LAUREL,MARYLAND20707 APPLICATION...HorizonHealthServicesInc. LAUREL,MARYLAND20707 APPLICATION HorizonHealthServicesInc.isanequalopportunityemployeranddoesnotdiscriminateagainstany

Horizon Health Services Inc.LAUREL, MARYLAND 20707

APPLICATIONHorizon Health Services Inc. is an equal opportunity employer and does not discriminate against any

individual in any phase of employment in accordance with the requirements of local, state, and federal law.

LAST NAME: FIRST NAME: MIDDLE NAME:

HOME PHONE: ALTERNATEPHONE:

ALTERNATE PHONE:

PHYSICAL HOME ADDRESS:

Street Address (include Apartment/Unit # if applicable) City State Zip Code

MAILING ADDRESS (If Different):

Street Address (include Apartment/Unit # if applicable) City State Zip Code

EMAIL ADDRESS:

DATE OF BIRTH:

SOCIAL SECURITY #:

U.S. CITIZEN? YES NO

ALIEN I.D. #: EXPIRES:

DRIVERS LICENSE? YES NO

LICENSE #: EXPIRES:

RELIABLE TRANSPORTATION?

YES NO

POSITION DESIRED:

Office Staff Family Caregiver Home Health Provider

CERTIFICATION(S):

CNA / GNA / CMA MD Board of Nursing License #: Expires:

CMT / HHA / PCA MD Board of Nursing License #: Expires:

AVAILABLE START DATE:

PREFFERED DAYS AND SHIFTS: Please circle your available shifts.*We will prefer all health aides to be available to work with patients at least 2 weekends per month.

SUN MON TUES WED THUR FRI SATAM PMEITHER

AM PMEITHER

AM PMEITHER

AM PMEITHER

AM PMEITHER

AM PMEITHER

AM PMEITHER

NAME of SCHOOL,CITY, AND STATE NUMBER OF YEARS ATTENDED DEGREE / CERTIFICATE

RECEIVEDHIGH SCHOOL:

COLLEGE:

NURSING SCHOOL:




EMERGENCY CONTACTNAME:

PHONE NUMBER: RELATIONSHIP:

EMERGENCY CONTACTNAME:

PHONE NUMBER: RELATIONSHIP:

CURRENT EMPLOYER: ADDRESS: PHONE #:

DATES OF EMPLOYMENT:

TOSTART END

POSITION: SALARY:

/START END

SUPERVISOR’S NAME: TITLE: REASON FOR LEAVING:

PREVIOUS EMPLOYER: ADDRESS: PHONE #:

DATES OF EMPLOYMENT:

TOSTART END

POSITION: SALARY:

/START END

SUPERVISOR’S NAME: TITLE: REASON FOR LEAVING:

SIGNATURE: DATE OF APPLICATION:




Registration Notice for All Incoming Independent Contractors

This is to notify all incoming Independent Contractors who wish to contract with Horizon Health Services Inc.of 312 Marshall Avenue, Laurel, MD 20707 that in order to be contracted with Horizon Health Services Inc.,you must have REGISTERED your company with the Department of Assessment and Taxation and yourcompany Article of Organization must be current and active with the Department of Assessment and Taxation(DAT). If you have not registered with DAT, you must do so prior to applying to be contracted with HorizonHealth Services Inc. Also, you must have obtained a Tax Identification Number for your company.

I * declare that I received this information from Horizon Health Services Inc. today,

the day of , 20 .

