THIS FORM IS A TEST.Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSocial Security NumberAre you 18 years or older? Yes NoPosition Applied For Speech Therapist Physical Therapist Registered Nurse Home Health Aide Licensed Vocational Nurse Medical Social Worker Occupational Therapist Physical Therapist Assistant Registered DieticianSalary DesiredDate available for work MM slash DD slash YYYY Employment Hours Per Diem Full Time Part TimePlease state days availableAre you currently employed? Yes NoHave you ever been employed by Comfort Assisting, Inc. - Home Health Agency? Yes NoFromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Provide starting date of employment with Comfort Assisting, Inc.ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Provide starting date of employment with Comfort Assisting, Inc.Have you ever been convicted of a felony, or within the last five years, a misdemeanor, which resulted in imprisonment? Yes NoIf hired, how far are you willing to travel?Please enter a numerical value representing the mileage area you are willing to cover.Educational BackgroundHigh SchoolName of your High SchoolNumber of yearsHow long did you go here?Graduated? Yes NoDegree/DiplomaCollege / UniversityName of your college or university.Number of yearsHow long did you go here?Graduated? Yes NoDegree/DiplomaVocational or BusinessName of your vocational school or business training.Number of yearsHow long did you go here?Graduated? Yes NoDegree/DiplomaLaboratory or X-Ray TrainingNumber of yearsHow long did you go here?Graduated? Yes NoDegree/DiplomaEmployment HistoryProvide the following from your past and current employer, assignments or volunteer activities starting from the most recent. Use additional sheets if necessary.EmployerPhoneDate Employed Month Day YearStarting date of employment.Date Employed Month Day YearEnding date of employment.Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job TitleImmediate Supervisor & TitleHourly Starting RateHourly Rate FinalReason for LeavingMay we contact for reference? Yes No LaterEmployerPhoneDate Employed Month Day YearStarting date of employment.Date Employed Month Day YearEnding date of employment.Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job TitleImmediate Supervisor & TitleHourly Starting RateHourly Rate FinalReason for LeavingMay we contact for reference? Yes No LaterDo you consider yourself able to perform all duties required by the job you are applying for without endangering yourself or other employees or patients? Yes NoPlease Explain:*Please explain why you do not consider yourself able to perform all duties required by the job you are applying to without endangering yourself or other employees or patients.Do you hold any professional licenses, regulations, and/or certifications? Yes NoUpload your licenses, regulations, and/or certifications Drop files here or Select filesMax. file size: 64 MB.We accept scans, photographs, screenshots, and similar digital reproductions in the following file types: pdf, jpg, png, gif, tif, jpeg, rtf, docx, doc, odtSignature of Applicant*I certify that all information submitted by me on this application is true and complete, and I understand that if any false information, omission, or misrepresentation are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time. I give the employer the right to contact and obtain in formation from all references, employers and educational institutions and otherwise verify the accuracy of the information contained in this application. I understand that if I am employed it will be on a probationary or trial basis for a period of 90 days. Upon termination, I authorize the release of reference on my work performance. I consent to take the pre-employment physical examination and I understand that Comfort Assisting, Inc.- Home Health Agency may require such future physical examination as at such times and places as Comfort Assisting, Inc.- Home Health Agency shall designate. I understand a photograph may be required after employment. I understand that I will be required to follow the personnel policies and rules of Comfort Assisting, Inc. -Home Health Agency and that infraction of said rules might lead to dismissal. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on the application form. I further understand that Comfort Assisting, Inc.- Home Health Agency follows the "fair employment practice code" and there is no discrimination in the firing of individuals based on race, color, religion, creed, national origin, ancestry, marital status, sex, sexual orientation or on the base of age or of physical or mental handicap unrelated to ability to perform the work required.Date Month Day YearThe information will be used ONLY in an emergency or as may be required by law under extraordinary circumstances. This form should be completed and returned to your supervisor who will forward one copy for inclusion in your personal folder. Should any of this information change, please submit a corrected form to your supervisor. It is Important that this data be kept current at all times.Employee Name First Middle Last Cell PhoneOther PhoneHome Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Person to notify in case of accident or illness First Last RelationshipPlease describe your relationship to this personAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneOther PhoneAlternate person to notify in case of accident or illness First Last RelationshipPlease describe your relationship to this personAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneOther PhonePlease Confirm:* I UnderstandIf you have a chronic medical problem (e.g. heart condition, epilepsy, asthma, allergy, etc) that could incapacitate you during working hours you are encouraged to discuss symtoms and emergency treatment with each of your supervisors during your employment.Emergency Doctor First Last In case of need for emergency medical treatment please contact this doctor.Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code InsuranceIf you carry health and/or hospital insurance please list it here.Please Confirm* I understandIf you do not list a preference for emergency medical treatment the Physician's Exchange will be called If an emergency arises.By completing this form you are telling us who to contact should you suffer an injury or illness at work.*When requesting an address change: please complete the Employee Action request (EAR), the Person Authorized to Receive Warrants and a new Emergency Notification Form. All of these forms ask for your current address and must be updated with each address change.Computer Password and Privacy Agreement*I understand the need to maintain a high level of security with computer, email, and other digital access. I accept responsibility in keeping work passwords confidential.Confidentiality Agreement*Protecting privacy and confidentiality of Patient, Employee and Organizational information.Comfort Assisting, Inc. acknowledges both the legal and ethical responsibility to protect the privacy of the patient. Consequently, the indiscriminate or unauthorized review, use, or disclosure of personal information, medical or otherwise, from any source regarding any patient is expressly prohibited except when required in the regular course of business. Included is the discussion, use, transmission or narration, in any form of any patient information. Any violation of this policy shall constitute grounds for severe disciplinary action, including possible termination of the offending employee.I have read and understand the significance of this policy and agree to abide by it.Title 22, State Department of Health and Human ServicesFacility Requirements to Qualify to ServiceI have read and understand my obligations to the following Title 22 requirements:* Elder Abuse Child Abuse Infection Control Universal Precaution Fire Safety Electrical Safety Disaster SafetyTitle 22 Signature* I have read and understand my obligations to the aforementioned Title 22 requirements.Abuse Reporting RequirementsCalifornia State Law requires home health agency's employees to report any and all instances of elder and dependent adult abuse as well as child abuse. Following is a list of documents employee must acknowledge and read: SOC-341A- Statement acknowledging requirementto report suspected abuse of dependent adults and elders (Employee's signature required) Form SOC-341- Confidential Report of Suspected Dependent Adult/Elder Abuse Definitions and general instructions for completion of Form SS 8572 Form SS 8572- Suspected Child Abuse Report I acknowledge and have signed (when required) the documents above and will abide by all requirements stated therein. I further acknowledge that I have been instructed of how to proceed in case of witnessing a suspected elder/dependent adult/child abuse.Signature*Conflict of Interest I understand that Comfort Assisting, Inc., Home Health Agency have developed rules to protect the patient and patient's relationship with the agency. I further understand that I will abide by these rules and am aware that patient has every right to express their concerns to the supervisor. Accepting Gifts: Comfort Assisting, Inc., Home Health Agency employees must not accept gifts, loans or gratuities from patients, patient family members or caregivers that could create an obligation or might appear to influence decisions made by the employees. Employees shall advise the patients or their family members to contact the supervisor or the Agency's administration to express their favorable opinion. Employment by Patients and/or their family Members: Home health employees are not permitted to work privately for patients or members of their families. Soliciting Business: Home health employees are not permitted to solicit personal business or services from patients or members of their families. Coercing Patients: Home health employees must not coerce or otherwise try to prevent patient from filing their complaint (i.e. by threatening the quality of future services).Conflict of Interest Signature*Electronic Signature Overview Kinnser Software's electronic signature system uses a dual password process to ensure authentic electronic signatures.Each Kinnser application user has a system password (log in authentication password) that must be updated every 6o days to ensure continued access to the system. When an electronic signature will be utilized to sign clinical documentation. The user will provide an additional signature password (Electronic Signature Passcode) to sign the document within the system. When an electronic signature is applied to a document,-the time and date are stored for later retrieval If at any time a document that has been electronically signed is reopened or otherwise edited, the electronic signature will be destroyed, and must be reentered by the user upon re-submission of the clinical documentation.Log in authentication passwords are created and assigned at the organization