Personal Care Attendant (PCA) Application & New Hire Packet · ProStat, Inc. 2208 Quarry Dr. (Suite...

1

Personal Care Attendant (PCA) Application & New Hire Packet

Employee/Applicant Name:_________________________________ Started By: _____________________________________________ Date:___________

Page 2 of 38

eDOC Checklist Personal Care Attendant (PCA)

Employee Name: ______________________________________ Office: ________________ Check the box for each verified document. All EDOCS must be completed and verified prior to extending an offer of employment.

❏ Employment (ARS) Application (Print & Review thoroughly) ❏ Attendance Policy ❏ Business Associates Agreement ❏ Childline Consent Release Form ❏ Criminal Background Check Policy with Fair Credit Reporting Act Notice (Attachment) ❏ Drug-Free Workplace Policy ❏ Elder Justice Act Agreement ❏ Employee Notification Form (worker’s comp) ❏ Employment Standards ❏ Fraud Prevention ❏ Hepatitis B Vaccination Consent/Refusal (Print and Review for Consent or Refusal. Give

form to employee if they consent so they may begin the Hep B vaccine series. Fill out Advanced Payment for Medical Services. We will pay for but not charge the employee for the series.)

❏ Hepatitis B Exposure Control Plan (ECP) ❏ PCA Competency Test (Verify score of 80% or higher) ❏ PCA Employee Code of Ethics ❏ HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT ❏ Per Diem Employee Agreement ❏ PCA Job Description ❏ PHA INSTRUCTIONS (Print and give to employee to complete) ❏ Prohibited Offenses List (Print & Review for Prohibited Offenses) ❏ Reporting a Crime ❏ Seat Belt Policy ❏ Travel-Time Policy

___________________________________________________________________________ Person Completing This Form (Print) Signature Date

ProStat, Inc. 2208 Quarry Dr. (Suite 206) Reading, PA 19609 Tel. (610) 736-9000 Fax (610) 736-9006

Page 3 of 38

Interview & Employment Offer Guide and Checklist

Candidate Name:_____________________________ Position: ____________ Location:____________

Interview: ❏ EDOC Checklist (Completed) ❏ Reference Request Forms {exact match from application} (Completed & Reviewed) ❏ Skills Checklist (Completed & Reviewed) ❏ Review Job Description AND Proceed with Interview:

❏ Face-to-face Interview Questionnaire (Completed & Reviewed) ❏ Abuse & Neglect Training (Completed) and Acknowledgment Form (Signed) ❏ Drug Screen Consent and Drug Result Form (Completed & Reviewed) ❏ WOTC Form 8850, 9061, & 9175. (Completed & Reviewed)

Offer of Employment:

❏ Present Offer of Employment to Applicant (Completed & Reviewed) ❏ Applicant signs and a copy is made for them (Completed)

------------------- STOP! Below to be completed post-offer of employment only -------------------

Post Offer Paperwork All Employees:

❏ Have Applicant complete the Medical Questionnaire (Completed & Reviewed) ● If employee answers “Yes” to any of the questions, either a Physician’s Statement or

Physical that states, “Able to work without any restrictions” will be required. ❏ Collect PPD or Chest x-ray results (Completed & Reviewed) ❏ W-4 (Completed & Reviewed) ❏ I-9 with authorized supporting documentation (Completed & Reviewed) ❏ Proof of Residency (Complete & Collect Documentation) ❏ Mandatory Reporter Form (Completed & Reviewed) ❏ Re-Payment Authorization Form (Completed & Reviewed) ❏ Criminal Background Consent Form (Completed & Reviewed) ❏ Notice of ACA to Employees (Provided to Employee) ❏ Direct Deposit Form (Completed & Reviewed) ❏ Child Abuse Training (Assigned) ❏ Take Picture for I.D. Badge (Completed and emailed to Corporate)

Only if DCW Applicant:

❏ Transportation Consent & Waiver Flowsheet ❏ Childline Application Form and Childline Waiver Cert. 3/16 (Completed & Reviewed) ❏ Family Caregiver Case Acknowledgement (Completed & Reviewed)

Only if Certified/Licensed Applicant:

❏ Resume establishing a minimum of one (1) year related experience.(Requested) ❏ Current CNA Certification or LPN/RN Licenses (Requested) ❏ Physician’s Statement and Flu Shot (Assigned) ❏ CPR for LPN & RN Employees Only (Requested)

Person completing this form: _________________________________________ Title: _______________ Signature: ______________________________________________ Date: ________________


Page 4 of 38

Face-to-Face Interview (NOTE: Use standardized interview questions for all applicants)

Name of Applicant: ____________________________________________ Title: ___________________ Phone: _____________________________ Email, if applicable: ________________________________ Date of interview: ____________________ Location: ________________________________________ Interview Conducted by: _____________________________________Title: ______________________

1. What brought you to us? How did you find out about us?

2. What do you think you can offer us/this position?

3. Do you have PROFESSIONAL or RELEVANT experience in this line of work? Please explain:

4. Give an example of a problem that you faced and how you handled it?

5. Describe how you handled a time when you were asked to do something you weren’t trained to do?

6. What do you think would be the hardest part of this job for you?

7. If a consumer would ask you to do something you knew you weren’t allowed to do, either it’s against

company policy/procedure or not on the consumer’s Service Plan, what would you do?