Applicant (Print Name) Applicant Signature

Date




EMPLOYER/INDEPENDENT CONTRACTORS/CONTRACTOR/CLIENTAGREEMENT: NON-COMPETE CLAUSE

I * agree that I cannot and will not work for any client/clients or be employed/contracted under another agency to provide services to any client/clients/patient/patients who were assigned tome by Horizon Health Services Inc. Located at 312 Marshall Avenue. Suite 1001, Laurel MD for a periodof 180 days following the termination/resignation of my contract or employment with Horizon HealthServices. I agree that these current patient/patients/client/clients were assigned to me by Horizon HealthServices Inc. and I am not to work with the patient/patients/client/clients through another Agency or any otherHealth Care Provider under any circumstances. If I attempt or begin to contract for/with anyclient/clients/patient/patients or work with another company for the same client/clients/patient/patientsassignedto me by Horizon Health Services, I agree that I will pay to Horizon Health Services the sum (total) of three (3)months of my weekly payment. I agree that Horizon Health Services Inc. has the right to pursueme and my(then) current employer through the court of law in order to obtain all necessary payment/payments and duesto be received by Horizon Health Services, Inc. Reimbursement of the sum of three (3) months of my weeklypayment will serve as compensation to Horizon Health Services Inc. If I decide to work for anotherAgency/Company, I agree and give Horizon Health Services full authority to hold my last/remaining paymentsdue until all court proceedings are concluded. I am signing this in agreement to the above contract

(Full Name and Signature)

I agree not to be employed or contracted by any client/clients assigned to me by Horizon Health Servicesfor a period of 180 days following the termination/resignation of any employment/contract/assignment.

I agree not to be employed by or go into contract with another Agency in order to render services to anypatients/clients who were previously assigned to me by Horizon Health Services Inc for a period of 180days following the termination/resignation of a contract assignment/employment.

By signing below, I am indicating that I fully understand the Non-Compete Clause as outlined and describedabove by Horizon Health Services, Inc.*Signature:*Horizon Health Services Inc.:

*Date*Date

Criminal Record ScreeningI understand that Horizon Health Services Inc. will conduct a search via “Public Request for Arrest Record”during the process of hire with the company. This will be maintained as confidential information. I understandthat this information is nondiscriminatory per company policy relative to race, creed, color, religion, sexualorientation, age or handicap. My signature below indicates that my background record is clear of any criminalcharges and/or convictions. If any criminal charge/conviction is discovered as a result of screening during theapplication/hiring process, I will not be given an assignment with any patient unless I provide proof that I havesubmitted a request for expungement application. If placed on assignment and the results of my fingerprintingthrough a CJIS approved agency are received by Horizon Health Services shows a history with criminalcharges and/or convictions, I understand that I will be removed from any client assignment I am currentlyworking.

*Signature

Date




*To: /Reference Name Reference Phone #

*Date of Application:

Business / Company Name

Independent Contractor Reference FormThe person listed below has applied to Horizon Health Services Inc. for employment in the health care field and has submitted your name as a former employer for reference purposes. Theserious nature of our responsibility to our patients and client institutions is such that the employment of the individual by Horizon Health Services Inc. is dependent upon satisfactory references.We would, therefore, appreciate your cooperation in replying to the questions listed below. Please be assured that your responses will be kept in the strictest confidence. Thank you inadvance for this courtesy.

*Applicant’s Name: Social Security #: / Alien ID #:

*Position held in your organization:

*Employment dates ~ From To *Would you rehire? Yes No

*Check one: Applicant resigned Applicant was a temporary independent contractor Applicant was terminated

PersonalEvaluation Above Average Satisfactory Needs

Improvement Poor

Quality of workInterest &EnthusiasmAbility to relate topatientsAbility to relate tostaffAdaptability tochangeAbility to handlestressWillingness/Abilityto float

Attendance

Punctuality

Personal Appearance

Comments:

Signature: Title: Date:




*To: /Reference Name Reference Phone #

*Date of Application:

Business / Company Name

Independent Contractor Reference FormThe person listed below has applied to Horizon Health Services Inc. for employment in the health care field and has submitted your name as a former employer for reference purposes. Theserious nature of our responsibility to our patients and client institutions is such that the employment of the individual by Horizon Health Services Inc. is dependent upon satisfactory references.We would, therefore, appreciate your cooperation in replying to the questions listed below. Please be assured that your responses will be kept in the strictest confidence. Thank you inadvance for this courtesy.

