostic and prognostic muscle, nerve, joint and functional abilitiestest.

1.

2. Discusses evaluation with physician to help establish a plan of treatment toassist patient to meet maximum rehabilitation potential.

3. Carry out prescribed treatments; and/or supervise physical therapist assistant incarrying out physical therapy program.

4. Observes and records activities and finding in the clinical record and report to thephysician of the patient's reaction to treatment and any changes in the patient'scondition or when there are deviations from the Plan of Care.

5. Instructs the patient, patient's family and/or care giver in care and use of physicaltherapy devices.

6. Instructs other health team personnel including, when appropriate, CNA/HHAand/or care givers in certain phases of physical therapy with which they maywork with the patient.

7. Instructs the patient's family and/or care giver on the patient's total physicaltherapy program.

8. Maintains appropriate documentation of all services provided to the patient.

9. Participates the agency's meeting, case conferences and in-service.

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Understands and adheres to established polices and procedures.10.

Prepares clinical and progress notes.11.

Helps develop the plan of care and revise as necessary.12.

Updates personnel file in a timely manner.13.

QUALIFICATIONS

Must be licensed in the State of Florida.1 .

Must be a graduate of approval school.2.

At least one (1) years of experience in physical therapy preferred3.

WORKING ENVIRONMENT

May occasionally work indoors, in the Agency's office and patient's homes, and travelsto/from patient homes.

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 inphysical activity.

• Heavy lifting.

• Ability to do extensive bending, lifting and standing on a regular basis.

REPORTS TODirector of Nursing

I have read and understand the above position, and will abide all rules and regulations.

Applicant's Signature Date

Print Name

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PHYSICAL THERAPISTPERFORMANCE EVALUATION

Date:Name:

ANNUALPROBATIONARY

BELOW MEETS EXCEEDSPERFORMANCE DUTIES AND RESPONSIBILITIES:

Provides physical therapy services as prescribed by a physician which canbe safely provided in the home and assisting the physician in evaluatingpatients by applying diagnostic and prognostic muscle, nerve, joint andfunctional abilities test.

COMMENTS:

Therapist's Signature: Date:

Supervision's Signature: Date:

Discuss evaluation with physician to help establish plan oil care toassists patient to meet maximum rehabilitation potential.

Carry out prescribed treatments; and/or supervise PTA in carrying outphysical therapy program.

Observes and records activities and finding in the clinical record and reportto the physician of the patient's reaction to treatment and any changes inthe patient's condition or when there are deviations from the Plan of Care.

Instruct patient, patient's family and/or care giver in care and use ofphysical therapy devices.

Instruct other team members on proper techniques and body mechanicsfor assisting patient with treatment plan, including home health aidewhen appropriate.

Instruct the patient's family and/or care giver on the patient's total physicaltherapy program

Maintain appropriate documentation of all services provided to the patient.

Participate in case conferences, team meetings, staff meetings, and in-service programs.

Understands and adheres to established policies and procedures.

Prepares clinical and progress notes

Helps develop the plan of care and revise as necessary.

Updates personnel file in a timely manner.

Date:PT PTATitle:Therapist Name:

Other (specify)At least every 3 yearsInitialType of Evaluation:

3 - Never PerformedSelf Assessment Key: 1 - Proficient 2 - Needs to be observe

N/A - Not ApplicableV = VerbalO= ObservedMethod Keys:

Competency ValidationDate by supervisor

MethodStandard N/ASELFMetASSESSMENTCOMPETENCY STANDARD

a. Walker

1

COMPETENCY SKILLS/EVALUATION CHECKLISTPHYSYCAL THERAPY/ PHYSICAL THERAPIST ASSISTANT

1 2 3 YES NO 0 V

SKILLS

Evaluation & Treatment of:

