List the last five years employment history, starting with the most recent employer.

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PROFESSIONAL REFERENCES

Persons who can furnish information about job performance

GENERAL

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employ.

APPLICANT REFERENCE CHECK(1)

To Whom It May Concern: The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

To be completed by previous employer

Date of employment:

APPLICANT REFERENCE CHECK(1)

To Whom It May Concern: The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

To be completed by previous employer

Date of employment:

JOB ACCEPTANCE STATEMENT

I have read, understand and agree to the terms specified in this job description for the position I presently hold. A copy of this job description has been given to me.

I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.

CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION

It is both the Agency's and the employee's responsibility to ensure that every patient's health information is protected at all times. By signing below you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency's policy regarding patient's Protected Health Information will be provided to you upon hire.

I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated for use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with HIPAA Rule and Regulations.

PROTECTION OF HEALTH INFORMATION

There are specific guidelines to ensure patient's Protected Health Information is kept private. I understand that my employment with the agency involves handling Protected Health Information. I will ensure patient's records are protected by enforcing the following measures:

• Patient Protected Health Information will be transported in a protected travel chart when traveling.
• When transmitting and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area.
• Patient Protected Health Information will be returned to the agency upon acknowledgement of the patient being discharged.

I pledge to make every effort to keep patient's Protected Health Information protected at all times.

Welcome! This Agency requires adherence to the following Standards and Procedures:

1. All employees are expected to dress in a manner appropriate to the health care environment, or as directed by the patient/client/family. This includes personal hygiene, jewelry, hair and makeup.
2. Please do not smoke in the presence of a patient/client.
3. Always wear your ID Badge. Licensed personnel must always carry their current nursing license and CPR care while on assignment.
4. You are expected to arrive on time to all assignment that you have accepted. However, if an emergency or any situation should cause you to be five minutes late, or more, or to be totally absent from the assignment you must notify the Agency immediately. PLEASE DO NOT CALL YOUR PATIENT DIRECTLY. You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment. A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION!
5. If you have any problem, incident or accident on the job, do not discuss it with the patient/client, but call the Agency immediately.
6. If the patient/client asks you to stay longer than your assignment or to leave earlier, you must call the Agency first, for approval
7. Paraprofessional personnel (i.e. Aides) hereby acknowledge that they WILL NOT, UNDER ANY CONDITIONS, DISPENSE OR ADMINISTER ANY MEDICATION.
8. UNDER NO CIRCUMSTANCES are you to ask for, or accept any money from your patient/client or take home property that belongs to the patient client
9. There shall not be any involvement with the patient/client’s financial affairs (i.e. check writing).
10. You are expected to honor the confidentiality of any patient/ client information which is obtained in the regular course of your employment.
11. No personal telephone calls should be made or received by you while on assignment.
12. Please do not discuss your pay or any other personal affairs with the patient/client/family.
13. As an employee of this Agency, you are not authorized to accept any direct employment that may be offered to you by your patient/client/family. If you are requested to do so, please have the patient/client contact us.
14. It is imperative that all signed notes and documentation including Daily Log, be filled out properly and returned to the office as per our schedule. If the patient/client is unable to sign your note, a family member or responsible party may sign.
15. During the course of employment, this Agency’s proprietary materials (i.e. forms, medical records) will be used only in connection with employment and will not be disclosed to anyone without authorization from the Agency.
16. Never leave your patient/client unattended.

CONFIDENTIALITY AND NON-COMPETITION AGREEMENT

The Agency requires that the Employee avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition.

The Employee agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding employees, clients and the Agency business.

The Employee will have access to information not generally made available to the public, such as identity of clients, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purposes other than for the Agency's own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to Agency administration and/or projects, or outside investigations of the Agency. The employee is prohibited from disclosing any defaming information regarding Agency personnel and/or personnel incidents related to any violations of the personnel policies.

During the course of employment and for a twelve month period thereafter the Employee is prohibited from engaging in any of the following: induce any employee of the Agency to resign, encourage any client or entity to discontinue any relationship with the Agency, solicit any client of the Agency (current and within the past twelve month period), enter into competitive employment or seek to provide competitive services while employed within twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source.

Upon termination of employment or at the request of the Agency, the Employee is required to return all of the Agency's property including keys, client records, forms, manual, beeper, etc. to the Agency and will not retain copies. Failure to return a key will result in a $25.00 charge and failure to return a beeper will result in a $50.00 charge deducted from the paycheck.

Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, cost of replacing and training employees improperly solicited for competitive employment, etc. suffered by the Agency. Employee will be required to reimburse the Agency for all legal fees, costs and other expenses.

