EMPLOYMENT APPLICATIONALL APPLICANTS WILL BE CONSIDERED FOR EMPLOYMENT WITHOUT REGARDS TO RACE, COLOR, SEXUAL ORIGIN,

AGE, MARITAL OR VETERAN STATUS, MEDICAL CONDITION OR DISABILITY, OR OTHER STATUS PROTECTED BY LAW. WE ARE AN EQUAL OPPORTUNITY EMPLOYER

LAST NAME FIRST NAME MIDDLE NAME

APPLICATION FOR POSITION OF: Date of Birth START DATE? RATE DESIRED?

WHAT SHIFT ARE YOU AVAILABLE TO WORK

CURRENT ADDRESS – Street, City, State & Zip Code Phone Number:

MAILING ADDRESS – If Different from Above Email:

DO YOU GO BY ANY OTHER NAME THAT IS NOT

PLEASE COMPLETE IF APPYING TO BE DIRECT CARE WORKERConsumer:

CIRCLE YES OR NODo You Have A Reliable Source of transportation to and from Work? YES NODo You Have A Valid Driver’s License? (Applicable only for certain positions) YES NOAre You At Least 18 Years of Age? YES NOAre You Legally Eligible to Work in the United States? YES NO

EDUCATION / TRAINIINGCIRCLE HIGHEST GRADE OR YEAR COMPLETED

1 2 3 4 5 6 7 8 9 10 11 12

DO YOU HAVE A HIGH SCHOOL DIPLOMA OR A GED EQUIVALENCY?

YES NO

NAME AND LOCATION OF HIGH SCHOOL

EDUCATION BEYOND HIGH SCHOOL (COLLEGE, UNIVERSITY, OR OTHER)NAME # OF YEARS

ATTENDEDCREDITS EARNED

MAJOR FIELD GPA/BASIS DEGREE EARNED

DESCRIBE OTHER EDUCATION OR TRAINING IN WHICH YOU FEEL IS RELEVANT TO JOB(S) FOR WHICH YOU ARE APPLYING. INCLUDE RELEVANT LICENSE & CERTIFICATES. BE SPECIFIC:

Do you have any pending criminal charges against you? YES NOHave you ever been convicted of a crimeregardless of whether it was a felony or misdemeanor? YES NOIf you answered yes to either criminal background inquiries above, provide the date and county of the pending charge or conviction, the type of charge or conviction, and an explanation. (A pending charge or prior conviction will not automatically bar you from employment.)__________________________________________________________________________________________________________________________________________________________________________________________

Previous Experience. Begin with the most recent employer (at least one) EMPLOYER #1Name

Location (STREET ADDRESS, CITY, STATE, ZIP CODE)

Phone Type of Business Position:Part Time Full Time Other

Reason for Leaving:

Name of Supervisor Job Title

Job Duties Length of Employment (Month & Year)

From To

EMPLOYER #2Name

Location (STREET ADDRESS, CITY, STATE, ZIP CODE)

Phone Type of Business Position:Part Time Full Time Other

Reason for Leaving:

Name of Supervisor Job Title

Job Duties Length of Employment (Month & Year)

From To

MAY WE COMMUNICATE WITH YOUR PRESENT EMPLOYER? Circle one YES NO FORMER EMPLOYER? YES NO

HAVE YOU WORKED FOR WYNCOTE WELLNESS BEFORE? YES NO HOW WERE YOU REFERRED TO THIS AGENCY? _______________________________________________________

In addition to job history, please provide satisfactory references. Please list two professional references.

Name Relationship Company Phone/Alternate Phone

CERTIFICATION

I certify that the above information is true and complete. I understand that any false statement I have made herein or in my future to disclose requested information may disqualify me for consideration for employment, of if employed, may result in my termination. I further authorize Wyncote Wellness, or its agent to perform an investigation of local, state or federal records relating to any criminal convictions I may have. In addition, the agency has my permission to obtain all necessary personal history or criminal history and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me.

I understand and acknowledge that I may be required to undergo a post-offer, pre-employment physical exam, and a post-offer pre-employment drug screening analysis for substance abuse. I understand that these may, to the extent permitted by law, result in the revocation of any offer of employment. I certify that this application does not constitute an employment contract of any kind. I further acknowledge that, if I am offered a position with Wyncote Wellness, my employment may be terminated at any time, with or without notice or cause, except as otherwise provided by law.

