ࡱ> ] )bjbj{{ 1\1\n 0 0 4hDP97777777$2;=7M7 9eeeR7e7ee02p}6E 17 90P91>4>,2>2e77jP9>0 > n: Please read these easy instructions first! We will not process your application if information is missing. Thank you for your interest in providing quality in-home care services for our clients. Before proceeding to the application, please read the following instructions to avoid any misunderstanding regarding your employment, and sign this page where indicated. n Do not use white out, erasable ink, red ink, or pencil on the application or other documents. n Complete Sections A, B, & D of the Family Care Safety Worker Registration. n Complete the employment application in its entirety. n Disclose any and all criminal history convictions in your background, including misdemeanor, felony, or ordinance violations, except minor traffic violations regardless of when it occurred. n Sign and date the application. n Include 2 forms of proper and current identification listed on the I-9 acceptable forms page. n A background screening via the Family Care Safety Registry (FCSR) and case.net will be performed by our staff. HILC In-Home Care will not pay you for any work completed prior to an FCSR background screening being performed and HILC In-Home Care has notified you that you are clear to work. Any subsequent screening identifying a criminal background for which you have not already disclosed to HILC In-Home Care shall result in termination of all employment through HILC In-Home Care. n Complete and sign the Criminal Records Verification and Consent before a Notary Public. If this is not signed in front of a notary, it is invalid and will not be accepted. Complete the Reference Check Authorization and Release with at least two professional or other acceptable references. These references cannot be related to you by blood, adoption, or marriage. n You cannot work for any client if you are related by blood, adoption, or marriage. n A 8-hour orientation prior to initial client contact is mandated by regulations. I verify that I have fully read and understand the conditions described in this letter. Additionally, I understand that I am legally mandated to disclose any and all criminal activity in my background. I will not hold HILC In-Home Care legally responsible, in any manner, if I begin working for any in-home client without clearance from an HILC In-Home Care staff member. I also understand that I am required to complete all employment documentation before I receive any wages. ______________________________________ Applicant Signature Date HILC In-Home Care Employment Application Applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or in the presence of a non-related medical condition or disability. Please complete all fields. If not applicable, mark N/A. Name_______________________________________________ Date __________________________ Have you ever been known by any other names or aliases? Yes No If yes, please list all other names: _________________________________________________________ Complete Address _____________________________________________________________________ City State Zip Code Telephone Number: (____) __________________ Alternate Number: (____) ____________________ Social Security #_____________________ Any Other Social Security #s Used______________________ Are you at least 18 years of age? Yes No Are you legally eligible for employment in the U.S.? Yes No Do you have a valid MO Driver s License? Yes No Do you own transportation? Yes No Driver License #: __________________ State Issued: _____________________ Do you have auto insurance coverage currently? Yes No Have you lived outside of MO in the past 5 years? Yes No If Yes, Where? _____________________ BACKGROUND: Have you lived in Missouri for the last consecutive five years? Yes No If NO, please list most previous state you resided in and dates you lived there: State: _______________ Resided in from ____________ to _____________ Have you ever been charged with an offense other than a minor traffic violation? Yes No Please disclose all criminal convictions, findings of guilt, pleas of guilt, and pleas of nolo contendere with dates, or provide a statement that there is no record of criminal background. Failure to disclose any criminal information is a violation of the law. This includes any offense in any state! __________________________________________________________________________________ __________________________________________________________________________________ Please ask how to complete a Good Cause Waiver when criminal history is disclosed. Have you ever been investigate by the Department of Social Services, Division of Family Services, Department of Health and Senior Services, or any other agency for any type of abuse, neglect or wrong doing? Yes No If Yes, please explain:___________________________________________________ Are you registered with the Family Care Safety Registry? Yes No Have you ever applied for a Good Cause Waiver? Yes No When? ______________________ Does your name currently appear on the Employee Disqualification List? [ ] No [ ] Yes Has your name appeared on the Employee Disqualification List in the