1. ROM/Gonimety

2. Strength

3. Balance

4. Coordination

5. Functional Mobility

a. Bed Mobility

b. Transfer

c. W/C Mobility

d. Gait

6. Sensation

7. Muscle Tone

8. Edema

9. Endurance

10. Positioning

1 1. H ome/environ mental Safety

12. Pt/CG Teaching

13. Body mechanics

Equipment

1. Gait Devices

Competency ValidationDate by supervisor

N/AStandard MethodSELFMetASSESSMENTCOMPETENCY STANDARD

2. Other

3. Exercise Aids

5. Patient Monitors

6. Splints

2

1 2 3 YES NO O Vb. Crutches

c. Hemiwalker

d. Quad Care

e. Straight Care

f. Platforms for Walker

g. Platforms for Crutch

a. Wheelchair

b. Hoyer Lift

c. Sliding Board

a. Overhead Pulley

b. Free Weights

c. Theraband

d. CPM

4. Modalities

a. Ultrasound

b. TENS

c. Hot Pack

d. Cold Pack

e. Ice

a. Stethoscope

b. BP Cuff

c. Goniometer

d. Dynamometer

a. AFO

b. Back Brace

c. Cervical Collar

d. Knee Immobilizer

Method N/ACompetency Validation

Date by supervisor

StandardSELFMetASSESSMENTCOMPETENCY STANDARD

Yes NoBased on this assessment, Therapist is competent to perform all duties:

Requires additional training/experience in the following areas:

Documentation of experience/training is filed in individuals' personnel record.

Therapist's Signature/Title/Date Supervisor's Signature/Title/Date

3

1 2 3 YES NO O VPatient assessment documented

Treatment provided/patientresponse documented

Documentation of specificinstruction to patient/c.g.

Notes are clear, legible, signed &dated

Assessing and Managing Pain

Other

BAG TECHNIQUECOMPETENCY EVALUATION

Staff Name: Discipline:

V = VerballyObservedMethod Keys: 0=

PERFORMANCE CRITERIADATE Standard Met METHOD

v0

PROCEDURE

OTHER PROCEDURE

DateSignature of Person Determining Competency/Title

DateSignature of Employee/Subcontractor

Yes No

Supplies are maintained in the bag and checked for expiration on aregular basis.

Clean and disinfect bag at least weekly

Bag is place on clean and safe area (surface)

Barrier is utilized appropriate

Bag is placed out of reach of children and animals.

Plan ahead where to discard disposable items and sharps

Prior of going inside bag, wash hands as per the agency's HandHygiene Policy,

After hand washing, remove supplies and/or equipment needed forpatient care

Close bag while performing patient care.

Need additional supplies from bag during patient care, wash handsagain

Clean and dirty supplies are maintained separately

When patient care visit finish, wash hands and clean reusableequipment and supplies, such as stethoscope, blood pressure cuff,etc prior returning in bag

Wash hands prior to returning clean equipment to bag

Close bag

Form I-9 Instructions 03/08/13 N Page 2 of 9

3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the same as the A-Number without the "A" prefix.

4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident, but are authorized to work in the United States, check this box.

a. Record the date that your employment authorization expires, if any. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, may write "N/A" on this line.

b. Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, record your Admission Number. You can find your Admission Number on Form I-94, "Arrival-Departure Record," or as directed by USCIS or U.S. Customs and Border Protection (CBP).

(1) If you obtained your admission number from CBP in connection with your arrival in the United States, then also record information about the foreign passport you used to enter the United States (number and country of issuance).

(2) If you obtained your admission number from USCIS within the United States, or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuance fields.

Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date.

The Preparer and/or Translator Certification must be completed if the employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees with Disabilities (Special Placement)Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook for Employers: Instructions for Completing Form I-9 (M-274) on www.uscis.gov/I-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.

Preparer and/or Translator Certification

If you check this box:

1. A citizen of the United States

2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking one of the following four boxes provided on the form:

Form I-9 Instructions 03/08/13 N Page 3 of 9

2. Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number and expiration date (if any) from the original document(s) the employee presents. You may write "N/A" in any unused fields.

3. Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first day the employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's first day of employment.

4. Provide the name and title of the person completing Section 2 in the Signature of Employer or Authorized Representative field.

5. Sign and date the attestation on the date Section 2 is completed.

6. Record the employer's business name and address.

7. Return the employee's documentation.

If the employee is a student or exchange visitor who presented a foreign passport with a Form I-94, the employer should also enter in Section 2:a. The student's Form I-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number);

and the program end date from Form I-20 or DS-2019.

Employers or their authorized representative must:1. Physically examine each original document the employee presents to determine if it reasonably appears to be genuine

and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner of the documents and the employee must both be physically present during the examination of the employee's documents.

Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found on the last page of Form I-9, to establish identity and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one selection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee must present combination documents together to be considered a List A document. For example, a foreign passport and a Form I-94 containing an endorsement of the alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. If an employee presents a List A document, he or she should not present a List B and List C document, and vice versa. If an employer participates in E-Verify, the List B document must include a photograph.