level. Electronic Signature Passcodes are created by individual users and subsequently managed by Kinnser Software, Inc. If a user forgets their Electronic Signature Passcode the user can reset the Electronic Signature Passcode themselves or can request a reset to be performed by Kinnser Customer Support. Resetting the Electronic Signature Passcode can only be done by the user or Kinnser to ensure the security of the dual password process.Electronic Signature PolicyPolicy: Comfort Assisting, 1nc. Home Health Agency staff may use electronic signature on all computer generated documentation. An electronic signature will serve as authentication on patient record documents generated via the organization's Kinnser application.Purpose: To utilize current technology in the provision of patient careResponsibility: All personnelProcedure: Comfort Assisting, Inc. Home Health Agency staff may create patient documentation via computer system.For the purpose of the electronic medical record and documents printed from the electronic medical record, the employee's use of an Electronic Signature Passcode after authenticating with their system log in. The organization-based application administrator will issue each employee a system username and a temporary password. The user will create a new password upon initial log in to the organization's Kinnser application. The employee will generate an Electronic Signature Passcode that will only be accessible to them. Each user will be required to change her/his Login authentication password.Upon her/his password being reset by an organization-based applicationEvery 6o daysAt the employee's discretion If an Electronic Signature Passcode must be reset. The user can reset her/his own Electronic Signature Passcode or Kinnser Customer Support may reset the Electronic Signature Passcode with employee authentication.After completion of a clinical document, the clinician must enter their Electronic Signature Passcode to submit the clinical document to the case manager.Each employee documenting electronically in the electronic medical record will be required to sign an Electronic Documentation and Signature Authenticity Agreement. This agreement will require that the employee:Ensure the security of their login authentication password and.Electronic Signature Passcode information, which may not be shared with anyone.Exit the electronic medical record software when the computer will not be used for clinical documentation or is out of their possession and at the end of each working day, andReview all documentation prior to submission.Each employee will review documentation and make necessary corrections per organization policy to documents returned by a case manager, at which time the clinician will be required to re-enter the Electronic Signature Passcode to re-submit the documentation. In the event of system downtime that results in the employee's inability to use the electronic documentation, the employee will complete records manually. Each user must keep their login username authentication password and Electronic Signature Passcode confidential. Only the user and at organization-based administrator may reset a user's login authentication password. Upon termination of employment, the administrator will immediately disable the employee user's credentials to prevent access to the electronic medical record.Electronic Documentation & Signature Authenticity Agreement I understand that Comfort Assisting, Inc. Home Health Agency staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as authentication on patient record documents and other organization documents generated in the electronic system. For purposes of the computerized medical record and other organizational documentation, I acknowledge that the combined use of my Electronic Signature Passcode and Login authentication password will. serve as my legal signature. I further understand that an organization-based administrator will issue my initial employee password and that I will create an Electronic Signature Passcode within the software application. Login authentication password must be updated every 6o days by the user, as well as on an as needed basis in the event system security is breached. I understand that prior to exporting documentation to the organization server, I must review and authenticate by use of electronic signature, my documentation on the field-based or office computer. I understand that I am responsible for the security and accuracy of information entered into my organization's Kinnser application, and as such, I will:Not share or otherwise compromise my electronic signature credentials (Login authentication password or Electronic Signature P.asscode)Exit the online application at the end of each working day or whenever the computer is not in my immediate possession; not save my Login authentication password and Electronic Signature Passcode on the computer, but will enter them upon each access of the application; andReview all of my documentation online prior to submitting to the organization.Kinnser Signature*Confidential Background Check AuthorizationName First Last Former Names and Dates they were usedCurrent Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address SinceMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Previous Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address FromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address FromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security NumberDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Telephone NumberDrivers/ID Number and Issuing StatePlease write your driver license and the issuing state.Example: B3219876 CAThe information contained in this application is correct to the best of my knowledge. I hereby authorize Comfort Assisting lnc. and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. l understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences, employment history, education background, character references, drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Comfort Assisting, Inc. or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. I hereby release Comfort Assisting, Inc. the -Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.Signature*Flu Vaccination FormHave you had a flu shot before? Yes NoDid you receive a flu vaccine last year? Yes NoHave you had any reactions to the flu vaccination? Yes NoSEASONAL INFLUENZA VACCINE INFORMATION*FLU SEASON IS FROM OCTOBER TO MARCH*Influenza is a serious respiratory disease that kills, on average, 36,000 Americans every year. Influenza virus may be shed for up to 48 hours before symptoms begin, allowing transmission to others.Up to 30% of people with influenza have no symptoms, allowing transmission to others.Flu virus changes often, making annual vaccinations necessary. Immunity following vaccination is strongest for 2 to 6 months. In California, influenza usually arrives around New Year through February or March.Vaccine Choices I have read "Influenza Vaccine Information Statement" above. I have had an opportunity to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine. I have provided documentation that I have had a flu shot this year. I have read "Influenza Vaccine Information Statement" above. I have had an opportunity to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine. I am opting to receivethe flu shot at Comfort Assisting, Inc., Home Health Agency (if available). I have read "Influenza Vaccine Information Statement" above. I have had an opportunity to ask questions which were answered to my satisfaction. I understand the benefits anc;l risks of influenza vaccine. I wish to decline the flu shot today and will state my reason in the Flu Vaccination Declination Form.Date MM slash DD slash YYYY Signature*FLU VACCINATION DECLINATION FORMI understand that by refusing the vaccine I may be putting MYSELF, FAMILY and PATIENTS at risk of getting influenza. I am aware that hospitalized patients are at increased risk of getting serious complications following influenza infection. I am declining receipt of flu vaccine based on reasons of:Declination ReasoningSurgical Mask Acknowledgement YesI understand that I will be required to wear a surgical mask within six feet of patient when engaged in patient care of having contact with patients while performing assigned duties of the respiratory virus season, which is generally October through March.Name First Last Signature*Date MM slash DD slash YYYY TB SCREENING QUESTIONNAIRE(To be completed on hire date and annually thereafter)Do you currently have any of the following symptoms?Any exposure to TB Yes NoUnusual fatigue Yes NoWeight Loss (unexplained) Yes NoAnorexia (loss of appetite) Yes NoPersistent cough lasting more than 3 weeks Yes NoHemoptysis (blood tinged sputum) Yes NoFever associated with cough of more than 2 week Yes NoNight sweats Yes NoDate MM slash DD slash YYYY Signature*EMPLOYEE COMMUNICATION AGREEMENTI understand that Comfort Assisting, Inc., Home Health Agency have developed means for internal communication and will use them and encourage their use among others. Staff Meetings:Comfort Assisting, Inc., Home Health Agency employees will participate in regular Quarterly Meetings during which employees will be informed on recent company activities, changes in workplace and employee recognition.Suggestion Box:Comfort Assisting, Inc., Home Health Agency encourages employees who have suggestions that they do not want to offer publicly, to write them down and leave them in the Suggestion Box located in the company's office. If this is done anonymously, agency's management will take every measure to preserve the employee's privacy.Handling of Complaints:Employees who have a job-related problem, question or complaint, should first discuss it with their immediate supervisor. At this level employees usually reach the simplest, quickest and most satisfactory solution. If the employee and supervisor do not solve the problem, agency encourages employees to contact the manager.I have read and will abide by this agreement*Name First Last Date* MM slash DD slash YYYY JOB DESCRIPTION:Home Health Aide (HHA)JOB SUMMARY:A paraprofessional person who is specifically trained, competent and performs assigned functions of personal care to the patient in their residence under the direction, instruction and supervision of the registered nurse (RN).QUALIFICATIONS:Must meet Medicare Conditions of Participation for Home Health Aide training program and competency.Have a sympathetic attitude toward the care of the sick and elderly.Ability to carry out directions, read and write.Maturity and ability to deal effectively with the demands of the job.Acceptance of philosophy and goals of this Agency.RESPONSIBILITIES:Understands and adheres to established Agency policies and procedures.Performs personal care and bath as ordered. Completes appropriate visit records in a timely manner as per Agency policy.Reports changes in the patient's condition and needs to the RN. Performs household services essential to health care in the home as assigned. Ambulates and exercises the patient as assigned. Performs simple procedures as an extension of the therapy services, e.g., range of motion (ROM) exercises as assigned. Assists with medications that are ordinarily self-administered as assigned. Attends inservice and continuing education programs as scheduled and necessary. Attends patient care conferences as scheduled.