personal information sheet · 2020. 7. 20. · personal information sheet name:_____ date of...

RES Home Care 1461 Lakeland Ave. Suite 12, Bohemia, NY 11716

631-732-4794 FAX: 631-732-0355 www.reshomecareli.com

Personal Information Sheet

Name:________________________________ Date of Birth:_______________________

Address:________________________________________________

Cell Number:__________________________ Alt Phone:__________________________

Emergency Contact Name:_________________________________

Emergency Contact Phone Number:__________________________

Relationship to Emergency Contact:__________________________

Number of hours willing to work per week: ____________

Position applied for:

__________Community Integration Counseling

__________Positive Behavior Interventions & Support Specialist

__________Independent Living Skills Trainer

__________Home and Community Support Services (HHA/PCA)

__________Structured Day Program

__________Service Coordination

__________Administrative

How did you hear about RES Home Care?

RES Home Care

1461 Lakeland Ave., Suite 12

Bohemia, NY 11716

631.732.4794

03/2020 RES HC APP

APPLICATION FOR EMPLOYMENT Please provide complete and legible information. An incomplete application may affect your consideration for

employment. If necessary, attach a separate sheet for additional information.

The Company is committed to a policy of Equal Employment Opportunity and will not discriminate against an

applicant or employee on the basis of age, sex, sexual orientation, race, color, creed, religion, ethnicity, national

origin, alienage or citizenship, disability, marital status, military status, or any other legally-recognized protected

basis under federal, state or local laws, regulations or ordinances.

Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with

Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the way things are

normally done that will ensure an equal employment opportunity without imposing an undue hardship on the

Company. Please inform the Company’s Human Resources Department if you need assistance completing any

forms or to otherwise participate in the application process.

GENERAL INFORMATION

Full Name Date FIRST MIDDLE LAST

Address STREET CITY STATE ZIP CODE

Phone Number ( ) Date available for work

Alternate Phone Number ( ) E-mail _______________________________________

Have you previously worked for the Company? Yes No

If yes, when?

Are you legally authorized to work in the United States? Yes No

(If hired, verification will be required consistent with federal law. Please provide Immigration ID if not a citizen)

Are you under the age of 18? Yes No

If under the age 18, please state your age: ______ (The primary reason for this question is to address any child labor laws.)

POSITION INFORMATION

Position applied for? Salary range expected (required)

Applying for: Full-time Part-time Seasonal

RES Home Care


Bohemia, NY 11716

631.732.4794

03/2020 RES HC APP

EDUCATION

Type of

School

School Name

and Location

Highest Grade

Completed Grade Point

Average

Course of Study

or Major

High School or G.E.D.

equivalent

9 10 11 12/GED

College or University 1 2 3 4

Vocational or Trade

School

Graduate

School

Other (including

military training)

List any work-related certifications or licenses you currently possess:

Please provide professional license and paraprofessional certification including expiration date:

BACKGROUND INFORMATION

The agency will request information regarding your background including work and personal references and a criminal

background check.

Have you ever been discharged, suspended or asked to resign from any position?

Yes No If “Yes,” please explain.

Have you ever been convicted of a crime that has not been expunged, sealed, pardoned or annulled?

Yes No Record

Have you ever been bonded/refused bond? Yes No Record

If you checked “Yes,” please explain below. A criminal conviction will not necessarily be a bar to employment. To help us

evaluate your application, please describe the nature of the crime and your subsequent rehabilitation.

____________________________________________________________________________________________

____________________________________________________________________________________________

_____________________________________________________________________________________________

RES Home Care


Bohemia, NY 11716

631.732.4794

03/2020 RES HC APP

EMPLOYMENT RECORD

List all employment experience for the past 10 years, starting with the most recent or present employer. The agency may

contact your past supervisors for professional references. Using a separate section for each position, describe in detail all

work experience, including periods of unemployment. You may include as part of your employment history any verified

work performed on a volunteer basis. Resumes may not be substituted in lieu of completing the following

employment information.

Current Employer Phone

Geographic Location From

Month Year Your Position

Supervisor’s Name/Title To

Month Year May we contact? Yes No If not, why?