*Applicant’s Name: Social Security #: / Alien ID #:

*Position held in your organization:

*Employment dates ~ From To *Would you rehire? Yes No

*Check one: Applicant resigned Applicant was a temporary independent contractor Applicant was terminated

PersonalEvaluation Above Average Satisfactory Needs

Improvement Poor

Quality of workInterest &EnthusiasmAbility to relate topatientsAbility to relate tostaffAdaptability tochangeAbility to handlestressWillingness/Abilityto float

Attendance

Punctuality

Personal Appearance

Comments:

Signature: Title: Date:




FACE TO FACE INTERVIEWWhat are your strengths?

What are your weaknesses?

What motivates you?

Tell me about a major achievement in your life?

How do you manage your day? How do you organize your time and assess your priorities?

What do you consider yourself good at?

Briefly describe a difficult situation with a patient and how you responded.

Give an example of how you have made a difference in your past nursing experience.

This position has a large amount of stress, teamwork, time management, isolation, travel (depending on what isapplicable). How will you cope with this?

How do you respond to stress? Can you provide a recent example?

What do you know about our organization?

Why have you decided to apply with us?

What sort of support / training/ instruction would you like for this job?

What will your previous supervisor / co-workers say about you?

Do you have any questions for us?




HORIZON HEALTH SERVICES INC.

*NAME: *DATE:

**** CNA GNA CMA CMT HHA PCA****SKILLS CHECKLIST

The objective of this skill sheet is to assess your current level of knowledge and experience in general nursing skills. Itis your responsibility to seek out opportunities to increase your experience and competency in these skill areas.Please complete this skills sheet by rating your current level of competence. Do not leave ANY empty boxes.

0 - No contact with equipment or this patient situation.1 - No knowledge of procedure.2 - Understand procedure and patient situation but never performed task.3 - Have performed this task infrequently and would need supervision.4 - Have performed this task frequently and can perform independently.

CARE ROUTINE SAFETY ANDACTIVITY (Cont.) COMMUNICATION GI/GU

General Activitiesof Daily Living

Disposing ofsharp objects

*Changes inPatient Condition Use of Catheter:

*AM/PM Care Handlinghazardous materials

*Patient needs,complaints and concerns

*ClampingCatheter

*Bathing Proper Bodymechanics

*UnusualIncidents

*Placing CondomCatheter

*Use of showerchair

Transferring to Bed,WC, Commode, etc.

Recording andReporting:

*Emptying/ReplacingColostomy bag

*Oral Care Turning /Positioning *charting Administering Enemas

Special Skin Care Use of Hoyer lift *vital signs SPECIMENCOLLECTION

Dressing Changes: Use of equipment: *BowelMovements

*CollectingSputum

*Sterile *crutches *MedicationIntake

*CollectingClean Catch urine

*Clean *walker *Diet Intake,Calorie Count *Collecting stool

Wound care *cane NUTRITION INFECTIONCONTROL

Universal Precautions *wheelchairand locks Feeding patients Use of gloves

Post-Mortem Care *transfer belt Aspiration Precautions Use of gowns/wearing scrubs

SAFETY ANDACTIVITY

*gait belt forambulation Tube Feeding: Use of masks/

goggles

DeterminingPatient ID

Range of MotionExercises *N/G Tube Hand washing

precautionsIdentifying safetyhazards

*Active *Peg Tube Infections or hazardouswaste disposal

Maintaining clean,orderly work area

*Passive NasopharyngealSuctioning Isolation Techniques

Use of CPR maskor bag

APPLICANT SIGNATURE: DATE:




HORIZON HEALTH SERVICES INCINITIAL SKILLS DEMONSTRATION AND CHECKLIST

YES(√)

NO(√)

DATEDESCRIBED

(ONLY if checked Yes)

DATEDEMONSTRATED(ONLY if checked Yes)

AIDE INITIAL /DATE

(Complete Every Box)