8. Would you have a problem giving a man a bath? Giving a woman a bath?

9. Can you cook meals and do light housekeeping and cleaning?

10. Is it a problem if the client smokes? If the client has a pet?

11. We will perform a drug test today. Is that OK?

12. Can you work days or nights? Weekends?

13. Do you have reliable transportation and vehicle insurance?


Page 5 of 38

Reference Request Applicant Profile Applicant Name ________________________________SSN:_________________Position __________

Employer Name ____________________________________ Employed from _________ to _________

Reference Name ______________________________________________ Tel. (____) _____-________

By my signature on this application, I hereby authorize ProStat to request and receive from all former employers, any and all pertinent information concerning my prior employment and its termination including the reasons for such termination. I forever release such prior employers and those references named herein from any and all liability which may arise out of any information provided hereunder. Applicant Signature _______________________________________________ Date ______________ ---------------------------------------------------------------------------------------------------------------------------------------- Employer The individual named above has applied for employment with ProStat. To ensure a thorough screening process, we ask that you provide the information requested below. Evaluation Skill Levels (please circle) 1=poor; 2=average, 3=above average Technical proficiency 1 2 3 Quality of work 1 2 3 Established priorities 1 2 3 Accepts direction/cooperation 1 2 3 Accurate documentation 1 2 3 Adheres to safety procedures /protocols 1 2 3 Adaptability 1 2 3 Communicates effectively 1 2 3 Attendance/reliability 1 2 3 Is this applicant eligible for rehire? (_)YES / (_)NO If no, please explain:________________________

Employment dates: From: ____________ To: ___________ Position: ____________________

Reference provided by: __________________________________________ Title: ________________

Signature: _______________________________________________ Date: _____________________

Verbal reference obtained by ProStat, Inc.:

Signature: _______________________________________________ Date: ______________________


Page 6 of 38







Signature: _______________________________________________ Date: _____________________


Signature: _______________________________________________ Date: ______________________


Page 7 of 38







Signature: _______________________________________________ Date: _____________________


Signature: _______________________________________________ Date: ______________________


Page 8 of 38

Abuse & Neglect Training Acknowledgement Form

I, __________________________________, hereby certify that I have been provided with the

Abuse & Neglect Training per the requirements of the Office of Long-term Living Guidelines as

provided in the Protective Services “Direct Service provider” Webinar; dated September 2013.

________________________________________ Signature

________________________________________ Date ________________________________________ Witness


Page 9 of 38

Consent to Pre-Employment Drug Testing I hereby agree, to submit to a drug or alcohol test and to furnish a sample of my saliva, urine, breath, hair and or blood for analysis. I understand and agree that if refuse to submit to a drug or alcohol test, or if I otherwise fail to cooperate with the testing procedures, I will not be considered for employment with ProStat, Inc. I further authorize and give permission to have ProStat, Inc. to send the specimen or specimens collected, to a company-approved laboratory or testing facility for a further screening to test for the presence of any prohibited substances at my own expense, and for the laboratory or other testing facility to release any and all documentation relating to such test to ProStat, Inc. __________________________________________________ ______________ Applicant Signature Date __________________________________________________ Applicant Name Printed __________________________________________________ _______________ ProStat Inc. Signature Date


Page 10 of 38

RE-PAYMENT AGREEMENT

Employee Name: ________________________ Social Security Number: _____-_____-______

I, ___________________________, (“Borrower”) understand that I may choose to provide ProStat, Inc. with current and acceptable copies of the below required testing that I have previously undergone, procure the below required testing elsewhere, or undergo the below required testing through ProStat, Inc. if I choose to undergo the below testing through ProStat, Inc., I agree to make payment to ProStat, Inc. (“Lender”) for all testing performed and items purchased, pursuant to the below fee schedule:

Date Performed Cost

❏ Drug Test ____/____/______ $20.00

❏ Criminal Background Check ____/____/______ $8.00

❏ ChildLine Verification ____/____/______ $8.00

(Only if providing home care services)

❏ FBI Clearance ____/____/______ $27.50

(Only if NOT a PA Resident for past 2 years)

❏ Uniform Top #1 Size: S, M, L, XL, XXL ____/____/______ FREE ❏ Uniform Top #2 Size: S, M, L, XL, XXL ____/____/______ $16.00

Total Repayment Due to ProStat, Inc.: $_______________

Method of Payment:

❏ Check/Money Order: #____________________ Amount Paid: $________________ ❏ Payroll Deduction:

I, ___________________________________, agree to pay Lender $__________. I wish to have Lender deduct this amount from my pay. I further understand that I will still be responsible to make payment to Lender, if for whatever reason Lender is unable to collect my payment from my paycheck.

Borrower Signature: ___________________________________ Date: __________________ Lender Witness: ____________________________________ Date: _________________

---------------------------------------------Do Not Write Below This Line---------------------------------------- Paid in Full: ____/____/______ Payment Authorization by: ________________________


Page 11 of 38

Drug Screen Form Required

(Print From(s) Portal and Insert Here)


Page 12 of 38

WOTC Paperwork Required



Page 13 of 38

PERSONAL CARE ATTENDANT (PCA) SKILLS SELF-ASSESSMENT Name: ________________________________________ Date: _______________________ Using the scale(s) below, please complete the following skill self-assessment based upon your experience within the last 2 years. EXPERIENCE: [1] None [2] Intermittent [3] Experienced [4] Supervise/Teach COMFORT: [1] Never/Observed Only [2] Less than 6 times/year [3] Twice a Month [4] Daily – Weekly

Skills Experience Level Comfort Level [1] [2] [3] [4] [1] [2] [3] [4]