past? [ ] No [ ] Yes If yes, please explain: _________________________________________________________________ ELIGIBILITY FOR EMPLOYMENT: To be eligible for employment, you must verify that you meet the following qualifications: Are you at least 18 years of age; able to read and write and follow directions; able to meet the physical and mental demands required to perform specific tasks of the client; agree to maintain confidentiality of personal and medical information; be emotionally mature and dependable; able to handle emergency situations; and are not related to the in-home clients you will serve? Yes No To be eligible for employment, you must meet one of the following qualifications (must supply proof of degree or certification where applicable): At least 6 months paid experience as: n Homemaker n Nurse Aide n Maid n Household worker One year or more experience paid or unpaid, in caring for children or for sick or aged individuals Successful completion of formal training in nursing arts Certification in good standing as a nurse aide (C.N.A.) or home health aide Licensed Practical Nurse with a Missouri License in good standing Registered Nurse with a Missouri License in good standing EDUCATION HISTORY: College/Trade/Business: _____________________ Address: ________________________________ Year Graduated: _______ Major: ______________Degree: ________________ GP: _____________ College/Trade/Business: _____________________ Address: ________________________________ Year Graduated: _______ Major: ______________Degree: ________________ GP: _____________ High School: ______________________________ Address: ________________________________ Year Graduated: _______ Major: ______________Degree: _______________ GP: _____________ EMPLOYMENT HISTORY List the last 5 years of employment, most recent first. Company Name: ________________________________ Supervisor: _________________________ Phone number: __________________________________ Mo/Yr Employed: From ___________ To__________ Position Held: ___________________________ Complete Address _____________________________________________________________________ City State Zip Code Duties: ______________________________________________________________________________ Reason for leaving: _______________________________ May we contact employer? Yes No Company Name: ________________________________ Supervisor: _________________________ Phone number: __________________________________ Mo/Yr Employed: From ___________ To__________ Position Held: ___________________________ Complete Address _____________________________________________________________________ City State Zip Code Duties: ______________________________________________________________________________ Reason for leaving: _______________________________ May we contact employer? Yes No Company Name: ________________________________ Supervisor: _________________________ Phone number: _________________________________ Mo/Yr Employed: From ___________ To__________ Position Held: ___________________________ Complete Address _____________________________________________________________________ City State Zip Code Duties: ______________________________________________________________________________ Reason for leaving: _______________________________ May we contact employer? Yes No ADDITIONAL SKILLS OR EXPERIENCE: Describe any special qualifications, skills or experience you have which is applicable to this positions: __________________________________________________________________________________________________________________________________________________________________________ Do you smoke: Yes No Are you willing to work for people who do smoke? Yes No Is there any reason why you would not be able to perform the job duties? Yes No If the answer is yes, please explain: ________________________________________________________ If selected for employment with HILC In-Home Care, what date could you begin? ___________________ REFERENCES: List at least two references not related to you or past employers. HILC In-Home Care staff will contact at least two (2) credible references 1) Name: ___________________________Relationship ______________ Phone #__________________ Full Address _________________________________________________________________________ City State Zip Code 2) Name: ___________________________Relationship ______________ Phone #__________________ Full Address _________________________________________________________________________ City State Zip Code 3) Name: ___________________________Relationship ______________ Phone #__________________ Full Address _________________________________________________________________________ City State Zip Code I certify the answers herein are true and accurate to the best of my knowledge. I hereby authorize HILC In-Home Care to investigate all statements contained in this application and perform all required background screenings as deemed necessary for employment purposes. I hereby give consent for HILC In-Home Care to perform a closed records check pursuant to Section 610.120 RSMO. I agree that HILC In-Home Care is not liable for any wages until the date of