SUPERVISORINITIALS/DATE

VITAL SIGNSPulse-ApicalRespirationsBlood PressureACTIVITESApplyingPassive ROMApplyingActive ROMUsing: -Crib-Stroller-WheelchairHoyer LiftACTIVITIES of DAILY LIVINGBed BathSponge, tub or showerNail/SkincareChanging diapersRepositioning the ClientOral HygieneAssist w/meal preparationAssist w/ feeding/supervision offeedingToileting & EliminationCommunication SkillsObservationBasic Infection ControlBasic Elements of body functions/changes in body function(to be reported to supervisor)Maintenance of a clean, safe andhealthy environmentRecognizing emergencies andknowledge of emergency procedure

Name and Signature of Personal Care Aide

Name and Signature of Supervisor




Horizon Criminal Record Screen

*Date:

*Name:First Middle Last

*Maiden/names previously used:

*Date of Birth:

*Social Security #:

I understand that Horizon Health Services Inc. will conduct a search via “Public Request for Arrest Record”during the process of hire with the company. This will be maintained as confidential information. With mysignature below, I am indicating that my background record is clear of any criminal charges and/or convictions.I understand that this information is nondiscriminatory per company policy relative to race, creed, color,religion, sexual orientation, age or handicap.

*Independent Contractor Signature

*Independent Contractor Signature

*Date

*Horizon Representative




Personal Vehicle GuidelinesI* agree and understand that as a contractor/independent contractor to Horizon

Health Services Inc. I am not authorized to take any client/clients in my personal vehicle to any appointments orerrands. I understand that part of my duty as an aide is to follow the client/clients to any appointments anderrands within a walking distance. I am to follow client/clients to long distance appointments, provided their

transportation is provided by Family Member, State, County, and Department on Aging or by some other meansfrom the patient/family. I understand if I do not follow the guidelines set forth by the company, I am fully liablefor any and all actions taken against me either by Horizon Health Services or any other agency/agencies as a

result of my behavior.Client Personal Property Guidelines:

I * agree, as independent contractor/contractor aide to Horizon Health ServicesInc., understand that I am not allowed to use the personal home or cell phone of any client I may be working for.If for any reason, it is discovered that I have used client’s telephone; I understand that my contract may beterminated, and required to pay back the amount of the phone bill I accrued. I agree and authorize HorizonHealth Services Inc. to deduct any amount of the patient’s telephone bill portion I have used from my lastpaycheck, if necessary. If I do not have any payment left with Horizon Health Services Inc.,I agree that I am fully responsible for the portion of any phone bill I accrued, and I must/will pay HorizonHealth Services Inc. and /or the patient back.I * understand that I am never to accept or borrow money or property fromthe client under any circumstance.

I * fully understand that anything I may need for the day MUST be broughtwith me at the beginning of my scheduled shift. If I need to leave the area for ANY REASON, I MUSTimmediately call Horizon Health Services for coverage.

Contractor Attire GuidelinesI * understand that when reporting to work I should wear a clean nursing uniformand be well-groomed at all times.

Remember that you are a contractor for HORIZON HEALTH SERVICES, INC. and must behave as such.Any person found speaking out against Horizon Health Services, Inc. will be immediately pulled from theirposition. We understand that sometimes there are issues that will need to be rectified but please, come to usfirst. Any deliberate malignment of the company will be taken as libel or slander and will be treated as such,including but not limited to prosecution. This includes both verbal and non-verbal remarks made to anyoneexcept Horizon Health Services.

CONTRACTOR SIGNATURE DATE

PRINT NAME

HORIZON HEALTH REPRESENTATIVE DATE


“LICENSED BY THE MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE”OFFICE OF HEALTH CARE QUALITY

RSA # R2230

Horizon Health Services Inc. is an equal opportunity employer and does not discriminate against any individual in any phase of employmentor contract in accordance with the requirements of local, state, and federal law