Bed Bath: a. Correct order followed b. Temperature of water appropriate c. Soap rinsed off thoroughly d. Skin dried thoroughly e. Lotion applied appropriately f. Client dressed, hair combed g. Client kept warm throughout

a b c d e f g

a b c d e f g

a b c d e f g

a b c d e f g

a b c d e f g

a b c d e f g

a b c d e f g

a b c d e f g

Sponge /tub/shower bath: a. follow all areas listed above b. transfer client safely to the shower or tub c. allow clients to assist when able

a b c

a b c

a b c

a b c

a b c

a b c

a b c

a b c

Shampoo in Sink/tub/bed: a. positions client appropriately b. Protects clothing from getting wet c. Avoids getting shampoo/ water in clients face d. Rinses and dries hair e. Combs hair f. Keeps client warm and comfortable throughout

a b c d e f

a b c d e f

a b c d e f

a b c d e f

a b c d e f

a b c d e f

a b c d e f

a b c d e f

Nail care: a. Nails cleaned gently b. Hands/ feet soaked prior to cleaning and trimming c. Files nails to safe length d. Nails never trimmed

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

Dressing: a. dressing sitting, standing, lying b. dressing para and/or quadriplegic

a b

a b

a b

a b

a b

a b

a b

a b

Skin Care: a. observes skin condition b. applies lotion c. massages bony prominences and redden areas d. ensures linens are wrinkle free

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

Provides oral hygiene as appropriate for each client: a. washed dentures b. brushes teeth or offers client necessary supplies to brush

teeth c. rinses clients mouth/ uses toothettes as needed observes

for any break in mucous membranes

a b c

a b c

a b c

a b c

a b c

a b c

a b c

a b c

(Continued on next page.)

Page 1 of 2


Page 14 of 38

Skills Experience Level Comfort Level [1] [2] [3] [4] [1] [2] [3] [4]

Meal Preparation: a. proper cooking techniques b. safe handling and storage of food c. good understanding of dietary restrictions

a b c

a b c

a b c

a b c

a b c

a b c

a b c

a b c

Caring for personal possessions: a. care of dentures b. care of hearing aides c. care of life alert necklaces

a b c

a b c

a b c

a b c

a b c

a b c

a b c

a b c

Light Housekeeping: a. Laundry b. Vacuum/Dust c. Changing bed linens d. sweeping/mopping e. kitchen, bathroom, living area cleanliness

a b c d e

a b c d e

a b c d e

a b c d e

a b c d e

a b c d e

a b c d e

a b c d e

Toileting & Elimination: a. proper positioning, use of bedpan and emptying b. proper positioning, use of urinal and emptying c. provides privacy d. catheter care- measures intake and output

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

a b c d

Safe transfer techniques and ambulation: a. uses good body mechanics to prevent injury b. makes environment safe for ambulation c. locks wheels on wheelchair and beds as needed d. ensures client wears non- skid footwear e. used gait belt correctly, as needed f. properly supports client throughout procedure without

unnecessary pulling/ jerking g. Properly supports extremity during exercise h. Properly operates Hoyer Lift i. Properly uses Gait Belt

a b c d e f

g h i

a b c d e f

g h i

a b c d e f g h i

a b c d e f

g h i

a b c d e f

g h i

a b c d e f g h i

a b c d e f g h i

a b c d e f g h i

Performs proper positioning & body alignment for the following positions:

a. on back(props heals of bed; keep weight of blanket off toes; only one pillow under head, use wedge for propping due to respiratory condition; props hands with pillows)

b. side lying (smaller pillow at head; small pillow/blanket between knees; pillow support to back)

c. turns client properly without unnecessary pulling/ jerking d. moves client up in bed without unnecessary pulling/jerking

a

b c d

a

b c d

a b c d

a

b c d

a

b c d

a b c d

a b c d

a b c d

By my signature below, I attest that the information provided on this self-assessment is true and accurate to the best of my knowledge. PCA Signature______________________________________ Date: __________________

Reviewed By: ______________________________________ Date: __________________

Page 2 of 2


Page 15 of 38

FAMILY CAREGIVER CASE ACKNOWLEDGEMENT (Repeated in Spanish Below for Reference Purposes Only. Have the Applicant Complete the English

Version Only.)

Name: ___________________________________ Social Security Number: ______________

Consumer: _______________________________ Relationship: _______________________

Are you the Power of Attorney for the Consumer? □ YES □ No

Are you engaged or married to the Consumer? □ YES □ No

Are you a Legal Guardian for the Consumer? □ YES □ No

Are you a Parent of the Consumer? □ YES □ No

Do you share a bank account with the Consumer? □ YES □ No

_____________________________________________________________________________ Applicant Signature Date Witness

----------------------------------------------------------------------------------------------------------------------------

CUIDADOR CASE FAMILY (Repitió en English arriba)

Nombre: _________________________________ Seguro Social Numbero: _______________

Consumidor: ______________________________ Relación: ___________________________

¿Es usted el Poder Notarial para el consumidor? □Si □ No

¿Es usted comprometido o casado con el consumidor? □ Si □ No

¿Eres un tuor legal para el consumidor? □ Si □ No

¿Es usted el padre de el consumidor? □ Si □ No

___________________________________________________________________________ Firma del Solicitante Fecha Testigo


Page 16 of 38

Provisional Offer of Employment Employee Name: ___________________________________________ Date: ______________ Dear Employee: We am pleased to offer you a Provisional Offer of Employment for the position of ___________ (TITLE). Continued employment will require satisfactory job performance and compliance with existing and future company, state, and federal regulations and policies. Prior to your first day of employment, you will need to complete the “orientation and onboarding process”. Please monitor your email for directions on the onboarding process. The onboarding process includes but is not limited to: completion of Section I of the I-9, entering government ID’s, necessary health screenings, contact and personal information, completion of federal withholdings, and the Direct Deposit Authorization form. ProStat, Inc. may use direct deposit as the method of salary payments for employees. Federal law requires that all employees complete an electronic I-9 verifying their eligibility to work in the United States. Our Human Resources Office will need to photocopy original documents in compliance with the Immigration and Naturalization Act. A list of acceptable documents for I-9 verification is available by visiting our website at (http://www.fau.edu/hr/files/I9_List_of_Acceptable_Documents.pdf). You are scheduled to attend New Hire Orientation on _______________________________________. Report to your local office at this date and time. Day Month Year Time Welcome to ProStat, Inc. we are very excited at the prospect of you joining our team. Please signify acceptance of this offer by signing and returning this letter to your supervisor. Sincerely, ProStat, Inc. …………………………………………………………………………………………………………………………

This offer is contingent upon the final review and approval of the Human Resources Department to include, but not be limited to: 1) the successful completion of a thorough background check to include a criminal background investigation, professional/personal reference validation, and relevant license verification, 2) the surrender of a saliva or other sample for the purpose of conducting a drug-screening test, and 3) the submission of a post-hire medical questionnaire conducted in compliance with the Americans with Disabilities Act (ADA) 42 U.S.C.A. §12112(d)(3). I, _______________________________________________(Employee Name), accept the position of

___________(TITLE) at the conditions and terms stated above, effective __________________(DATE)

with the full understanding that while I am employed by ProStat, Inc., I will be an employee “at will” and

that I or ProStat, Inc. may terminate employment at any time.

______________________________________________________________________________________

(EMPLOYEE SIGNATURE) (DATE)


http://www.fau.edu/hr/files/I9_List_of_Acceptable_Documents.pdf

Page 17 of 38

APPENDIX B EMPLOYEE HANDBOOK - ACKNOWLEDGMENT OF RECEIPT

I have received a copy of ProStat’s Employee Handbook. I will read and become familiar with its

contents. If I do not understand any policy or procedure outlined in this manual, I will contact my

supervisor or the Human Resources Department for clarifications.

This Handbook is only a guideline for employees and is not all-inclusive of the policies or

procedures that may affect my employment. I understand that ProStat has the right to interpret,

revoke, change, or supplement this Handbook or any other personnel policy at any time and

without any notice.

Neither this Handbook nor any other communication by a management representative, either

written or verbal, is intended to in any way create an employment agreement, contract or a

guarantee of continued employment or of a specific number of working hours. Rather, this

Handbook merely describes ProStat’s general philosophy concerning policies and procedures.

My signature indicates that I have read and understand this Acknowledgment of Receipt and I

have received a copy of the Employee Handbook. I agree to maintain complete confidentiality of

confidential or trade secret information that I become aware of during the course of my

employment. I also authorize ProStat to withhold from my pay any amounts that I may owe

ProStat as a result of loans or other advance payments made to me by ProStat during the

course of my employment.

I have read this Acknowledgment and understand its contents.

EMPLOYEE NAME:__________________________________________________ (please print)

SIGNED:___________________________________________________________ (employee signature)

DATE:_____________________________________________________________


Page 18 of 38

ChildLine Application Form Required



Page 19 of 38

Client Transport Flowsheet

Employee Name: _________________________________________ Title: ____________

Office: __________________________________

Please complete for every DCW employee:

1. Does the DCW consent to client transport? ❏ If “Yes”, have the DCW complete:

❏ “Driver Acknowledgement & Consent Form” and provide all required

documentation.

❏ “Motor Vehicle Record Disclosure and Release”

❏ “Driver Waiver and Release of Liability”

❏ “Consumer Mileage Record” Orientation

❏ If “No”, have DCW complete :

❏ “Non-Driver Acknowledgement Form” stating he or she will NEVER transport a

consumer on ProStat, Inc.’s behalf.

Person completing this form: ___________________________________ Date: ___________


Page 20 of 38

Driver Acknowledgement & Consent

I ___________________________(Employee), am attesting that I agree (if permitted by ProStat, Inc.) to drive my consumer to and/or from appointments, errands, or otherwise on behalf of ProStat, Inc.

I understand that driving a consumer requires that I submit an acceptable Motor Vehicle Record, a copy of my valid driver’s license, and proof of automobile insurance to ProStat, Inc. prior to operating a motor vehicle that is that is properly licensed, registered, inspected, and deemed acceptable for use in the Commonwealth of Pennsylvania.

If found driving without following the procedures and/or submitting the required documentation, I understand that I will be subject to disciplinary action that may include the immediate termination of my employment.

Should I ever transport a consumer on behalf of ProStat, Inc., I shall agree to provide the below information and applicable copies for each of the following:

❏ Driver’s License: #______________ Exp. _______________

❏ Auto Insurance: Company:______________________ Policy #___________________

Telephone: ____________________________ Exp. _______________

❏ Auto Plate: State: ___________ # ______________________

❏ Auto Registration: State: __________ # ______________________

❏ State Auto Inspection: State: _____________ Exp. _____________

❏ Pass

❏ Fail

❏ MVR Record: Completed: ______________ (Date)

Furthermore, I shall agree to provide ProStat, Inc. with any and all updated or revised documentation as necessary. __________________________________ __________________________ Employee Signature Date __________________________________ __________________________ Witness (Supervisor) Date