This agreement is in effect during the Employee's employment and for twelve months thereafter. It does not modify the right of the Employee to resign at any time or of the Agency to terminate employment without prior cause, notice or liability and does not modify any other Agency policy

EMPLOYEE POLICIES AND PROCEDURES

I understand that copies of policy and procedure manuals are available and that it is my responsibility to read, understand and conform to all applicable Agency policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions.

I have read the Agency’s Policy and Procedure on Abuse, Neglect and Exploitation and agree to Comply with and be bound by the Policy.

I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its employees, nor is it an expression of my term of employment.

I affirm that I have auto insurance coverage as required by this state and the Agency and I agree to keep it fully in force on any vehicle I use for the conduction of Agency business during the term of my employment. The Agency has the right to request proof of insurance at any time during the term of employment and that I am required to follow all Agency requirements and state and local laws.

I understand that only the Agency has the authority to admit clients and will supervise with appropriate personnel all services provided.

As a caregiver, I will carry out the plan of treatment, submit time sheets, clinical and progress notes as appropriate and, at a minimum, on a weekly basis, I will participate in developing and reviewing plans of care, periodic client evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend required staff meeting and in service training. Home health aides are required to have 12 hours of inservice training annually.

I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided. I understand that all information, both written and verbal, regarding client and employee health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease; testing, results or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, drug or alcohol abuse is protected under specific law. All information in connection with the examination, care or provision of services to any client will not be disclosed without the individual's written consent except as may be necessary to provide services as required by law. Information may be used in statistical or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of client/ employee confidentiality is subject to civil and criminal penalties

If I mistakenly exceed my accrued or earned sick or vacation leave balance, I authorize the Agency to deduct any amount from my paycheck(s) to correct my accrued or earned sick or vacation leave balance. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will.

CRIMINAL HISTORY CHECK, EMPLOYEE MISCONDUCT REGISTRY

NURSE AIDE REGISTRY NOTIFICATION AND STATEMENT OF EMPLOYABILITY

By execution of this document, I acknowledge that I have been informed by the Agency that a criminal history check will be performed on my name. I have informed that Agency of all names (for example, maiden name, aliases) that I have used in the past. I understand that I have been employed on an emergency basis and that my employment is temporary pending the results of the criminal history check. I also understand that if I have been convicted of the following offenses, that I may not be employed by this Agency. I also understand that the Agency will search the Employee Misconduct Registry and the Nurse Aide Registry (if applicable) to determine whether any acts of abuse, neglect or exploitation have occurred and whether my name is designated on either registry. If my name is designated on either registry I understand the Agency must deny me employment.

Offenses which constitute a bar to employment and for which an administrative review is not available, are offenses under:

Chapter 19, Penal Code (Criminal homicide)
Chapter 20, Penal Code (Kidnapping and unlawful restraint)
Chapter 21.11, Penal Code (Indecency with a child)
Chapter 22.02, Penal Code (aggravated assault)
Chapter 22.04, Penal Code (injury to a child, elderly individual, or disabled individual)
Chapter 22.041, Penal Code (abandoning or endangering a child)
Chapter 25.031 Penal Code (Agreement to abduct from custody)
Chapter 25.06, Penal Code (Solicitation of a child)
Chapter 25.11, Penal Code (Sale or purchase of a child)
Chapter 28.08, Penal Code (Arson)
Chapter 29.02, Penal Code (Robbery)
Chapter 29.30, Penal Code (Aggravated robbery)or

A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice of an offense containing elements that are substantially similar to the elements of an offense listed under the above Subdivision A person convicted of an offense under Chapter 31, Penal Code (theft), that is punishable by a felony may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date of the conviction. (This requirement only applies to those employees first employed by the facility or Agency on or after September 1, 2003).

A person convicted of an offense under section 22.01, Penal Code (assault),
that is punishable as a Class A misdemeanor or as a felony;
An offense under section 30.02, Penal Code (burglary)
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 as a felony; or
An offense under section 32.45 Penal Code (securing execution of a document
by deception), that is punishable as a Class A misdemeanor of a felony.

I understand that all information obtained by this Agency regarding any criminal history will remain confidential.
By signing this form, I certify that the information on this form contains no willful misrepresentation and that the
information is true and complete to the best of my knowledge.

Applicant is a person being considered as a service provider (employee, independent contractor or vendor [when required]); or a person being considered for appointment as a designated representative (DR).
Section I – Applicant Authorization/Acknowledgment (Applicant must complete this section.)

I, (applicant’s printed name) {name-13} , give my permission to check for a criminal conviction history and to check the required registries as part of my application as a service provider or a DR through the Consumer Directed Services (CDS) option. I also understand that a criminal conviction or a registry listing that prohibits a person from employment in a health care setting in the state of Texas may prohibit my employment or my appointment as a DR. I also understand that I may not provide services for payment or be appointed as a DR until the required criminal conviction history and registry checks are found to comply with requirements, are reviewed by the employer and this form is signed by the Consumer Directed Services Agency (CDSA).