Primary responsibilities

Reason for Leaving

Employer Phone




Month Year


Reason for Leaving

Employer Phone




Month Year


Reason for Leaving

Employer Phone




Month Year


Reason for Leaving

Employer Phone




Month Year


Reason for Leaving

RES Home Care


Bohemia, NY 11716

631.732.4794

03/2020 RES HC APP

Employer Phone




Month Year


Reason for Leaving

Employer Phone (___)




Month Year


Reason for Leaving

Employer Phone (___)




Month Year


Reason for Leaving

PROFESSIONAL REFERENCES

List three professional references whom we may contact (in addition to past supervisors listed within your experience):

Name Telephone No. ( )

E-mail Address Type of Acquaintance





RES Home Care


Bohemia, NY 11716

631.732.4794

03/2020 RES HC APP

LICENSES/CERTIFICATIONS (if applicable)

PROFESSIONAL LICENSE:

Profession: License #: Expiration Date:

Verified(for office use only): Yes No

PROFESSIONAL LICENSE:

Profession: License #: Expiration Date:


PARA-PROFESSIONAL CERTIFICATION:

HHA PCA School/Training Program:


PARA-PROFESSIONAL CERTIFICATION:

HHA PCA School/Training Program:


Other:

ADDITIONAL COMMENTS

Please comment on how your prior education and experiences qualify you for the type of employment you are seeking. Detail

any past responsibilities and achievements. Note any special coursework, honors, activities, special projects or any other data

that will assist us in considering your application for employment. (You may exclude any activities that would reveal any

classification protected by federal, state, and local laws and ordinances, including, but not limited to, race, color, or religious

belief.)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

RES Home Care


Bohemia, NY 11716

631.732.4794

03/2020 RES HC APP

PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE

SIGNING

I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment. ___________ Initials

I understand, where permissible under applicable state and local law, I may be subject to a drug test after receiving a

conditional offer of employment, and must receive a negative result before being permitted to commence work with the

Company. ___________ Initials

I hereby certify that the information given by me is true in all respects. I authorize the Company and its representatives

to contact my prior employers and all others for the purpose of verification of the information I have supplied and release

same from any liability resulting from the information released. I authorize employers, schools and other persons named

on this application to provide any information or transcripts requested. ___________ Initials

I understand employment with the Company is contingent on my providing sufficient documentation necessary to

establish my identity and eligibility to work in the United States. ___________ Initials

I expressly understand and agree that, if employed, my employment, having no specified term, is based upon

mutual consent and may be terminated at will, with or without cause, by either party (the employer or me)

without prior notice to the other, unless otherwise prohibited by law. ___________ Initials

I understand that no representation, whether oral or written, by any representative or agent of the Company, at

any time, can constitute an implied or expressed contract of employment. I further understand no representative

or agent of the Company has the authority to enter into an agreement for employment for any specified period of

time or to make any change in any policy, procedure, benefit or other terms or condition of employment other

than in a document signed by the Director of Human Resources or his/her authorized representative.

___________ Initials

I certify, under penalty of perjury, that all of the above information is true and complete, and I understand that any

falsification or omission of information may result in denial of employment or, if hired, may result in termination

regardless of the time lapse before discovery.

I understand an offer of employment is conditioned upon complying with all of the Company’s requirements including,

but not limited to, signing any requested consent for the Company to conduct an investigation or obtain a report about

my background.

MY SIGNATURE IS EVIDENCE I HAVE READ AND AGREE WITH THE ABOVE STATEMENTS.

Applicant’s signature Date

Disclosure to Applicant and Consent to

Request Consumer Report Information

RES Home Care 1461 Lakeland Ave., Suite 12, Bohemia, NY 11716

631-732-4794 FAX: 631-732-0355 www.reshomecareli.com

APPLICANT’S CURRENT INFORMATION

Last Name(s)___________________________ First__________________________ Middle___________________

Address:____________________________________ City______________________ State_____ zip____________

How long have you lived at this address?____________ If less than 7 years, list previous address below

Phone___________________________cell_________________________________

Your name AS IT CURRENTLY APPEARS on Drivers License_____________________________

Social Security#________________________ Date of Birth_________________________________

PREVIOUS NAMES AND ADDRESSES

Name(s)_________________________________________________ Dates you lived there_________________










I understand that RES Home Care will/may utilize the services of part of the procedure for processing my

application for employment. I also understand if my application for employment is granted, RES Home Care may

obtain further information through subsequent investigations by a consumer reporting agency so as to update, renew

or extend my employment. Upon request, I will be informed whether a report was requested from a consumer

reporting agency and provided with the name and address of the consumer reporting agency. I understand a consumer reporting agency’s investigation may include obtaining information regarding my

credit background, references, character, past employment, work habits, education, general reputation, personal

characteristics, mode of living, judgments, liens, and criminal conviction record consistent with federal and state

law.