Independent Contractors Agreement

I _________________________________________ declare that I have received from Horizon HealthServices full explanation of Independent Contractor versus Employee and I ACCEPT the terms andcondition of this contract. I declare that I have been explained to about my position with Horizon HealthServices Inc. That I am an Independent Contractor, I will be given 1099 (not W2) each year for allservices done for Horizon Health Services in a particular year. I declare that in providing the SERVICESunder this Agreement it is expressly agreed that Contractor is acting as an Independent Contractor andnot as an employee. The Contractor and the Customer (Horizon Health Services) acknowledge that thisAgreement does not create a partnership or joint venture between them, and is exclusively a contractfor SERVICE. I declare that I’m fully aware that I am to FILE/PAYmy own taxes at the end of each yearfor the State of Maryland and Federal Government. I declare that I’m fully aware that IndependentContractor are not eligible to receive unemployment benefit ___________ (initial)

I _________________________________ agree that as Independent Contractor I MUST submit weeklyINVOICES by MONDAY of the pay period to be able receive payment from HORIZON HEALTH SERVICESINC._____ (initial)

I ________________________________________ declare that in order to be an IndependentContractor with Horizon Health Services Inc. located at 312 Marshall Avenue, Suite 1001, Laurel, MD.20707, I must have REGISTEREDmy company with Department of Assessment and Taxation and mycompany Article of Organizationmust be current and active with the Department of Assessment andTaxation (DAT). I agree that with my Article of Organization being current, I must also have obtained mycompany Tax Identification Number (EIN) ________ (initial)

___________________________________ __________________________Print Name Date

___________________________________

T

T

T

T

7)______________________________________(____________________________________

ARTICLES OF ORGANIZATION

The undersigned, with the intention of creating a Maryland Limited Liability Company files the

following Articles of Organization:

(1)

The name of the Limited Liability Company is:

(2)

The purpose for which the Limited Liability Company is filed is as follows:

(3)

he address of the Limited Liability Company in Maryland is

(4)

The resident agent of the Limited Liability Company in Maryland is

whose address is

(5)Resident Agent

Signature(s) of Authorized Person(s)

Filing party's return address:

INSTRUCTIONS FOR DRAFTINGA LIMITED LIABILITY COMPANY

To create a Maryland Limited Liability Company (LLC) an originally executed Articles of Organizationmust be submitted to:Department of Assessments and Taxation301 W. Preston StreetBaltimore, MD 21201-2392

(1) Insert the name here. The name must not be misleadingly similar to that of another LLC, Corporation,Trade Name, Limited Partnership or Limited Liability Partnership on file with the Department and the nameof the LLC must include one of the following: a. Limited Liability Companyb. L.L.C.c. LLCd. L.C.e. L C

(2) Insert the purpose of the LLC. A one or two sentence description of the business is sufficient.

(3) Insert the address of the LLC. The address must be in Maryland and cannot be a P.O. box.

(4) Insert the name and address (cannot be a P.O. box) of the resident agent. A resident agent is anotherentity or individual designated to accept service of process for the LLC. The resident agent can be anyMaryland citizen who is over eighteen, a Maryland corporation or a Maryland LLC. This person mustalso sign the document.

(5) Execution - must be signed by any adult individual authorized by the persons forming the LLC.

(6) The resident agent must sign here.

(7) Insert the return address for any correspondence regarding this filing.

NOTE: This list is the mandatory provisions. Any provision the parties decide is relevant may be added to theArticles of Organization. Documents must be typed or printed. No handwritten documents will be accepted.

FEES:(1) Certificate of Organization $100.00(2) Certified Copy of document above $20.00 + $1.00 page(3) Certificate of Status at time of filing $20.00Revised 8/05

Maryland State Department of Assessments & Taxation

NOTES: Due to the fact that the laws governing the formation and operation of business entities and theeffectiveness of a UCC Financing Statement involves more than filing documents with our office, we suggest youconsult an attorney, accountant or other professional. State Department of Assessments & Taxation staff cannot offerbusiness counseling or legal advice.