Employers or their authorized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment. For example, if an employee begins employment on Monday, the employer must complete Section 2 by Thursday of that week. However, if an employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day of employment. An employer may complete Form I-9 before the first day of employment if the employer has offered the individual a job and the individual has accepted.

In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employee entered in Section 1. This will help to identify the pages of the form should they get separated.

Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they should be made for ALL new hires or reverifications. Photocopies must be retained and presented with Form I-9 in case of an inspection by DHS or other federal government agency. Employers must always complete Section 2 even if they photocopy an employee's document(s). Making photocopies of an employee's document(s) cannot take the place of completing Form I-9. Employers are still responsible for completing and retaining Form I-9.

Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted a job offer.

Section 2. Employer or Authorized Representative Review and Verification

Page 9 of 9Form I-9 03/08/13 N

LISTS OF ACCEPTABLE DOCUMENTS

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

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

listed above:

LIST A LIST B LIST C

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

8. Employment authorization document issued by the Department of Homeland Security

1. 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

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

9. Driver's license issued by a Canadian government authority

1. U.S. Passport or U.S. Passport Card

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

3. School ID card with a photograph5. For a nonimmigrant alien authorized

to work for a specific employer because of his or her status:

6.  Military dependent's ID card4.   Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

7. U.S. Coast Guard Merchant Mariner Card

5. Native American tribal document8.   Native American tribal document

7. Identification Card for Use of Resident Citizen in the United States (Form I-179)

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. 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

4.   Voter's registration card

5.   U.S. Military card or draft record

Documents that Establish Both Identity and

Employment Authorization

Documents that Establish Identity

Documents that Establish Employment Authorization

OR AND

All documents must be UNEXPIRED

6. 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

6.   U.S. Citizen ID Card (Form I-197)

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-9

OMB No. 1615-0047 Expires 03/31/2016

START HERE. 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 documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Address (Street Number and Name)

E-mail Address Telephone NumberDate of Birth (mm/dd/yyyy)

Other Names Used (if any)

U.S. Social Security Number

►

Middle Initial

Apt. Number City or Town State 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):

An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy)

Signature of Employee: Date (mm/dd/yyyy):

Date (mm/dd/yyyy):Signature of Preparer or Translator:

Address (Street Number and Name) City or Town Zip CodeState

A lawful permanent resident (Alien Registration Number/USCIS Number):

A citizen of the United States

A noncitizen national of the United States (See instructions)

1. Alien Registration Number/USCIS Number:

For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number:

If you obtained your admission number from CBP in connection with your arrival in the United States, include the following:

2. Form I-94 Admission Number:

Country of Issuance:

Foreign Passport Number:

(See instructions)

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

First Name (Given Name)Last Name (Family Name)

- -

. Some aliens may write "N/A" in this field.

Page 7 of 9Form I-9 03/08/13 N

Employer Completes Next Page

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.

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.)

OR

First Name (Given Name)Last Name (Family Name)

3-D Barcode Do Not Write in This Space

Page 8 of 9Form I-9 03/08/13 N

Employee Last Name, First Name and Middle Initial from Section 1:

Section 2. Employer or Authorized Representative Review and Verification(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.)

CertificationI attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions.)

Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Employer's Business or Organization Address (Street Number and Name)

Last Name (Family Name) Employer's Business or Organization NameFirst Name (Given Name)

City or Town Zip CodeState

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below.

B. Date of Rehire (if applicable) (mm/dd/yyyy):

Document Title: Document Number: Expiration Date (if any)(mm/dd/yyyy):

Signature of Employer or Authorized Representative: Date (mm/dd/yyyy):

I 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) I have examined appear to be genuine and to relate to the individual.

Middle InitialFirst Name (Given Name)Last Name (Family Name)

Issuing Authority: Issuing Authority:

Document Number:

Document Title:Document Title:

Document Number:

Issuing Authority:

List A OR ANDList B List C

Document Number:

Document Title:

Expiration Date (if any)(mm/dd/yyyy):

Document Title:

Issuing Authority:

Expiration Date (if any)(mm/dd/yyyy):

Document Title:

Issuing Authority:

Expiration Date (if any)(mm/dd/yyyy):

Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy):

Identity and Employment Authorization Identity Employment Authorization

Document Number:

Document Number:

Print Name of Employer or Authorized Representative:

3-D Barcode Do Not Write in This Space