a background screening via the FCSR has been performed and the results are clear and, if applicable, my Good Cause Waiver is in good standing. Additionally, I understand that if I am employed by HILC In-Home Care and it is discovered that there is any false or misleading information given on this application or during my interview, my employment may be terminated. Signature of Applicant: ______________________________________ Date: ____________ IS YOUR APPLICATION COMPLETE IN ITS ENTIRETY? IF IT IS NOT, WE WILL NOT PROCESS THE PAPERWORK. LET US KNOW IF YOU HAVE QUESTIONS OR NEED HELP. LISTS OF ACCEPTABLE DOCUMENTS All documents must be unexpired LIST A LIST B LIST C Documents that Establish Both Document that Establish Documents that Establish Identity and Employment Identity Employment Authorization Authorization 1. U.S. Passport or U.S. Passport Card1. Drivers 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. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United StatesPermanent Resident Card or Alien Registration Receipt Card (Form I-551)2. Certification of Birth Abroad issued by the Department of State (Form FS-545) 3. Foreign passport that contains a temporary I-551 printed notation on a machine-readable immigrant visa2. 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 address3. Certification of Report of Birth issued by the Department of State (Form DS-1350) 4. Employment Authorization Document that contains a photograph (Form I-766)3. School ID card with a photograph4. Voters registration card Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 5. In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the aliens nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form5. U.S. Military card of draft record  6. Military dependents ID card7. U.S. Coast Guard Merchant Mariner Card 5. Native American tribal document8. Native American tribal document 6. U.S. Citizen ID Card (Form I-197) Drivers license issued by a Canadian government authority 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 RMIFor person under age 18 who are unable to present a document listed above:7. Identification Card for Use of Resident Citizen in the United States (Form I-179) School record or report card 8. Employment authorization document issued by the Department of Homeland SecurityClinic, doctor, or hospital record 12. Day-care or nursery school record INSERT NEW FCSR FORM  WHAT IS THE FAMILY CARE SAFETY REGISTRY? The Family Care Safety Registry (FCSR), administered by the Missouri Department of Health and Senior Services (DHSS), provides families and other employers with a method to obtain background screening information. The Registry, through various state agencies, offers several resources to screen child care, elder care and personal care workers and child care and elder care providers: State criminal history and sex offender registry records maintained by the Missouri State Highway Patrol Child abuse/neglect records, maintained by the Department of Social Services The Employee Disqualification List, maintained by the Department of Health and Senior Services The Employee Disqualification Registry maintained by the Department of Mental Health Child care facility licensing records, maintained by the Department of Health and Senior Services Foster parent, residential care facility, and child placing agency licensing records, maintained by Department of Social Services Residential living facility and nursing home licensing records, maintained by the Department of Health and Senior Services WHO HAS TO REGISTER? Any person hired on or after January 1, 2001, as a child care worker or elder care worker, or hired on or after January 1, 2002 as a personal care worker, as defined in 210.900, subsection 2, RSMo, is required to make application for registration in the Family Care Safety Registry within fifteen (15) days of the beginning of employment. Such person who fails to submit a completed registration form to the DHSS without good cause, as determined by the department, is guilty of a class B misdemeanor. Employees and volunteers from non-State and/or Federally regulated entities are NOT REQUIRED to register with the FCSR. HOW DO I COMPLETE THE REGISTRATION FORM? Section A: Type of Worker - Check one box that best describes your worker category. A "voluntary registrant" is a person who is not mandated to register with the Family Care Safety Registry pursuant to 210.900 to 210.936, RSMo. Section B: Identifying Data for Background Screening - List your current name, maiden name, all prior names used, Social Security number, date of birth, gender, home address, and mailing address. You must provide your Social Security number pursuant to 210.906.2, RSMo Supp. 1999. This identifying information, including Social Security number, will be used for internal identification purposes and to conduct background screenings for the resource information listed in paragraph one above. Section C: Current Employer Information (If Applicable) - If you are currently employed by or are seeking employment with a child care or elder care provider, please list the facility name, owner/operator, telephone number and