Page 21 of 38

Motor Vehicle Record Disclosure and Release Form

In connection with my ongoing employment or my application for employment, should I have or secure a position with ProStat, Inc., I understand that a motor vehicle record, which contains public record information, may be requested. I further understand that such report(s) will contain personal information and public record information concerning my driving record from federal, state, and other agencies that maintain such records, as well as independent services that provide driving record information. I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information to Liberty Insurance Agency or its agent. I hereby authorize procurement of my motor vehicle report. If hired, this authorization shall remain on file and shall serve as ongoing authorization for you to procure such reports at any time during my employment. ProStat, Inc.’s commercial auto insurer and agent will also use this information in conjunction with loss control and safety review efforts. Employee Information: ____________________________________________________________________________ Full Legal Name (include Middle initial) __________________________________ _____________________________ Driver’s License Number State of Issuance __________________________________ _____________________________ Date of Birth Social Security Number __________________________________ _____________________________ Signature Date Once completed, please fax this form to Steve Pcsolar at (412) 571-9909.

The information contained in this electronic transmission and any attachments hereto is considered proprietary and confidential. Distribution of this material to anyone other than the addressed is prohibited. Any disclosure, copying, distribution or use of the contents of this transmission or any attachments hereto for any reason other than their intended purpose is prohibited. If you have received this transmission in error, please contact the sender.


Page 22 of 38

Driver Waiver and Release of Liability By signing this Waiver and Release of Liability (Agreement), I, ______________________________ (ProStat Employee) waive and release ProStat, Inc. , its agents, servants, employees, insurers, successors and assigns (hereafter referred to as ”the Company”), from any and all claims, demands, causes of action, damages or suits at law and equity of any kind, including but not limited to claims for personal injury, property damage, medical expenses, loss of services, on account of or in any way related to or growing out of the use of a personal auto, for driving a consumer (hereafter referred to as “the Client”) as part of the services provided. This waiver and release is intended to and does release the company from any and all liability for damages or injuries on account of, or in any way related to, or growing out of my negligence, or the negligence of third parties. This is not intended to release me from any liability resulting from any intentional misconduct. I further covenant and agree not to institute any claims or legal action against the company for any claim released by this Agreement. I further agree that should any claim be made against the company, in contravention of this Agreement, including but not limited to derivative claims, I will protect, defend and completely indemnity (reimburse) the company for any such claim and expenses including attorney’s fees and costs incurred by the company in defending itself and/or themselves or security indemnity hereunder. I understand that ProStat, Inc. is not responsible for any damage done or incurred to my personal vehicle while used in the course of providing services to the Client. I acknowledge that I have received and read a copy of the current rules and regulations governing the use of the personal vehicles while providing services. I agree that I will fully comply with all rules and regulations and with any amendments.

I have read the Agreement and understand that by signing the Agreement I have consented to be bound by its terms, including the waiver/release of any legal right I may have to sue the company for any incurred costs because a claim or legal action is brought in violation of this Agreement. I agree any violation of the Agreement and its terms and conditions, as determined by the company, will void and terminate this Agreement and may result cancellation and refusal of home care services for the client.

I am signing this Agreement freely, voluntarily and competently and I am at least eighteen (18) years of age. ___________________________________________________________________________________ Employee Name (please print) Employee Signature Date


Page 23 of 38


Page 24 of 38

Non-Driver Acknowledgement

I ______________________________ am attesting that I will not drive to and from appointments on behalf of ProStat,Inc.

I understand that driving a consumer requires that I submit an acceptable Motor Vehicle Record, a copy of my valid driver’s license, and proof of automobile insurance to ProStat, Inc. prior to operating a motor vehicle that is that is properly licensed, registered, inspected, and deemed acceptable for use in the Commonwealth of Pennsylvania.

If found driving without following the procedures and/or submitting the required documentation, I understand that I will be subject to disciplinary action that may include the immediate termination of my employment.

Employee Signature: ___________________________________ Date:_____________

Witness ( Supervisor ):__________________________________ Date: ____________


Page 25 of 38

CONSENT FOR CRIMINAL HISTORY BACKGROUND CHECK AUTHORIZATION FORM

Employee First, Middle, and Last Name: _______________________________________________ Employee Maiden Name: ____________________________________ SSN: _____-_____-_______ Driver’s License Number: ________________ State: ________ Date of Birth: _____/_____/______ Employee Street Address: __________________________________________________________ City: _______________________________________ State: __________ Zip: ______________ Primary Tel: (______)_______-__________ Alternate Tel: (_______)_______-__________ Please answer the questions below.

1. I have been a resident of Pennsylvania for the two (2) years immediately preceding the date as

signed below. ( ) YES ( ) NO

2. If you have answered “NO” and have NOT been a resident of Pennsylvania for the two (2) years

preceding the date as signed below, please list any states (or countries) in which you had held

residency in within the previous ten (10) years:

1)________________ 2) ________________ 3) ________________ 4) _______________

3. Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to

a crime? ( ) YES ( ) NO

4. If you have answered “YES”, Please explain: ______________________________________

I hereby give permission for ProStat, Inc. and its representatives to obtain information relating to my potential criminal history record. The criminal history background check may include arrest and conviction data. I understand this information will be used in part to determine my eligibility for employment with ProStat, Inc. I also understand, that if I accept employment, the criminal history background check may be repeated at any time as long as I remain employed. I also understand that I will have an opportunity to review the criminal history as reported if I request in writing within 10 calendar days of notification of any problems or concern regarding information received. I, the undersigned, hereby and forever agree to hold prostat, Inc., their officers, employees and agents harmless from any and all causes of actions, suits, liabilities, costs, debts, and sums of money, claims and demands whatsoever resulting from an investigation of my potential criminal history background in connection with my eligibility for employment. Employee Signature:_____________________________________________ Date: ________________


Page 26 of 38

POST OFFER MEDICAL HISTORY QUESTIONNAIRE

Employee Name: ________________________________________ Position: __________________

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.

To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic Information,’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

I AGREE TO INDEMNIFY AND HOLD HARMLESS PROSTAT, INC. AND ITS SUBSIDIARIES, TOGETHER WITH ALL THEIR TRUSTEES, OFFICERS, EMPLOYEES AND AGENTS FROM ALL LOSSES, CLAIMS, DAMAGES, AND LIABILITIES ARISING FROM THE USE OF THE INFORMATION CONTAINED IN THIS FORM AND IN MY EMPLOYEE HEALTH FILE BY ANY THIRD PARTY.

Employee Signature: __________________________________________ Date:________________

Notice: In compliance with the Americans with Disabilities Act of 1990 (ADA) you have received a conditional offer of employment. This medical history statement is required. The answers to the medical history statement will be kept confidential as required by the ADA and HIPPA. The job offer, which you have received is conditioned upon satisfactory completion and review of this medical history statement; any required medical examination or follow up and job assignment availability.

Employee Affirmation: I herewith affirm that the employer has made me an offer of employment. The purpose of this inquiry is to determine whether I currently have the physical qualifications necessary to perform the job that has been offered; to determine whether and what accommodations may be necessary; and to determine whether I can perform the job without posing a significant/direct threat to the health and safety of myself and others. This information will be kept confidential in a separate medical file, apart from my personnel file. I hereby affirm that the medical questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job.


POST OFFER MEDICAL HISTORY QUESTIONNAIRE Page 1 of 4


Page 27 of 38

Instructions: Please answer “YES” or “NO” as to whether or not you currently are being or have been previously medically treated for the following list of injuries and/or conditions.

Head Injury ( ) YES ( ) NO Neck Injury ( ) YES ( ) NO Difficulty Moving neck ( ) YES ( ) NO Shooting Pain Down from Neck or Upper Back through Arms ( ) YES ( ) NO Back Injury ( ) YES ( ) NO Difficulty Moving Back ( ) YES ( ) NO Shooting Pain Down from Back through Lower Extremities ( ) YES ( ) NO Hip Injury ( ) YES ( ) NO Difficulty Moving Hip ( ) YES ( ) NO Leg Injury ( ) YES ( ) NO Difficulty Moving Leg ( ) YES ( ) NO Knee Injury ( ) YES ( ) NO Difficulty Moving Knee ( ) YES ( ) NO Foot Injury ( ) YES ( ) NO Fractured or Broken Bones ( ) YES ( ) NO Ruptured Disc(s) ( ) YES ( ) NO Bulging Disc(s) ( ) YES ( ) NO Amputated Foot, Leg, Arm or Hand or Loss of Use Thereof ( ) YES ( ) NO Shoulder injury ( ) YES ( ) NO Rotator Cuff Injury ( ) YES ( ) NO Difficulty Moving Shoulder ( ) YES ( ) NO Arm Injury ( ) YES ( ) NO Difficulty Moving Arm ( ) YES ( ) NO Elbow Injury ( ) YES ( ) NO Wrist Injury ( ) YES ( ) NO Hand and/or Finger Injury ( ) YES ( ) NO Difficulty Lifting ( ) YES ( ) NO Difficulty Stooping ( ) YES ( ) NO Difficulty Bending ( ) YES ( ) NO

If Yes to any of the above, please fill-in space provided below. (Additional sheet(s) may be used if needed.)

Medically Treated Injury/Condition

Date(s) Nature of Injury/Condition

Please list any injuries or conditions not listed above for which you have been treated for in the past 5 years. (Additional sheet(s) may be used if needed.)

Medically Treated Injury/Condition

Date(s) Nature of Injury/Condition

Employee Signature: __________________________________________ Date:________________ POST OFFER MEDICAL HISTORY QUESTIONNAIRE Page 2 of 4


Page 28 of 38


Please select the answer to each question. If you answer “YES” to any of the questions, please explain in detail in the space provided. (Additional sheet(s) may be used if needed.)

1. Do you have any work restrictions or limitations?

( ) YES ( ) NO If “YES”, please list: ________________________________________

_________________________________________________________________________

_________________________________________________________________________

2. Are you presently under any medical treatment by a doctor or any other health care provider?

( ) YES ( ) NO If “YES”, please list: _________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. Are you presently taking any prescription or nonprescription medication(s) that would interfere

with your job duties?


__________________________________________________________________________

__________________________________________________________________________

4. Do you have any physical or mental difficulties that could interfere with the performance of your

job duties?


__________________________________________________________________________

__________________________________________________________________________

5. Are you aware of any condition or injury that might impair or limit your ability to perform any this

job?

( ) YES ( ) NO If “YES”, please list: __________________________________________

___________________________________________________________________________

___________________________________________________________________________

Employee Signature: __________________________________________ Date:______________



Page 29 of 38

POST OFFER MEDICAL HISTORY QUESTIONNAIRE

ATTESTATION OF TRUTHFULNESS

Employee Name: ________________________________________ Position: _________________

By my signature below, I attest that all the information I provided on this form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

Employee Signature: ___________________________________________ Date: _____________

------------------------------------------DO NOT WRITE BELOW THIS LINE------------------------------------------- ProStat, Inc. Use Only

I HAVE REVIEWED THE INFORMATION PROVIDED BY THE ABOVE-SIGNED EMPLOYEE ON THIS POST-OFFER MEDICAL HISTORY QUESTIONNAIRE AND AFFIRM THAT I HAVE KNOWLEDGE OF ANY MEDICAL CONDITIONS/INJURIES DISCLOSED HEREIN BY THE EMPLOYEE.

EMPLOYER NAME(PRINT): _________________________________________________

EMPLOYER SIGNATURE: ___________________________________________________

DATE: ____________________



Page 30 of 38

PHYSICIAN’S STATEMENT Medical Release Authorization: I, ____________________________(Employee Name), do hereby authorize, the Medical

Practice of Dr. __________________________, to release to ProStat, Inc., its affiliates, and any

of its Client hospitals or institutions any information acquired in my medical examination that is

relevant to my employment.

Employee Signature: ____________________________ Today’s Date: _____________

Social Security Number: _________________________ Date of Birth: _____________

Physician to complete this section:

I have examined the individual named above and to the best of my knowledge, he/she is in good physical and mental health and free of communicable disease. Employee is fit for duty without restrictions including of performing max-assist patient transfers; being able to lift 50 lbs, independently and repeatedly, and to function in his/her profession at full capacity.

By signing below, I certify that the above information is valid.

Physician’s Printed Name: ____________________________ Tel: __________________

Physician’s Signature: ____________________________ Date of Exam: _____________

Address: _________________________________________________________________


Page 31 of 38

Mantoux Tuberculin Skin Test Record Form Patient Information:

Name: ___________________________________________ Job Title: ______________________

Address: __________________________________________________________________________

City/Town: _______________________________________ State: ________ Zip: _____________

Home Tel: _______________________________ Work Tel: ____________________________ Patient Questionnaire:

1. Are you currently pregnant or nursing? (_)Yes (_)No 2. Have you completed a Mantoux (PPD) test within the past year? (_)Yes (_)No 3. If “Yes”, when? ______________ 4. Have you ever had a positive reaction?* (_)Yes (_)No 5. If “Yes”, did you receive a Chest X-Ray? (_)Yes (_)No 6. Do you consent to having a PPD Skin Test? (_)Yes (_)No

Signature: _______________________________________________ Date: _____________________ STEP 1: Skin Test Information STEP 2: Skin Test Information

Administrator’s Administrator’s Name: _______________________ Name: _______________________

Date/Time Date/Time Administered: _________________ Administered: _________________

Arm Administered: _____________ Arm Administered: _____________

Manufacturer: _________________ Manufacturer: _________________

Expiration Date: ________________ Expiration Date: ________________

Lot#: _________________________ Lot#: _________________________

STEP 1: Results STEP 2: Results

Induration: _________________mm Induration: _________________mm

Date/Time Read: _______________ Date/Time Read: _______________

Comments and Adverse Reaction(s) Comments and Adverse Reaction(s)

If any: ________________________ If any: ________________________

Name of Reader: _______________ Name of Reader: _______________

Signature: _____________________ Signature: _____________________

*It is highly unlikely that a side effect to the test will occur. If such an event does happen, the most common reaction is pain or redness at the test site. In very rare cases, a person who is hypersensitive to the solution could have a severe allergic reaction near the injection site. Such rare reactions may include blistering or a skin wound.


Page 32 of 38

W-4 (2017) Required



Page 33 of 38

I-9 (2017) Required



Page 34 of 38

Acceptable List of Documents for Proof of Residency for Applicants 18 Years of Age or older:

IMPORTANT: All IDs for proof of residency must be dated within the past 2 years of hire date. Please Note: All documents must show the same name and date of birth, or an association between the information on the documents. Additional documentation may be required if a connection between documents cannot be established (e.g. Marriage Certificate, Court Order of name change, Divorce Decree, etc.) Check each form(s) used to prove residency:

❏ W-2 Form ❏ PA Drivers License ❏ PA State ID ❏ Employment Records ❏ Unemployment Records ❏ Two (2) Professional References ❏ Current Utility Bills (Water, gas, electric, cable, etc.) ❏ Tax Records ❏ Lease Agreement ❏ Mortgage Documents ❏ Current Weapons Permit

Copies of all “checked” documents must be made and retained in the employee’s file. Person completing this form: ___________________________Date: ____________ PUB 195US (9-14)


Page 35 of 38

DIRECT DEPOSIT REQUEST FORM ProStat, Inc. requires DIRECT DEPOSIT of your paycheck. Please complete and sign the bottom of this form and return it to this office along with a VOIDED check or deposit slip. Should you not have a checking or savings account a debit card will be issued to you and paychecks will be deposited to the debit card. If you have any questions please call 610-736-9000. Thank you, ProStat, Inc.