Regarding annual documents to be filed with the Department of Assessments & Taxation: All domestic and foreignlegal entities must submit a Personal Property Return to the Department. Failure to file a Personal Property Returnwill result in forfeiture of your right to conduct business in Maryland

Where and how do I file my documents?By mail or in-person submissions should directed to:State Department of Assessments and Taxation, Charter Division301 W. Preston Street; 8th FloorBaltimore, MD 21201-2395

All checks must be made out to State Department of Assessments and Taxation. The cost to filedocuments should be included with the form. A schedule of filing fees is available online athttp://dat.maryland.gov/businesses/Documents/FEES.pdf

Online business registration and document filing via the Maryland EGov Business portal. See theMaryland Business Express link on the homepage at www.dat.maryland.gov

Effective February 1, 2016, the Department of Assessments and Taxation will no longer accept viafacsimile (fax) corporate documents for filing or document copy request.

How long will it take to process my documents?Regular document processing time can be 8 weeks or more.

Expedited processing request will be handled within 7 business days. The expedited service fee is anadditional $50.00 for each document; other fees may also apply.

Hand-delivered documents in limited quantities receive same day expedited service between 8:30a.m. and 4:30 p.m., Monday through Friday. You must be in line no later than 4:15 p.m. in orderto receive service that same day.

Online filed documents are considered expedited and will be processed within 7 business days.

Revised: January 2016

http://dat.maryland.gov/businesses/Documents/FEES.pdf

http://www.dat.maryland.gov/

HORIZON HEALTH SERVICES - AIDE/HHA/HOMEMAKER ACTIVITY SUMMARY

AIDE NAME:PATIENT'S NAME:PATIENT'SMA #:

WEEK: / DATE:→ Sun Mon Tues Wed Thurs Fri SatTime In:Time Out:Total Hours:

HYGIENE / GENERAL CARETotal Bed/BathAssistanceTub BathShowerNails FiledShavedShampooSkin CareOral HygieneAssisted/ Dressing

NUTRITION / FEEDINGMeal PreparationApetite (F,G,P)Fluids (amt.)Feeds self/assisted

ELIMINATIONIncontinent/UrineVoiding OSPeri CareEmpty drainage bagBedpan/BSC/Up to BRIntakeOutput

Incontinent/StoolBM TodayConstipationDiarrhea

MOBILITY / ACTIVITYBed RestOut of BedUp in ChairAmbulatingRange of MotionRepositioned

VITAL SIGNSTemperaturePulseRespirationBlood Pressure LEFTBlood Pressure RIGHT

IADL'SAccompany to Physician~Check when completedMeal Preparation~Check when completedGrocery Shopping~Check when completedLaundry~Check when completedBathroom Cleaned~Check when completedKitchen Cleaned~Check when completedBedroom Cleaned~Check when completedBed/Bed Made~Check when completed

Sun: MON: TUES: WED: THUR: FRI: SAT:Aide/HHA/Homemaker ~ Initial→

Aide/HHA/Homemaker Signature

312 Marshall Avenue, Suite 1001, Laurel, MD. 20707Tel: 301-362-3600 Tel: 301-362-3333


Hepatitis B Immunization Consent/Refusal Form

Please Check One:

_ YES, I want to receive the Hepatitis B Vaccine.

I have read the information given to me about Hepatitis B Virus and Hepatitis B Vaccine and I had theopportunity to ask question. My question were answered.

I want to participate in the vaccination program. I understand this includes three injections at prescribedintervals over a 6-months period and it will be given at no cost to me. I understand that there is noguarantee that I will become immune to Hepatitis B and that I might experience an adverse side effect asthe result of the vaccination.

Date Given Lot# Administered By Next Date Due

1stDose

2ndDose

3rdDose

_ NO, I don’t want to receive the Hepatitis B Vaccine

I understand that due to my occupational exposure to blood or other potentially infectious material, Imay be at risk of acquiring Hepatitis B Virus (HBV). I was given the opportunity to be vaccinated withHepatitis B Vaccine at no charge to me. However, I DECLINE Hepatitis B Vaccination at this time. Iunderstand that by declining this vaccine, I continue to be at an increased risk of acquiring Hepatitis B, aserious disease.

If in the future I want to be vaccinated with Hepatitis B Vaccine, I understand that I can receive thevaccine series at no charge to me.

_ _

Independent Contractor’s/Contractor’s Name (print) Date

_

Address #, City, State, Zip

Telephone # Signature