facility address. If you are a foster parent, a voluntary registrant, or receive state or federal funds for child care or elder care services, leave this section blank. Section D: Authorization to Release Background Check Information - Sign and date the registration form. Your signature will authorize the Family Care Safety Registry to conduct the background screening outlined in 210.903.2, RSMo and to provide the information to requestors for employment purposes, as provided in 210.921.1, RSMo. WHERE DO I SEND MY REGISTRATION FORM? Send your completed registration form and photocopy of Social Security card and required fee to the Missouri Department of Health and Senior Services, Family Care Safety Registry, P.O. Box 570, Jefferson City, MO, 65102. If you have questions, please call the Registry using the toll-free telephone number, 1-866-422-6872. WHEN WILL I KNOW THE RESULTS OF MY BACKGROUND CHECK? After the background screening has been completed, you will be notified in writing of the results that will be recorded in the Family Care Safety Registry. You will also be notified in writing each time background screening information is provided. The notification will contain the name and address of the person who made the request and the background information disclosed. The person making the request will be informed that information will be released for employment purposes only as defined pursuant to 210.921.1, RSMo. Any person using Registry information for any other purpose is guilty of a class B misdemeanor. In addition, state agencies can request information for licensure or regulatory purposes. Prior to disclosing information, the Registry obtains the name and address of the person calling, and determines that the request is for employment or regulatory purposes. To ensure you receive these notifications, it will be important for you to notify the Family Care Safety Registry when you have a change in your mailing address. You can send address changes to Family Care Safety Registry, P.O. Box 570, Jefferson City, MO, 65102. WHAT IF I DON'T AGREE WITH THE RESULTS OF MY BACKGROUND CHECK? Pursuant to 210.912, RSMo, you have the right to appeal the information transferred onto the Family Care Safety Registry. Your right to appeal is limited only to the accuracy in the transfer of information from the state agency that maintains the background information and does not include a right to appeal the accuracy of the substance of the information transferred. An appeal needs to be filed in writing to the Office of the Director, Missouri Department of Health and Senior Services, P.O. Box 570, Jefferson City, MO, 65102, within 30 days of receiving the results of the background screening determination. An administrative appeal shall be set within 30 days of the filing of the appeal and a decision shall be made within 60 days. This right to appeal is in addition to any other appeal rights granted by state law. WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY? Disclosure of background information on a person registered in the Family Care Safety Registry will be limited. A Registry worker will first confirm whether the person in question is registered. If the person is registered, the Registry worker will then disclose whether the person's name is listed in any of the background checks pursuant to 210.903, subsection 2, RSMo, and if so, which one. Specific information will only be disclosed by the Registry upon receipt of a written request from the caller. MO 580-2421 (FP) HILC In-Home Care Reference Check Authorization and Release HILC In-Home Care 1010 Hwy 50 West, Owensville MO, 65066 (573) 437-5100; Fax (573) 437-5117 I hereby authorize HILC In-Home Care and its bona fide agents to contact the references I have voluntarily provided for the purpose of evaluating my qualifications for consideration of employment. This authorization is given in accordance with all applicable federal and state laws, regulations, and policies. I understand all information obtained shall be kept confidential. Date____________ Printed Name__________________________________________________ Other names, aliases, and/or maiden name(s) worked under_____________________________________ Signature________________________________ All SSNs used________________________________ (((((((((((((((( We would appreciate your input on the following areas of work-related questions. This information shall be kept confidential. Thank you for your response. Please rate the above named individual on the following: Above Average Average Below Average Attendance ____________ ___________ ____________ Dependability ____________ ___________ ____________ Quality of Work ____________ ___________ ____________ Punctuality ____________ ___________ ____________ Honesty ____________ ___________ ____________ Dates of Employment___________________________ _______________________________ Would you rehire: ___yes ___no Reason for leaving______________________________________________________________________ Company_____________________________________ Location______________________________ Telephone__________________________ Fax Number_________________________ Name of Person providing reference___________________________ Title_____________________ Type of Reference: ___Business ___Personal Printed Name of person taking reference_____________________________ Date_______________ l  X Z ` b ( . 