I understand such information may be obtained by direct or indirect contact with former employers,

schools, financial institutions, landlords and public agencies or other persons who may have such knowledge.

I also understand that before the Company takes any adverse action, in whole or part, on information

obtained in the report, I will be provided a copy of the report and a description in writing of my rights under the

federal Fair Credit Reporting Act.

I understand if I disagree with the accuracy of any information in the report, I must notify RES Home

Care within five business days of my receipt of the report that I am challenging the accuracy of the information with

the Consumer Reporting Agency.

I hereby consent to this investigation and authorize RES Home Care to procure reports on my background

as stated above from a consumer reporting agency.

_____________________________ _________________________

(Signature of applicant) (Date)

DOH CHRC 102 (1/07) NYS Department of Health

ACKNOWLEDGEMENT AND CONSENT FORM FOR FINGERPRINTING AND DISCLOSURE OF CRIMINAL HISTORY RECORD INFORMATION

THIS FORM IS TO BE RETAINED BY THE AGENCY- DO NOT FORWARD TO THE DOH CHRC UNIT. [email protected]

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

SECTION 1 – SUBJECT INDIVIDUAL INFORMATION LAST Name FIRST Name M.I.

Date of Birth (mm/dd/yyyy) Mother’s Maiden Name Alias: AKA

Mailing Address (street) City State Zip

SECTION 2 - ATTESTATION 1. I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI). 2. I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI. 3. I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary to be provided to the agency to which I applied for a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I have a criminal history, as maintained by DCJS or the FBI, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. I have been advised that by law, DOH is authorized and may be required to provide the results of the criminal history record check through a criminal history record summary to the agency. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be disclosed to persons authorized by law. 4. I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place. 5. I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI. 6. I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information. 7. I certify to the best of my knowledge and belief that I (check as appropriate): Have Have not been convicted of a crime in New York State or any other jurisdiction Do Do not have a final finding of patient or resident abuse If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional) ______________________________________________________________________________________________________________________ 8. My current mailing or home address is indicated in Section 1 of this form. 9. I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own (not applicable for Expedited Review submitted pursuant to CHRC Form 104).

Applicant Signature: _____________________________________________________________________ Date: __________________________

Signature of Parent or Legal Guardian________________________________________________________ Date: __________________________ (if subject individual is under 18 years of age)

SECTION 3 – AGENCY AUTHORIZED PERSON INFORMATION Agency Name:

PFI/Operating License Number:

Print Name of Authorized Person:

Title:

Signature of Authorized Person:

Date:

mailto:[email protected]

RES HOME CARE

REFERENCE REQUEST

To: ____________________________ Agency: ___________________ Title: _____________

Reference Contact Number: ____________________________________________________

Reference Contact Email: _____________________________________________________

Name of Applicant: ____________________________________________________________ Position Applied for: __________________________________________________________

Release of Information: I hereby release from all liability the company, institution or person named above and authorize them to release all information regarding my employment with them. Signature of Applicant: ______________________________________ Date: ______________

The person identified above has applied for a position at RES Home Care. Would you kindly complete the reference information below and return the reference information. This information will be kept confidential. Thank you.

Position held at your organization: _____________________________________________________ Reference’s relationship to applicant: __________________________________________________ Dates of Employment: From: ____________________ To: _________________________________ Reason for Leaving: _________________________________________________________________ Would you re-employ? Yes No If no why? ________________________________________

Applicant’s Work Record Satisfactory Unsatisfactory Unable to Evaluate

Quality of Work

Productivity

Attendance

Punctuality

Initiative

Cooperation

Dependability

Accepts constructive Criticism

Professionalism

Additional Comments:

Reference’s Signature: ____________________________________________ Date: ____________ RES Home Care VALIDATION: ___________________________ TITLE:____________ DATE:______________

