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Provider Care at Home LLC does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor. However, this application does NOT guarantee employment.

Social Security #: _________________________ (Office Use Only)

Social Security #: _________________________ (Office Use Only, DO NOT COMPLETE)

I, the undersigned, have had no prior convictions of any of the offenses listed below which would bar or potentially bar employment: 
(1) an offense under Chapter 19, Penal Code (criminal homicide); (2) an offense under Chapter 20, Penal Code (kidnapping and unlawful restraint); (3) an offense under Section 21.02, Penal Code (continuous sexual abuse of young child or children), or Section 21.11, Penal Code (indecency with a child); (4) an offense under Section 22.011, Penal Code (sexual assault); (5) an offense under Section 22.02, Penal Code (aggravated assault); (6) an offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual); (7) an offense under Section 22.041, Penal Code (abandoning or endangering child); (8) an offense under Section 22.08, Penal Code (aiding suicide); (9) an offense under Section 25.031, Penal Code (agreement to abduct from custody); (10) an offense under Section 25.08, Penal Code (sale or purchase of a child); (11) an offense under Section 28.02, Penal Code (arson); (12) an offense under Section 29.02, Penal Code (robbery); (13) an offense under Section 29.03, Penal Code (aggravated robbery); (14) an offense under Section 21.08, Penal Code (indecent exposure); (15) an offense under Section 21.12, Penal Code (improper relationship between educator and student); (16) an offense under Section 21.15, Penal Code (improper photography or visual recording); (17) an offense under Section 22.05, Penal Code (deadly conduct); (18) an offense under Section 22.021, Penal Code (aggravated sexual assault); (19) an offense under Section 22.07, Penal Code (terroristic threat); (20) an offense under Section 32.53, Penal Code (exploitation of child, elderly individual, or disabled individual); (21) an offense under Section 33.021, Penal Code (online solicitation of a minor); (22) an offense under Section 34.02, Penal Code (money laundering); (23) an offense under Section 35A.02, Penal Code (Medicaid fraud); (24) an offense under Section 36.06, Penal Code (obstruction or retaliation); (25) an offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to non-livestock animals); or (26) a conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.
A conviction of the following within the last 5 years: (1) an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony; (2) an offense under Section 30.02, Penal Code (burglary); (3) an offense under Chapter 31, Penal Code (theft), that is punishable as a felony; (4) an offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; (5) an offense under Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony; (6) an offense under Section 37.12, Penal Code (false identification as peace officer); or (7) an offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).
I understand that the agency will conduct a criminal history search [will include a State of Texas criminal history search], a Texas Employee Misconduct Registry (EMR) search, and a search of the Texas Nurse Aide Registry (NAR). I understand that I cannot be employed if the criminal history results identify offenses that bar employment or if I am listed as unemployable as a result of the employee misconduct registry search or the nurse aide registry search. I understand that the agency will complete the searches of the EMR and the NAR at least on an annual basis for unlicensed staff with face-to-face client contact. The EMR rules are referenced at Title 40, Part 1, Chapter 93 and Chapter 253, Texas Health and Safety Code, Employee Misconduct Registry. I understand the agency reserves the right to conduct a criminal history search and/or searches of the EMR and the NAR at any time for any reason on all staff regardless of whether the staff has direct client contact. I understand that if the agency believes that a conviction or other criminal history results may bar my employment or may be a contraindication to employment that I can be fingerprinted at my own cost and request that the criminal history results be forwarded to the agency as a way of verifying the accuracy of my criminal history record. I, the undersigned, hereby authorize this agency to conduct the employability/background screenings as listed above

Position Description: Caregiver/Attendant/Provider
Responsible for providing personal assistance services to agency clients in accordance with agency policies and procedures, duties may include the following:

• Bathing
• Dressing
• Grooming/Personal Hygiene
• Feeding/Eating
• Exercising
• Toileting
• Positioning or Bed Mobility
• Assist with self-administered medication
• Routine hair/Skin Care
• Transfer and/or Walking/Ambulation
• Shaving and/or Oral Care
• Cleaning
• Laundry
• Meal Preparation
• Escort/Errands
• Companionship
• Other assigned tasks
• Completion of records and reporting to appropriate supervisor
• Use EVV system as instructed