Applicant Information Required by the Texas Department of Public Safety (DPS) (Applicant or DR must print.)

Section II – Criminal Conviction History Check and Registry Verification Process (Employer must complete this section.)

Section III – Criminal Conviction History and Registry Check Results (Employer or CDSA must complete this section.)
DPS Criminal Conviction Criminal History Check (The DPS Criminal Conviction History must be attached to this form.)

ACKNOWLEDGMENT

I have been instructed in the use of this equipment and understand that I must comply with Policies and Procedures regarding use of personal protective equipment.

Employer Information

Federal Employer ID Number (FEIN):   812799911

Employer Name:   ASCENTIA HEALTHCARE LLC

Employer Address:  24707 MALCA MANOR DR

Employer City:   KATY

State:   TX

ZIP Code:   77493-2061

Province/Region:    USA

Employer Telephone:    2817864880

Employer FAX:     2817862084

INSTRUCTIONS FOR COMPLETING THE TEXAS EMPLOYER NEW HIRE REPORTING FORM

The purpose of the Texas New Hire Reporting Form is to allow employers to fulfill new hire reporting requirements. You may enter your employer information and photocopy a supply and then enter employee information on the copies.

REPORTING OF NEW HIRES IS REQUIRED:

All required items (numbers 1,3, 4, 5,6,7,14,15,16,17, 18,19,20,21,22)on this form must be completed.

Box1: Federal Employer ID Number (FEIN). Provide the 9-digit employer identification number that the federal government assigns to the employer. This is the same number used for federal tax reporting. Please use the same FEIN that appears on quarterly wage reports.

Box2: State Employer ID Number (Optional). Identification number assigned to the employer by the Texas Workforce Commission.

Box3: Employer Name. The employer name as listed on the employee’sW4 form. Please do not provide more than one employer name (for example, “ABC, Inc DBA. John Doe Paint and Body Shop” is not correct).

Box4: Employer Address. Please indicate the address where the Income Withholding Orders should be sent. Do not provide more than one address(for example, P.O. Box123, 1313 Mockingbird Lane is not correct).

Box8: Employer Province/Region(if foreign). Provide this information if the employer address is not in the United States.

Box9: Employer Country(if foreign). Provide the two letter country abbreviation if the employer address is not in the United States.

Box10: Postal Code (if foreign). Provide the postal code if the employer address is not in the United States.

Box13:NewHire Contact Person(Optional). Providing the name of a contact staff person will facilitate communication between the employer and the Texas Employer New Hire Reporting Program.

Box15: Date of Hire. List the date in month, day and year order. Use four digits for the year (for example, 2001). This should be the first day that services are performed for wages by an individual. If you are reporting a rehire (where a newW-4 is prepared) use the return date, not the original date of hire.

Box23: Employee Province/Region(if foreign). Provide this information if the employee does not reside in the United States.

Box24:Employee Country (if foreign). Provide the two letter country abbreviation if the employee address is not in the United States.

Box25: Postal Code (if foreign). Provide the postal code if the employee address is not in the United States.

Box26: State Where Employee was Hired. Use the abbreviation recognized by the U.S. Postal Service for the state in which the employee was hired.

Box27:Employee DOB(Date of Birth)(Optional). List the date in month, day and year order. Use four digits for the year (for example,
1985).

Box28: Employee Salary(Optional). Enter employee’s exact wages in dollars and cents. This should correspond to the salary pay frequency indicated in Box29.

Box29:Salary(Check One ONLY)(Optional). Check the appropriate box relating to the employee’s salary pay frequency. Check “ Biweekly” if the salary is based on 26 pay periods. Check “Semi-monthly” if the salary is based on 24 pay periods. Check “Annually” if salary payment is a one-time distribution.

SUBMISSION OF NEW HIRE REPORTS. The Texas Employer New Hire Reporting Program offers variety of methods that employers can use to submit new hire reports. For further information on which method may be best for you, call 1-800-850-6442. Employers are encouraged to keep photocopies or electronic records of all reports submitted. When the form is completed, send it to the Texas Employer New Hire Reporting Program using one of the following means:

• FAX: 1-800-732-5015
• U.S Mail: EN HR Operations Center P.O Box 149224 Austin, TX78714-9224
• Telephone Submissions: 1-800-850-6442
• Internet Submissions: http://employer.oag.state.tx.us

Employers must provide all of the required information within 20 calendar days of the employee's first day of work to be in compliance. State law provides a penalty of $25 for each employee and employer knowingly fails to report, and a penalty of $500 for conspiring with an employee to1)fail to file a reportor2)submit a false or incomplete report.

I {name-15} acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself.

TB TARGETED MEDICAL QUESTIONNAIRE FORM

To be completed by employee: