Affordable Medical Resources by 8289566Y

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									                              A One Home Care Services
                                 1159 Monte Drive,
                                 Marietta, GA 30062

                              Application for Employment

                                    Personal Information

Name (Last, First, Middle): _________________________________ Date:_________________
Social Security Number:__________________________________________________________
Home Address:_________________________________________________________________
City:________________________ State:__________________ Zip Code:__________________
Home Phone:______________________ Business / Mobile Phone:________________________
Emergency Contact:_______________________________ Phone:________________________
Date of Birth:__________________________________________________________________
List Handicaps or ailments that would prevent you from performing on-the-job duties:
______________________________________________________________________________
List days absent in the past two years due to illness:____________________________________
Have you ever had an industrial accident or occupational disease?_________________________
Have you ever abused drugs and/or alcohol?__________________________________________
Would you agree to be bonded?__________ Do you have your own liability insurance?_______


Position you are applying for:______________________________________________________
Title:______________________________________ Salary Requirement:__________________
Referred by:________________________________ Date you can start:____________________


                                    Education Record
High School (Name, City, State):___________________________________________________
Graduation Date:________________________________________________________________
Business or Technical School (Name, City, State):_____________________________________
Dates Attended:_____________________________ Degree Earned:_______________________
Undergraduate College (Name, City, State):__________________________________________
Dates Attended:_____________________________ Degree, Major:_______________________
Graduate School:________________________________________________________________
Dates Attended:_____________________________ Degree, Subject:______________________
                                  Work History
     (Give information about your last three jobs, starting with the most recent)
1.   Employer:____________________________________________________________
     Address:_____________________________________________________________
     City:___________________________ State:_______________ Zip:______________
     Phone:____________________________ Ending Salary:_______________________
     Title/Duties:__________________________________________________________
     Manager’s Name and Title:______________________________________________
     Employment Dates:_____________________________________________________
2.   Employer:____________________________________________________________
     Address:_____________________________________________________________
     City:___________________________ State:_______________ Zip:______________
     Phone:____________________________ Ending Salary:_______________________
     Title/Duties:__________________________________________________________
     Manager’s Name and Title:______________________________________________
     Employment Dates:_____________________________________________________

3.   Employer:____________________________________________________________
     Address:_____________________________________________________________
     City:___________________________ State:_______________ Zip:______________
     Phone:____________________________ Ending Salary:_______________________
     Title/Duties:__________________________________________________________
     Manager’s Name and Title:______________________________________________
     Employment Dates:_____________________________________________________

                              Business Reference
         (If applying for your first job, you may use academic references)
1.   Name:_______________________________________________________________
     Work Phone:______________________ Home Phone:________________________
     Address:_____________________________________________________________
     City:___________________________ State:_____________ Zip Code:___________
     Relationship to you:____________________________________________________



2.   Name:_______________________________________________________________
           Work Phone:______________________ Home Phone:________________________
           Address:_____________________________________________________________
           City:___________________________ State:_____________ Zip Code:___________
           Relationship to you:____________________________________________________
   3.      Name:_______________________________________________________________
           Work Phone:______________________ Home Phone:________________________
           Address:_____________________________________________________________
           City:___________________________ State:_____________ Zip Code:___________
           Relationship to you:____________________________________________________



                                      Please Read and Sign

I certify that all information provided by me in this application is true and accurate. I understand
that any falsification or misinterpretation may result in termination of employment even if the
job offer is extended. I understand and permit A One Home Care Services to conduct necessary
investigation on me to determine my eligibility of employment.

A One Home Care Services is an equal opportunity employer. It employs without regard to race,
age, color, religion, sex or national origin.




          _____________________________________                      ____________________
                          Signature                                            Date
                          A ONE HOME CARE SERVICES

                                  Orientation Checklist
Please initial each item, sign and date


   1.      Received, read and understood the policies and procedures manual _____________

   2.      Read and signed Client rights and responsibilities _____________

   3.      Read and signed TB Exposure Statement _____________

   4.      Read and signed confidentially of client form _____________

   5.      Read and signed Handling of complaints_____________

   6.      Read and signed employee’s job responsibilities _____________

   7.      Read and understood emergency procedures _____________

   8.      Agree to complete CLTC task sheet and submit to the office monthly _____________

   9.      Agree to complete time sheet weekly and submit to the office _____________

   10.     Agree to inform nursing supervisor of any changes in client status, environment
           and/or change in the level of any services provided _____________

   11.     Agree to notify supervisor of any changes in my address and/or phone numbers
           _____________

   12.     Agree to notify this office of any changes in my address and/or phone numbers
           _____________

   13.     Agree to notify nursing supervisor at least three hours before any scheduled visit to
           client house, if I am unable to report for work and on emergency situations, call my
           nursing supervisor immediately _____________

   14.     Agree to keep my CPR(every 2 years) and PPD(yearly) current and submit proof to
           office _____________

   15.     Agree to attend in-service provided by this company _____________




         _____________________________________                    ____________________
                         Signature                                          Date
                            A ONE HOME CARE SERVICES
                                         Staff Orientation
A One Home Care Services provides personal care task and companion or sitter tasks in the
Atlanta region.