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIPS:Supervised by: DPCS/RNRISK EXPOSURE: High riskLIFTING 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 in physical activity.Heavy lifting.Ability to do extensive bending, lifting, and standing on a regular basis.JOB DESCRIPTION:Speech Language Pathologist (SLP)JOB SUMMARY:A Speech Language Pathologist (SLP) administers speech therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director ofNursing. Speech therapy senrices are furnished only by or under the supervision of a qualified speech pathologist or audiologist.QUALIFICATIONS:A person who meets the education and experience requirements for a certificate of Clinical Competency in Speech Pathology or audiology granted by the American Speech-Language Hearing Association, or A person who meets the educational requirements for ce1iification and is in the process of accumulating the supervised experience required for certification. Currently licensed in the state(s) in which practicing. Two (2) years experience, preferred.RESPONSIBILITIES:Improves or maximizes the communication of the patient.Returns the individual to optimum and productive living within the patient's capabilities.Periodically participates with all other health care personnel in patient care planning.Provides full range Speech Language Pathology Services as ordered by physician. Directs and supervises personnel, as assigned. Takes initial history and makes initial evaluation. Performs all skilled procedures. Consults with physicians regarding change oftreatment. Writes reports to physicians regarding-patient's -progress: Instructs patients and family members in home programs. Periodically presents an inservice to the Agency's staff members. An initial evaluation, including plan of treatment and goals, must be completed and submitted to the physician for approval. A recertification by physician every 60 days is necessary if further treatment is to be continued. A progress note is written each visit. A reevaluation is written when expected duration of treatment is reached. A summary is written upon patient's discharge. A supervisory visit is made every fourteen days on each patient seen by a home health aide as assigned. Assists the physician in evaluating level of function. Helps develop the plan of care and revises as necessary. Prepares clinical and progress notes.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIP:Supervised by: Director of NursingRISK EXPOSURE: High riskLIFTING 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 in physical activity.Moderate lifting.Ability to do extensive bending, lifting and standing on a regular basis.JOB DESCRIPTION:Registered Physical Therapist (PT)JOB SUMMARY:A Registered Physical Therapist (PT) administers physical therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Patient Care Services.QUALIFICATIONS:Graduate from a physical therapist curriculum approved by the American Physical Therapy Association, or the Committee on Allied Health Education and Accreditation of the American Medical Association, or the Council of Medical Education of the American Medical Association and American Physical Therapy Association.Currently licensed in the state(s) in which practicing.Two (2) years experience, prefened.Acceptance of philosophy and goals of this Agency.Ability to exercise initiative and independent judgment.RESPONSIBILITIES:Understands and adheres to established policies and procedures.Provides physician prescribed physical therapy.Improves or minimizes residual physical disabilities of the patient.Returns the individual to optimum and productive level within the patient's capabilities.Participates with all other health care personnel in patient care planning.Directs and supervises personnel as required. Takes initial history and makes initial evaluation. Performs all skilled procedures as ordered by physician. Consults with physicians regarding change in treatment. Writes reports to physicians regarding patient's progress. Instructs patients and family/significant others in home programs and activities of daily llving. Participates in inservice programs and presents inservice programs as assigned. Participates in performance improvement activities as assigned. Attends all patient care conferences as scheduled. Prepares clinical and progress notes. Assists physician with evaluating level of function. Helps develop the plan of care and revise as necessary. Consults with family and Agency personnel.Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defmed time frames. Appropriately utilizes ICD-9 codes.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIP:Supervised by: Director of Patient Care Services Workers Supervised: Physical Therapy AssistantRISK EXPOSURE: High riskLIFTING 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 in physical activity.Moderate lifting.Ability to do extensive bending, lifting and standing on a regular basis.JOB DESCRIPTION:Registered Nurse (RN)JOB SUMMARY:A Registered Nurse administers skilled nursing care to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of patient Care Services.QUALIFICATIONS:Graduate of an approved school of professional nursing and currently licensed in the state( s) in which practicing.One (1) year professional current nursing experience or two (2) years professional nursing experience, preferred. Acceptance of philosophy and goals of this Agency.Ability to exercise initiative and independent judgment.RESPONSIBILITIES:Provides services in accordance vvith the plan of care.Makes the initial evaluation visit and regularly reevaluates the patient's nursing needs.Initiates the plan of care and necessary revisions.Provides those services requiring substantial specialized nursing skills.Initiates appropriate preventive and rehabilitative nursing procedures. Prepares clinical and progress notes for each patient visit and summaries of care conferences on his/her patients in a timely manner as per Agency policy.Coordinates services.Informs personnel of changes in the condition and needs of the patient.Counsels the patient and family/significant others in meeting nursing and related needs.Participates in and presents inservice programs.Understands and adheres to established Agency policies and procedures.Processes orders and notifies physician of patient needs and changes in condition.Completes certification/recertification orders and discharge summaries. Determines the amount and type of nursing needed by each individual patient. Refers to Physical Therapist, Speech Language Pathologist, Occupational Therapist and Medical Social Worker those patients requiring their specialized skills. Supervises and teaches other nursing personnel. Conducts patient care conferences on patients assigned to his/her care. Participates in peer review and performance improvement as assigned. Participates in utilization review of medical records as assigned. Gives total patient care as needed. Takes on-call duty nights, weekends and holidays, as assigned. Completes and submits OASIS assessments~ reassessments, transrers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames.Appropriately utilizes ICD-9 codes. Assesses and manages pain.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIPS:Supervised by: Director of Patient Care Services Workers Supervised: Licensed Practical Nurse, Home Health AideRISK EXPOSURE: High riskLIFTING 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 in physical activity.Heavy lifting.Ability to do extensive bending, lifting, and standing on a regular basis.JOB DESCRIPTION:Licensed Vocational Nurse (LVN)JOB SUMMARY:A qualified Licensed Vocational Nurse administers skilled nursing care to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Registered Nurse. Services are furnished in accordance with Agency policies.QUALIFICATIONS:Graduate of a state approved school of practical (vocational) nursing and currently licensed in the state(s) in which practicing.Minimum of one (1) year professional current experience in nursing or two (2) years professional experience in nursing, preferred.Acceptance of philosophy and goals of this Agency.Ability to exercise initiative and independent judgment.RESPONSIBILITIES:Understands and adheres to established policies and procedures.Implements the nursing care plan for each patient. Provides nursing services, treatments and diagnostic and preventive procedures as assigned. Initiates preventive and rehabilitative nursing procedures as appropriate.Observes signs and symptoms and reports to the physician and RN reactions to treatments, including drugs and changes in the patient's physical or emotional condition.Teaches and counsels the patient and family/significant others regarding the nursing care needs and other related problems of the patient at home. Evaluates with registered nurse the effectiveness of the L VN1s nursing service to the patient and family under the guidance of the registered nurse. Maintains accurate and complete records of observations, treatments and care of patient. Participates in medical record audit as assigned. Attends staff meetings, patient care conferences and inservices as scheduled. Talkes on-call duty, nights, weekends and holidays as assigned. Is responsible for: - Submitting any changes in schedule to Director of Patient Care Services or the Administrator on a daily basis. - Participating in patient care conferences to discuss the need for involvement of other members of the health team, such as physical therapist or speech language pathologist.Prepares clinical and progress notes.Assists the physician and RN in performing specialized procedures. Prepares equipment and materials for treatments. Observes aseptic technique as required.Assists the patient in learning appropriate self-care techniques.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIPS:Supervised by: DPCS/RNRISK EXPOSURE: High riskLIFTING 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 in physical activity.Heavy lifting.Ability to do extensive bending, lifting, and standing on a regular basis.JOB DESCRIPTION:Medical Social Worker (MSW)JOB SUMMARY:A Medical Social Worker (MSW) provides social work services to patients on an intermittent basis in their place of residence. This is perfom1ed in accordance with physician orders and plan of care under the direction and supervision of the Director of Patient Care Services. Services are furnished by a qualified social worker or by a qualified social work assistant under the supervision of a qualified social worker.QUALIFICATIONS:A person who has a master's degree fiĀ·om a school of social work accredited by the Council on Social Work Education, and has one year experience in a health care setting, or Has a baccalaureate degree in social work, psychology, sociology or other field related to social work, and has had at least one year experience in a health care setting (functions as an assistant). One to three (1-3) years professional experience, preferred. One (1) year experience in health care setting, preferred. Acceptance of philosophy and goals of Agency. Ability to exercise initiative and independent judgment. Ability to work with individuals to enlist cooperation of many people to perform/achieve a common goal.RESPONSIBILITIES:Understands and adheres to established Agency policies/procedures.Understands and promotes principles of continuous perfonnance improvement. Acts as a consultant to other Agency personnel. Participates in the coordination of Agency's services with the services of other community resources; uses community resources.Observes confidentiality and safeguards all patient information. Serves as a resource person to employees, patients, physicians and other allied healthcare providers.Develops a cooperative relationship and communicates effectively and professionally with physicians. Accepts responsibility for regular attendance and punctuality. Maintains current knowledge of Medicare Conditions of Participation for social work services. Immediately reports any accident, incident, lost articles or unusual occmTence to Director of Patient Care Services. Participates in inservices and/or continuing education programs. Participates in patient care conferences. Maintains contact with community support groups and provides professional expertise as required. Plans/coordinates all social services within the Agency. Documents all patient/family services provided as required by Agency policy.Assists physician and other team members in understanding the significant social and emotional factors related to health problems. Participates in the development of the plan of care ..Prepares clinical and progress notes. Works with the family.Participates in discharge planning. Other duties assigned by DPCS (or Social Worker, if Social Work Assistant).WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIPS:Supervised by: Director of Patient Care Services If Social Work Assistant: Social WorkerRISK EXPOSURE: High riskLIFTING REQUIREMENTS:Ability to perform the following tasks if necessary:Ability to participate in physical activity and to do bending, lifting and/or standing on a regular basis.Light lifting may be required.Ability to work for extended period of time while sitting or standing.JOB DESCRIPTION:Occupational Therapist (OT)JOB SUMMARY:An Occupational Therapist (OT) administers occupational therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Director of Patient Care Services.QUALIFICATIONS:Graduate of an Occupational Therapy curriculum accredited jointly by the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Occupational Therapy Association (AOTA) and/or certified by successfully completing the National Certification examination, or Is eligible for the National Registration Examination of the American Occupational Therapy Association. Currently licensed in the state(s) in which practicing. Two (2) years experience, preferred. Acceptance of philosophy and goals of the Agency.RESPONSIBILITIES:Improves or minimizes residual physical disabilities of the patient.Retums the individual to optimum and productive living within the patient's capabilities. Periodically participates with all other health care personnel in patient care planning. Provides prescribed occupational therapy.Directs and supervises personnel as required. Takes initial history and makes initial evaluation. Performs all skilled procedures. Consults with physicians regarding change in treatment. Writes reports to physicians regarding patient's progress. Instructs patients/family members in. home programs and fine motor movement exercises.An initial evaluation, including plan of treatment and goals, must be completed and submitted to the physician for approval. A Tecertification by physician every 60 days is necessary, if further treatment is to be continued. A progress note is written each visit. A reevaluation is written when expected duration of treatment is reached. A summary is written upon patient's discharge.Periodically presents an inservice to the Agency staff.Assists the physician in evaluating level of function. Helps develop the plan of care and revises as necessary. Prepares clinical and progress notes. Advises and consults with the family and other Agency personnel. Participates in inservice programs.