EMPLOYMENT APPLICATION Personal Information

Transcription

1 EMPLOYMENT APPLICATION Personal Information Name D.O.B. Date: Address Telephone Number Social Security # Emergency Number Position Desired Position Date that you are available to start Salary Desired Are you Currently Employed? Education School Name Did you Graduate Degree/Diploma Yes/No Yes/No Yes/No List any special training that you have for this job: Former Employers Last 3 Employers Name Dates Employed Reason for Leaving Phone Number (required) References List 2 Professional References and 1 Personal Reference Name Phone number Number of Years 1

2 SUPPLEMENTAL EMPLOYMENT APPLICATION FORM As an employee of Agape Health Services, LLC I understand and agree to the following: A criminal background check will be conducted on me by SLED, as required by SC state law. That I have not been convicted or involved in any form of child or adult molestation or abuse. That I am required to purchase and wear a back brace at all times when I am doing PCA/Home Management duties with clients. That I can lift at least fifty (50) pounds of weight. If I own or drive a vehicle for Agape Or Care, I will herein provide the following information for proof of insurance. Agree to see clients when and where they are assigned. Title ownership Insurance Policy Date policy is in Effect I will also within seven (7) days provide a copy of my driving record dating back at least three (3) years. EMPLOYEE SIGNATURE: DATE: 2

3 ***FOR NURSES AND CONTRACT WORKERS ONLY*** INDEPENDENT CONTRACTORS AGREEMENT: NAME: ADDRESS CITY/STATE ZIP: SOCIAL SECURITY & TAX ID. #: PHONE: ( ) I, WILL PERFORE THE FOLLOWING SERVICES FOR AGAPE AS AN INDEPENDENT CONTRACTOR AT AN HOURLY RATE OF $ TO BE PAID BI-WEEKLY. LIST JOB TASKS: As an independent contractor, Agape will not be responsible for reporting any federal or state income taxes on your behalf. All federal and state taxes are the responsibility of the independent contractor. You will be issued an IRS Form 1099-MISC statement at the end of the year and not an employee Form W2. If you do not provide your taxpayer identification number, by federal law back-up withholdings at a rate of 31% will be withheld for fees paid to you in excess of $

4 EMPLOYEE PAYROLL CHANGE/ADD FORM ***INDICATE PURPOSE OF THIS FORM B Y CHECKING ONE CATEGORY BELOW*** NEW HIRE: TERMINATION: PAY RATE CHANGE: ADDRESS CHANGE: FORM W4 CHANGE: (ATTACH) HIRE DATE: TERMINATION DATE: OLD PAY RATE/ HR: $ OLD BI-WEEKLY SALARY (GROSS): $ NEW PAY RATE/HR: $ NEW BI-WEEKLY SALARY (GROSS): $ EMPLOYEE NAME: ADDRESS: CITY/STATE/ZIP: SOCIAL SECURITY NO: PHONE: ( ) If a new employee, Form 19 must be completed and kept on file. Also, the state of SC does not have a separate W 4 form for state withholding. Employees may have the same withheld from Federal as they have for state, in such case only one federal Form W4 needs to be completed (it should be marked (Federal & State). If the employee wants a different amount withheld from state (SC, then the two federal Form W4 need to be completed by the employee; mark one (Federal Only) and the other (State Only). By law if no federal Form W4 is on file for employees, withholding will be withheld at the highest rate of single with no dependents. EMPLOYEE SIGNATURE: 4

5 AGAPE HEALTH SERVICES, LLC & SAINTS CARE, INC DISCIPLINARY POLICIES FOR ADMINISTRATORS AND AIDES VIOLATION FIRST OFFENSE 2 ND OFFENSE 3 RD OFFENSE 1. Care Call strikes: calling-in from wrong number 2. Excessive Care Call strikes 3. Failure to complete weekly Care Plan reports 4. Filing false records/reports 5. Leaving clients unattended or leaving work area 6. Bringing other people into a client s home during working hours 7. Missing 2 or more days from work without excuse 8. Missing an inservice training 9 Borrowing money and other items from clients or their caregivers 10. Ill-treatment of clients 11. Use of profanity or abusive language toward client/staff Verbal warning Written warning/forfeiting of pay for a day Suspension without pay, 3- days/dismissal Verbal Warning Written Warning Possible dismissal and forfeiting of pay Verbal Warning and telephone instructions Immediate, possible dismissal and 1-week suspension 12. Sleeping on duty 2-day suspension 13. Use of or being Immediate suspension under the drugs or for 1-day alcohol while on duty 14. Excessive personal use of telephone and mandatory session with Supervisor 2-week suspension Suspension without pay, 5-days 1-week suspension 2-day suspension and 5-day suspension ; pending investigation Verbal warning & 3- day suspension, 2-week suspension 3-day suspension, possible dismissal 5-day suspension and/or dismissal, 2- week suspension/dismissal Verbal warning 3-day suspension 15. Smoking in a 5-day suspension, client s home VIOLATION FIRST OFFENSE 2 ND OFFENSE 3 RD OFFENSE 16. Sexual Harassment or lewd, 3- day suspension, 5

6 behavior toward staff/clients 17. Solicitation of clients or caregivers 18. Making private contracts to do personal services for clients 19. Recruiting our clients for other agencies 20. Performing skilled medical care, or giving medication 21. Disrespect of staff/clients 22. Violation of HIPPA laws 23. Unprofessional appearance 24. Unprofessional behavior 25. Failure to follow universal health precautions 26. Lateness in submitting reports 27. Failing to follow or altering the Client s Care Plan 27. Poor job performance 28. Failure to get annual TB test 29. Disregard of Company policy 30. Failure to maintain driver s license. 31. Quitting without providing 2-week notice 32. Failure to go to assigned clients at the time assigned. pending investigation Verbal warning, 5- day suspension, forfeiture of pay and fine of $ Immediate dismissal and $ fine 3-day suspension Warning, mandatory 3-day suspension supervisory session Verbal warning Written Warning 1-week suspension and possible dismissal 3-day suspension 3-day suspension /dismissal and 2-day suspension 3-day suspension /dismissal 3-day suspension Written Warning Forfeiture of last paycheck. Verbal warning 3-day suspension 3-day suspension Termination I, have read these guidelines and fully intend to abide by them. Signature: Date 6

7 TO: FROM: ALL ADMINISTRATIVE STAFF PERSONS AND AIDES Dr. Alonzo Johnson, CEO DATE: July 1, 2007 RE: TERMINATION OF EMPLOYMENT Voluntary termination of employment will require a written letter of resignation, which must be submitted at least (2) two weeks prior to the effective date of an aide s resignation and (4) four weeks prior for an administrator s. A sample copy of the resignation letter is included in the employee handbook. This letter should state the principal reasons for leaving. All items belonging to Agape or Care should be returned on or before the last day of employment (i.e. keys, ID Badge, client care plans, paperwork, etc. Violation of this policy will result in a negative employment record and may affect the release of your final paycheck. Employee Signature: Date: 7

8 SAMPLE RESIGNATION FORM TO: Alonzo Johnson, Ph.D., President/CEO FROM: DATE: I,, herein resign from my position as a with AGAPE Health Services, LLC and or effective, ten working Days from today. Regretfully, I am resigning because Employee Signature: 8