RES HC 2020

New York State Department of Health Division of Home and Community Based Services

TBI A 1.4 Rev. July 2009 Page 1 of 1

RRDC:

EMPLOYEE VERIFICATION OF QUALIFICATIONS

HOME AND COMMUNITY BASED SERVICES MEDICAID WAIVER

Traumatic Brain Injury (TBI) ________________________________________________________________________________ _________________________________________ ______________________________________________

Employee to provide the Waiver Service Service Provider Name _________________________________________ ______________________________________________

Waiver Service you are applying for Address _________________________________________ ______________________________________________

Waiver Service Position, if applicable Telephone

________________________________________________________________________________ I have submitted my resume and supporting documents which accurately reflects my education and work experience. _________________________________________________________________________________________________

Employee Signature Date

This individual has met the eligibility criteria for this position in the following manner: Education: A copy of this individual’s _____diploma or official sealed transcript _____ license is attached to this form. Experience: ____This individual’s experience, relevant to this position, is highlighted on his/her

attached resume. (**Please circle this person’s relevant experience on the attached resume for quick reference for the interviewers).

I have interviewed this individual and reviewed his/her resume. I verified his/her education, required licensures and work experience. Per waiver eligibility criteria, this individual is qualified to provide waiver services in the above named position and has been hired as an employee of our agency. ______________________________________________________________________________________________ Service Provider Representative Title Signature Date

New York State Department of Health Division of Home and Community Based Services

NHTD A.1 Page 1 of 1 April 2008

RRDC:

EMPLOYEE VERIFICATION OF QUALIFICATIONS

HOME AND COMMUNITY BASED SERVICES MEDICAID WAIVER

Nursing Home Transition and Diversion (NHTD) ________________________________________________________________________________ _________________________________________ ______________________________________________ Employee to provide the Waiver Service Service Provider Name _________________________________________ ______________________________________________ Waiver Service you are applying for Address _________________________________________ ______________________________________________ Waiver Service Position, if applicable Telephone ________________________________________________________________________________ I have submitted my resume and supporting documents which accurately reflects my education and work experience. _________________________________________________________________________________________________ Employee Signature Date This individual has met the eligibility criteria for this position in the following manner: Education: A copy of this individual’s _____diploma or official sealed transcript _____ license is attached to this form. Experience: ____This individual’s experience, relevant to this position, is highlighted on his/her

attached resume. (**Please circle this person’s relevant experience on the attached resume for quick reference for the interviewers).

I have interviewed this individual and reviewed his/her resume. I verified his/her education, required licensures and work experience. Per waiver eligibility criteria, this individual is qualified to provide waiver services in the above named position and has been hired as an employee of our agency. ______________________________________________________________________________________________ Service Provider Representative Title Signature Date

1. Personal Information Sheet2. Application For Employment3. Consent For Background Check4. DOH-CHRC ConsentSECTION 1 – SUBJECT INDIVIDUAL INFORMATIONSECTION 2 - ATTESTATIONSECTION 3 – AGENCY AUTHORIZED PERSON INFORMATION

5. Reference Form6. A 1.4 Employee Verification of Qualifications July 2009 TBI (1)7. A.1 Employee Qualifications Verification form NHTD (1)