------------------------------------Employee to complete below.---------------------------------------- Employee Name _________________________________

Social Security Number _________________________________

Bank Name _________________________________

Bank Address _________________________________

_________________________________

Bank Phone Number _________________________________

Contact Name _________________________________

Routing Number _________________________________

Account Number _________________________________

Account Type Checking ________Savings___________

Effective Date _________________, 20_____

I hereby grant ProStat, Inc. permission to directly deposit my payroll check into my bank account beginning with the effective date noted above. EMPLOYEE SIGNATURE __________________________DATE ______________


Page 36 of 38

Pre-Placement-Checklist Office Location: __________________________________

Employee Name: ________________________________ Title: _________ Date: _____________ Instructions: Check each task as completed and provide any additional information that’s requested below. This form is to be completed post-offer BUT prior to the individual working his or her first shift. A copy of this form must accompany the weekly payroll packet. 1. Application:

❏ Face-To-Face Interview (Completed) - Date ___________________ ❏ Application/RSS eDocs/Interview & New-Hire documents (Reviewed & Completed)

2. Background Investigations:

❏ ePatch Criminal Background (Full Results Required/“Under Review” is not acceptable) ❏ Verification of Residency:________________________________________(Source/s) ❏ Positive Reference Form #1 (Completed) - Name: _____________________________ ❏ Positive Reference Form #2 (Completed) - Name: _____________________________ ❏ (If PCA) MVR (Results) ❏ OIG (Results) ❏ Megan’s Law (Results) ❏ Medi-Check (Results) ❏ EPLS (Results) ❏ E-Verify (Completed) ❏ Verification of PA Nursing License/CNA Certification/HHA Certification (If Applicable)

❏ FBI Clearance (Results) (If Applicable) 3. Tuberculin Testing:

❏ PPD #1 (Results) - Date Read: _________________ ❏ PPD #2 (Results) - Date Scheduled/Read: _________________

❏ Chest X-Ray (Results) (If past positive PPD) ❏ Quantiferon (Results) (If past positive PPD)

❏ Flu Shot (Medical Staffing Only) ❏ Physician’s Statement (Always for Medical Staffing but also PCAs if Applicable)

4. Other: ❏ LPN/RN Nursing License or CNA Certification (If CNA, LPN, or RN) ❏ CPR Certificate (If LPN/RN) ❏ Discipline Specific Competency Testing: ________% (Results) ❏ Core Competency Testing: ________% (Results) (If CNA, LPN, or RN) ❏ Photo ID emailed to Corporate: ____________(Date Emailed) ❏ Child Abuse Training Scheduled: ________________(Due Date) ❏ (If PCA) DCW Eval Scheduled: _______________(Eval Date)

5: Record of Documents:

❏ All applicant & employee forms uploaded to CSS (Reviewed Date) ______________

This form was completed by: ______________________________ Title: ______________________

Manager Signature: ____________________________________ Date: _______________________


Page 37 of 38

Maintenance Sheet

*Office/Branch: ___________________________________ *Today’s Date: ______________ *Title: ( )DCW ( )CNA ( )LPN ( )RN ( )SLP ( )Other: _______________________________

❏ New Hire: _____________________(date) Previous Employee? (_) YES (_) NO ❏ Termination:________________________ (date) AND Attach Event Report ❏ Change of Home Address (complete below) ❏ Change in Pay Rate to $___________ ( ) Annual ( ) Hourly / Effective Date: _________ ❏ Change of Email Address (complete below) ❏ Change of Telephone # (below) ❏ Change of Withholding (Complete below AND attach Revised W-4)

(_) Single (_) Married # of Dependents: _____ Additional Weekly Withholdings: $_____ Local Tax: _____________________ Withhold: _______% OCP Tax: (_)Take (_)Paid

❏ Change of GHP Benefits (_) Add (_) Change (_) Discontinue – Attach Change Form ❏ Direct Deposit: (_) Add (_) Change – attach completed Direct Deposit Form

(_) Discontinue ❏ Pay Card: (_) Add (_) Change - attach completed Pay Card Enrollment Form

(_) Discontinue ❏ Other: ________________________________________________________________

____________________________________________________________________________ *Employee Name (first, middle, last) *SSN *Date of Birth

____________________________________________________________________________ Street Address Apt #

____________________________________________________________________________ City State Zip County

______________________________________ ___________________________________ Email Address Tel

*This form was completed by: __________________________________________

Printed Name

“*” Indicates the field MUST be completed.


Page 38 of 38

New Hire Checklist

(Send to Corporate with Payroll Package)

Office:__________________________________ Today’s Date:_____________ Employee Name:__________________________________ Title: _______________ SSN: _______________________________ Date of Birth: ___________________ Date First Shift Worked:_____________________ Pay Rate $__________ per hour Check each box to indicate that you have reviewed and included a copy of the document with your payroll package. All documents must be legible and fully and properly completed. Incomplete forms will be returned to office for proper completion.

❏ Maintenance Sheet (Complete W-4 Information) ❏ W-4 (Send Copy) ❏ Re-Payment Authorization - Add up deductions & provide total / circle shirt size. ❏ Direct Deposit Form or Money Card Application (if applicable.)

❏ Direct deposit please provide copy of voided check. ❏ Money card, please provide card application.

❏ E-Verify - Case Verification Form ❏ Consent for Criminal History Background Check - Completed ❏ PA ChildLine Certification - Completed ❏ Consent/Release of Info Authorization Form for PA ChildLine Cert - Completed ❏ Form 8850, 9061, and 9175- Pre-Screen Notice and Cert. Request for the WOTC - All pages ❏ I-9 Form - Signed by person who witnessed supporting documents.

Supporting documentation provided: ❏ Social Security Card/Birth Certificate;and ❏ Drivers License/State Photo ID; or ❏ Passport; or ❏ Other:_______________-Verify document is valid per I-9 Form instruction.

❏ Pre-Placement Checklist - Completed _____________________________________ ____________________________________ Person Completing this form Manager's Signature --------------------------------------------------Do not write below this line----------------------------------------------------

❏ Reviewed by Payroll: ___________Initials / Date _________________

❏ Reviewed by HR: ___________Initials / Date _________________

❏ Reviewed by QC: ___________Initials / Date _________________


Date post:	15-Apr-2019
Category:	Documents
Upload:	dinhtram
View:	215 times
Download:	0 times