Caregivers MAY NOT:
Administer medications of any kind including but not limited to: oral, rectal, topical, eye drops, ear drops, inhalation treatments, nasal, injectable or any other direct application to the client’s body. If you are asked to perform a task that is not assigned, consult the PAS Supervisor immediately.
Reports to: PAS Supervisor and Administrator Qualifications:

• Must be 18 years or older
• Demonstrate competency in providing tasks and have 6 months expereieince in provinding personal assistance services to cleint.
• Must be able to read, write, and follow directions.
• Observes and practices rules of conduct, ethics and con dentiality.
• Must observe all work rules and must have read, understand, and comply with all applicable agency policies.

I have read and understand the job description and qualifications for the above position and accepted.

The following contract is between,

,Referred to as “I”, and Provider Care at Home LLC, referred to as “agency” or “office”.
1. I understand I am an employee of Provider Care at Home LLC. 2. I understand that Provider Care at Home LLC is a temporary agency and cannot guarantee full time, part time, or steady assignments. 3. I understand that I work for Provider Care at Home LLC , and cannot work for or accept private payment from any clients or their family or responsible party or other organization assigned to me by the agency unless authorized. 4. I agree to report any attempts or offers by clients of the agency to encourage me to break this agreement. 5. If I accept any private payment or assignment from a client of the agency this may be grounds for immediate termination and legal action. 6. I agree to perform the duties specified in the Job Description for Provider Care at Home LLC Caregiver/Attendant/Provider, to the best of my ability on every assignment I work for the agency. 7. I have read, understood, and accepted the Provider Care at Home LLC’s Caregiver/Attendant/ Provider job description, job qualification, and policies and procedures. 8. I understand that I will be required to follow the personnel policies and rules of Provider Care at Home LLC and that any infractions of said rules may lead to my dismissal. 9. I have read and do understand the Confidentiality Statement and any infractions of said rules may lead to my dismissal. 10. I agree to Provider Care at Home LLC communicating with me via Email and/or SMS (text message) to the cellphone number or email address I provided at anytime during or before employment. Email communication can include the delivery (including secure delivery) of electronic tax and/or employment information. 11. I understand Provider Care at Home agrees to pay personal attendant employees a base wage of at least $10.60 per hour.
I have read, understand and will comply with all applicable agency policies.

Provider Care at Home Signature: ___________________________________________________ Date: ____________________ (Office use only)

I understand that Provider Care at Home will check references, as part of the hiring process, to learn about my work history.
I understand that these references will be confidential. I also understand that I will not have access to them.
I release Provider Care at Home and all providers of information from any liability as a result of furnishing and receiving this information.
Failure to authorize contact may exclude you from being considered for employment.

Social Security #: ____________________ (Office use only)
Drivers License/Texas ID: ____________________ (Office use only)

The information contained in this application is correct and to the best of my knowledge. I hereby authorize Provider Care at Home LLC and its designated agents and representatives to conduct a comprehensive review of my background and possibly causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes.
I 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 Provider Care at Home LLC 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 Provider Care at Home LLC, 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.

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time.
I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease.
If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Provider Care at Home Signature: ___________________________________________________ Date: ____________________ (Office use only)

Provider Care at Home Signature: ___________________________________________________ Date: ____________________ (Office use only)

I acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company. Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

(This copy must remain on file by your agency. Required for future DPS Audits)

OFFICE USE ONLY

Agency Name: ___Provider Care at Home__

Agency Representative: ___________________________________

Signature of Agency Representative: ___________________________________

Date: ___________________________________

CCH Report Printed: Yes/No Initial: _______________

Purpose of CCH: Empl/Vol/Contractor Initial: _______________

Date Printed: __________________ Initial: _______________

Destroyed Date: _________________ Initial: _______________