As a representative of A One Home Care Services:

   1. You must provide competent, state of the art care to its patients

   2. Follow the ‘Client Service Plan’ to perform the tasks agreed upon

   3. For security reasons, you shall not disclose or knowingly permit the disclosure or any
      information in a client record except to appropriate provider staff, the client responsible
      party(if applicable), the client’s physician or other health care provider, the regulatory
      department, other individuals authorized by the client in writing or by subpoena.

   4. In case of any emergency at a client’s home, you must immediately contact the client’s
      emergency contact name (as stated in the client’s file), and notify the A One Home Care
      Services office.

   5. You must notify the A One Home Care Services office and the client’s responsible party
      of any changes in the client’s condition.

   6. As a part of a commitment to quality, we encourage you to report to the office any
      changes that may improve the quality of care a patient is receiving.

   7. Intake sheets have been provided to keep track of every service that is being provided.
      You must note the service provided, date it and initial it.

   8. You must report known exposure to Tuberculosis and Hepatitis to A One Home Care
      Services.

I certify that I have read the above and understand it.


_______________________________________________
Print Name


_______________________________________________
Signature




________________________
Date
                           A ONE HOME CARE SERVICES




I, ____________________________________________________________ do hereby state and
declare that I have never been shown by credible evidence (e.g. a court of law or jury, a
department investigation or other reliable evidence) to have abused, neglected, sexually
assaulted, exploited, or deprived any person or have subjected any person to serious injury as a
result of intentional or grossly negligent misconduct as evidence by oral or written statement to
this effect obtained at the time of application. I also promise hereby to promptly notify the A One
Home Care Services, if any of these events occur in the future.




Name:_________________________ Sign:_______________________ Date:_______________
                          A ONE HOME CARE SERVICES

                               JOB DESCRIPTION
                           PERSONAL CARE ASSISTANT
Qualifications:

   1. Must be able to read and write, follow verbal and written instructions, and complete
      written report of care given.

   2. Must present documentation of nurses aide certification from the department of medical
      assistance or must have received 40 hours training, at least 20 hours of training prior to
      seeing the client and the additional 20 hours to be completed within 6 months of
      employment to include items covered under policies and procedures of personal support
      services, part 2 chapter 1400 pages xiv-8 to xiv-9.

Responsibilities:

     Provide or assist with any of the appropriate duties as Personal Care Assistant with
      minimum qualifications of
   a. Never have been shown by credible evidence (e.g. a court of jury, a department
      investigation, or other reliable evidence) to have abused, neglected, sexually assaulted,
      exploited, or deprived any person or to have subjected any person to serious injury as a
      result of intentional or grossly negligent misconduct as evidenced by an oral or written
      statement to this effect obtained at the time of application.
   b. Participate in the orientation and training required by the rule.
   c. Not have made any material false statements concerning qualification requirements either
      to the department or the A One Home Care Services.

      Encourage client to make decisions and to remain as independent as possible.

      Encourage family members to be involved and responsible for care of client.

      Report changes in client condition to the nurse supervisor.

      Maintain progress note indicating changes in the client’s condition, problems that hinder
       services delivery and additional needs of the client.

      Complete the PSS service documentation on monthly basis for each client.

      Apply information acquired through training.




Signed:________________________________

Date:__________________________________
                          A ONE HOME CARE SERVICES
                                  P O Box 70277
                             Marietta, GA 30007 – 0277


                            Independent Worker Agreement

I, _______________________________________ an independent contractor, agree to provide
service to clients referred to me by A One Home Care Services(AHC) at the rate of
$________/hr.

As an independent contractor, I understand and agree to the following:

   1. That nothing in the relationship between AHC and me creates an employer/employee
      relationship.

   2. That no direct daily supervision of my work will be conducted by this company. The
      client directly supervises my work and reports to the agency(AHC) on his/her satisfaction
      with my performance.

   3. That the agency serves as a referral agency and sub contracts this work to me.

   4. That I will be responsible to pay all applicable fees and taxes including, but not limited
      to, federal and state taxes as required by the Internal Revenue Service and Georgia
      Department of Revenue, worker compensation insurance, and any other tax agency as
      required by law.

   5. That the agency reserves the right to withdraw work not performed according to care plan
      and upon client’s request.




________________________________________                     ______________________
           Independent Contractor                                         Date



________________________________________                     ______________________
        A One Home Care Services                                         Date
                           A ONE HOME CARE SERVICES

I, ________________________________________________________, understand that all
medical information contained in the patient’s records is confidential and should not be released
without a valid patient’s consent. I am aware of the written and verbal policy of A One Home
Care Services and I understand fully. I also understand that failure to comply with the company
policy of patient confidentiality and release of information may result in punitive action, and that
I may subject to instant dismissal and possibly legal repercussion or prosecution.




_______________________________________
Signature of Employee




_______________________________________
Dated

								
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