NAME: DATE OF BIRTH: ADDRESS: Emergency Contact Name: Emergency Contact Phone Number: Relationship to Emergency Contact: Number of hours willing to work per week: Position Applied For: OffHow did you hear: Full Name: Date available for work: If yes when: If under the age 18 please state your age: Position applied for: Salary range expected: Have you previously worked: OffAre you legally authorized: OffAre you under the age: OffCheck Box4: OffSchool Name and LocationHigh School or GED equivalent: Grade Point Average: Course of Study or Major: School Name and LocationCollege or University: College Grade Point Average: College Course of Study or Major: School Name and LocationVocational or Trade School: Vocational Grade Completed: Vocational GPA: Vocational Course of Study: School Name and LocationGraduate School: Grad Grade Completed: Grad GPA: Grad Course of Study: Other School: Other Grade Completion: Other GPA: Other Course of Study: List any workrelated certifications or licenses you currently possess Please provide professional license and paraprofessional certification including expiration date: Have you ever been discharged suspended or asked to resign from any position: evaluate your application please describe the nature of the crime and your subsequent rehabilitation 1: evaluate your application please describe the nature of the crime and your subsequent rehabilitation 2: evaluate your application please describe the nature of the crime and your subsequent rehabilitation 3: Grade Completed: OffCollege Grade Completed: OffWork-Related Licenses: Discharged from position: OffEver been convicted: OffEver been bonded: OffCurrent Employer: Geographic Location: From: Your Position: Supervisors NameTitle: To: If not why: Primary responsibilities 1: Primary responsibilities 2: Reason for Leaving 1: Reason for Leaving 2: Employer: Phone_2: Geographic Location_2: From_2: Your Position_2: Supervisors NameTitle_2: To_2: Primary responsibilities 1_2: Primary responsibilities 2_2: Reason for Leaving 1_2: Reason for Leaving 2_2: Employer_2: Phone_3: Geographic Location_3: From_3: Your Position_3: Supervisors NameTitle_3: To_3: Primary responsibilities 1_3: Primary responsibilities 2_3: Reason for Leaving 1_3: Reason for Leaving 2_3: Employer_3: Phone_4: Geographic Location_4: From_4: Your Position_4: Supervisors NameTitle_4: To_4: Primary responsibilities 1_4: Primary responsibilities 2_4: Reason for Leaving 1_4: Reason for Leaving 2_4: Employer_4: Phone_5: Geographic Location_5: From_5: Your Position_5: Supervisors NameTitle_5: To_5: Primary responsibilities 1_5: Primary responsibilities 2_5: Reason for Leaving 1_5: Reason for Leaving 2_5: May we contact: OffEmployer_5: Phone_6: Geographic Location_6: From_6: Your Position_6: Supervisors NameTitle_6: To_6: Primary responsibilities 1_6: Primary responsibilities 2_6: Reason for Leaving 1_6: Reason for Leaving 2_6: Employer_6: undefined: Geographic Location_7: From_7: Your Position_7: Supervisors NameTitle_7: To_7: Primary responsibilities 1_7: Primary responsibilities 2_7: Reason for Leaving 1_7: Reason for Leaving 2_7: Employer_7: undefined_2: Geographic Location_8: From_8: Your Position_8: Supervisors NameTitle_8: To_8: Primary responsibilities 1_8: Primary responsibilities 2_8: Reason for Leaving 1_8: Reason for Leaving 2_8: Email Address: Type of Acquaintance: Email Address_2: Type of Acquaintance_2: Email Address_3: Type of Acquaintance_3: PARAPROFESSIONAL CERTIFICATION HHA PCA SchoolTraining Program Verifiedfor office use only Yes No: HHA: OffPCA: OffPARAPROFESSIONAL CERTIFICATION HHA PCA SchoolTraining Program Verifiedfor office use only Yes No_2: HHA_2: OffPCA_2: OffAdditional Comments: Additional Comments2: Additional Comments3: Additional Comments4: Initials: Initials_2: Initials_3: Initials_4: Initials_5: Initials_6: Last Name: First Name: Middle Name: Address: zip: How long have you lived at this address: cell: Your name AS IT CURRENTLY APPEARS on Drivers License: Social Security: Names: Dates you lived there: Address_2: City_2: State_2: zip_2: Names_2: Dates you lived there_2: Address_3: City_3: State_3: zip_3: Names_3: Dates you lived there_3: Address_4: City_4: State_4: zip_4: Names_4: Dates you lived there_4: Address_5: City_5: State_5: zip_5: Names_5: Dates you lived there_5: Address_6: City_6: State_6: zip_6: Date: LAST Name: FIRST Name: MI: Date of Birth: Mothers Maiden Name: Alias AKA: City: State: Zip: Certify to the best: OffDo or not have a final finding: OffIf you have checked either Have andor Do please provide a brief explanation Optional: Date_2: Name of Applicant: Applicant Name: MOBILE NUMBER: ALT PHONE NUMBER: Phone1: Reference Name1: Reference Name2: Reference Name3: Email Address1: ReferencePhone1: ReferencePhone2: ReferencePhone3: Profession: LicenseNo: LicenseExp: Profession2: LicenseNo2: LicenseExp2: OtherLicense: How did you hear2: PhoneNumber: Street Address:

personal information sheet · 2020. 7. 20. · personal information sheet name:_____ date of...

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