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9bcccdd,eiiii3m4m{mxoyoooo$h^h`a$gdC$a$gdC$hh]h^ha$gdt$hh]h^ha$gdCgdC$hh]h^ha$gdC$hh]h^ha$gdCooop$p%pqqqMrrrrrTsUssstmttuxuyuuuBv^gdL$a$gdCdhgdCgdCooopppp#p8pJprrrUssssssw'3;Pbmxy香~ph>hi5OJQJ^J! jh>h5OJQJ^JhOJQJ^Jh>hOJQJ^Jh>h5OJQJ^JUhLOJQJ^Jh>hC5OJQJ^J! jh>hC5OJQJ^JhOJQJ^Jh>hCOJQJ^Jh>OJQJ^J,BvCvvv8wdwewwGH<=edhgdgd$h^h`a$gd$a$gddhgdCgdCSignature/Title_______________________________________________________ In-Home Coordinator Signature_________________________________ Date_____________________ HILC In-Home Care Reference Check Authorization and Release HILC In-Home Care 1010 Hwy 50 West, Owensville MO, 65066 (573) 437-5100; Fax (573) 437-5117 I hereby authorize HILC In-Home Care and its bona fide agents to contact the references I have voluntarily provided for the purpose of evaluating my qualifications for consideration of employment. This authorization is given in accordance with all applicable federal and state laws, regulations, and policies. I understand all information obtained shall be kept confidential. Date____________ Printed Name__________________________________________________ Other names, aliases, and/or maiden name(s) worked under_____________________________________ Signature________________________________ All SSNs used________________________________ (((((((((((((((( We would appreciate your input on the following areas of work-related questions. This information shall be kept confidential. Thank you for your response. Please rate the above named individual on the following: Above Average Average Below Average Attendance ____________ ___________ ____________ Dependability ____________ ___________ ____________ Quality of Work ____________ ___________ ____________ Punctuality ____________ ___________ ____________ Honesty ____________ ___________ ____________ Dates of Employment___________________________ _______________________________ Would you rehire: ___yes ___no Reason for leaving______________________________________________________________________ Company_____________________________________ Location______________________________ Telephone__________________________ Fax Number_________________________ Name of Person providing reference___________________________ Title_____________________ Type of Reference: ___Business ___Personal Printed Name of person taking reference_____________________________ Date_______________ Signature/Title_______________________________________________________ In-Home Coordinator Signature_________________________________ Date_____________________ HILC In-Home Care Criminal Records Verification and Consent HILC In-Home Care may inquire with the Department of Health and Senior Services and any other agency whether I am listed on the Employee Disqualification List (EDL) or other lists upon receipt of my employment application. Therefore, I give consent to a criminal records review during my employment. I consent and acknowledge that record reviews may disclose any criminal history, including conviction, pleas of guilty, or nolo contendere plea to any charge in Missouri or any other state. The statute also includes conviction of a Class A misdemeanor, reporting acts of abuse or neglect as required. The disclosure must include any suspended imposition of sentence (SIS), suspended execution of sentence (SES), or any period of probation or parole; and disclose if my name is listed on the EDL. I further consent that HILC In-Home Care may obtain criminal records from any legal reporting agency or use a private investigating agency. HILC In-Home Care may request name checks, fingerprint checks, Missouri criminal history and/or national criminal history for employment purposes only. (Complete the following section before a Notary Public) Legal Printed Name_____________________________________ All other names/aliases used______________________________________________________________ All Social Security Numbers used_________________________________________________________ All criminal history, including conviction, pleas of guilt, or nolo contendere, acts of abuse and/or neglect: _________________________________________________________________________________________________________________________________________________________________________ (If no activity exists, please indicate there is no criminal history or acts of abuse and/or neglect.) I certify that I have disclosed all criminal history and/or acts of abuse and/or neglect in the foregoing, and I understand that I may face legal penalty and punishment should further criminal history be disclosed. ___________________________________________________ __________________ Applicant Signature Date On this _____ day of ___________________, ______, before me personally appeared _____________________________________, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. 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