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIPS:Supervised by: Director of Patient Care ServicesWorkers Supervised: Certified Occupational Therapy AssistantRISK EXPOSURE: High riskLIFTING 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 in physical activity.Heavy lifting.Ability to do extensive bending, lifting, and standing on a regular basis.JOB DESCRIPTION:Licensed Physical Therapy Assistant (LPTA)JOB SUMMARY:A Licensed Physical Therapy Assistant (LPTA) administers physical therapy to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction and supervision of the Registered Physical Therapist (PT).QUALIFICATIONS:Graduate from a two-year college level program approved by the American Physical Therapy Association.Currently licensed in the state(s) in which practicing.Two (2) years experience, preferred. Acceptance of philosophy and goals of Agency. Ability to exercise initiative and independent judgment.RESPONSIBILITIES:Understands and adheres to established Agency policies and procedures. Provides physician prescribed physical therapy under a plan of care established by the PT. Improves or minimizes-residual physical disabilities of the patient. Returns the individual to optimun1 and productive level within the patient's capabilities. Participates with all other health care personnel in patient care planning. Performs all skilled procedures as ordered by physician and according to the plan of care established by the PT.Consults with PT regarding change in treatment. Instructs patients and family members in home programs and activities of daily living. Participates in inservice programs and presents inservice programs as assigned. Participates in performance improvement activities as assigned. Attends all patient care conferences as scheduled. Prepares medical records, progress notes and updates care plans for each patient visit in a timely manner as per Agency policy. Performs services planned, delegated and supervised by the PT. Assists in preparing clinical and progress notes. Participates in educating the patient and family.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to/from patient homes.JOB RELATIONSHIPS:Supervised by: Registered Physical Therapist or Director of NursingRISK EXPOSURE: High riskLIFTING 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 in physical activity.Heavy lifting.Ability to do extensive bending, lifting, and standing on a regular basis.JOB DESCRIPTION:Registered Dietitian Nutritionist (RDN)JOB SUMMARY:A qualified Registered Dietitian Nutrition (RDN) is responsible for the planning and delivering nutrition care of patients in accordance with the physician's diagnosis and requirements of regulatory agency. Functions a member of the health care team to asses and provided nutritional intervention for all patients identified at nutritional risk by the health care team. Develops orientation, education, knowledge and skills as appropriate for the patients, including the adolescent, geriatric and adult patient, plus terminal ill patient. The RDN analyses body composition, supplement evaluation and recommendation- implementing behavior modification and life style management techniques.QUALIFICATIONS:Graduate ofthe state approved by the Academy ofNutrition and Dietetics holding a Bachelor's degree in Food & Nutrition, Dietetics or related field. Minimum of one (1) year experience as Registered Dietitian or 1 to 2 years Knowledge of the principles and practices of Medical Nutrition Therapy for Patients with Complex medical conditions. Expertise in planning, developing and implementing appropriate interventions. Demonstrated skill and knowledge of age-related nutritional needs. Understand the patient population's cultural and ethnic background and how it impacts patient's level of care, diet and food . restrictions. Valid Registration as a Registered Dietitian. Acceptance of philosophy and goals ofthis Agency. Ability to exercise initiative and independent judgment.RESPONSIBILITIES:Understand and adheres to establish policy and procedures.Implements food nutrition and dietetics to the nursing care plan for each patient.Providing nutrition services, treatment and diagnostic and preventive procedures as assigned.Responsible for providing medical nutrition therapy, patient education, and diet communication functions.Initiates preventive and rehabilitative nursing procedures as appropriate. Observe signs and symptoms and reports to the physician and RN reaction to treatments, including drugs and changes in the patient's physical or emotional. Teaches and counsels the patient and family/significant others regarding the nutrition and dietetic needs and other related problems of the patient at home. Evaluates with registered nurse the effectiveness of these nursing services to the patient and family under guidance of the registered nurse. Maintains accurate and complete records of observations, treatments and care of patients.Participates in medical record audit as assigned.Attends staff meeting, patients care conference's and in-services as scheduled.Takes on-call duty, night's weekends and holidays as assigned.Is responsible for : - Submitting any changes in schedule to Director of Patient Care Services or to the Administrator on daily basis. - Participating in patient care conferences to discuss the need for involvement of other members of the health team, such as physical therapist, speech language pathologist or respiratory therapist.Prepares clinical and progress notes.Assist the physician and RNAssists the patient in learning the appropriate self-care techniques.WORKING ENVIRONMENT:Works indoors in Agency office and patient homes and travels to /from patient homes.JOB RELATIONSHIPS:Supervised by: DPCS/RNsRISK EXPOSURE: High riskLIFTING 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 in physical activity.Heavy lifting.Ability to do extensive bending, lifting, and standing on a regular basis.Job Description Agreement*I have read the above job description and fully understand the conditions set forth therein, and if employed I will perform these duties to the best of my knowledge and ability.Date* MM slash DD slash YYYY