Signature _____________________________________________ Date: _____________________

Employee Referral Form

Employee Name: _____________________________ Date: _________________

Email Address: _______________________________ Phone Number: ____________

Below, please list two professional referrals that are not directly related to the employee.

******************************************************************************

Referral Information

1. Name: ___________________________ Relationship: ____________________

Years Known: _________ Phone Number: ____________________

2. Name: ___________________________ Relationship: ________________________

Years Known: ___________ Phone Number: ______________________

Employee Emergency Contact Information

Name: ________________________________________________________________________

Address:_______________________________________________________________________

Home Phone: ________________________ Mobile Phone: _____________________________

******************************************************************************

Name: _____________________________ Phone Number: ____________________________

Relationship: ________________________ Home Address:_____________________________

Name: _____________________________ Phone Number: ____________________________

Relationship: ________________________ Home Address:_____________________________

8480 Limekiln PikeBuilding 3 Suite L20Wyncote, PA 19095

215-277-5914

You may be hired on a provisional basis pending receipt of a criminal history and child abuse report. PLEASE COMPLETE THE FOLLOWING:

I, _________________________________have been a resident of PA since_______________.

I have applied for: Please initial.1.______ PA State Criminal History report. Date of application filed_____________________2. ______FBI Child Abuse Clearance-Department of Human Services filed________________ I hereby attest that, within five years immediately preceding the date of my application into employment in the waiver program that I have not been named on a central child abuse registry as being a perpetrator of founded or indicated child abuse.3._______I have not tampered with the public record information by making false entry in, or false alteration of, any record or document.4._______I have not committed a crime that would disqualify me from employment or referral.

I understand that while I am in a provisional status:

I will only be assigned to adults with no children in the home. I will be monitored by the agency through random, direct observation and consumer feedback with documentation results retained in my personal file.

In addition, I under that if I have been a Pennsylvania resident for 2 years or more I cannot serve a provisional period of more than thirty days; if I have NOT been a resident of PA for 2 years or more I cannot serve a provisional period of more than 90 days.

I understand that I will be terminated if I am listed on the Statewide Central Register as the perpetrator of a founded or indicated report of child abuse as defined in 55 PA Code 3490.4, and if prohibited offenses are identified on the State Criminal History report. If a criminal history report is founded, the consumer will be informed without disclosure, and has the option of continuing care by signing acknowledgement form.

I attest that the above information is true to the best of my knowledge.

___________________ __________ _________________________ _________Signature of DCW Date Signature of Employer Date

8480 Limekiln PikeBuilding 3 Suite L20Wyncote, PA 19095

215-277-5914Consumer: ___________________________

Please be advised that for Wyncote Wellness home care agency to hire an employee, we are required by the state to submit both a Child Abuse Clearance and a Criminal Background search. Although the information that is reported to our agency is confidential, our agency needs to inform our client that the report reflected an incident.

Direct Care Worker, ______________________________report on their Criminal Background and/or Child Abuse Clearance returned with an occurrence.

Your signature is stating that you been informed and agree to continue services with__________________________________ and Wyncote Wellness Home Care, and acknowledge you are accepting this notification as an informed consumer.

Consumer_______________________ Date: _______________

Case Manager____________________ Date: _______________

Dawn Seeger, M.Ed.Executive Director ______________________ Date________________

8480 Limekiln PikeBuilding 3 Suite L20Wyncote, PA 19095

215-277-5914Date:

Consumer:

Please be advised as an employee of Wyncote Wellness Home Care Agency to hire a direct care worker, you are required by the state to complete a Tuberculosis examination. In order to take care of a consumer, it is mandatory to complete a two-step PPD test or Chest X-ray within two weeks of employment. You may provisionally care for the consumer after the 1st PPD is complete. Failure to comply with a 2nd step result in a suspension of employment until complete. This is a state mandatory test and we must comply with regulations.

Your signature is stating that you have been informed and agree to continue services with__________________________________ and Wyncote Wellness Home Care, and acknowledge you are accepting this notification as an informed consumer.

Consumer_______________________ Date: _______________

Case Manager_______________ Date: _______________

CERTIFICATION

of perjury, I

that I (we)

information, including

TO EMPLOYERS/TAXPAYERS: This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes. This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.

all accompanying schedules and statements and to the best of my (our) belief, they are true, correct and complete.

SIGNATURE OF EMPLOYEE DATE (MM/DD/YYYY)

PHONE NUMBER EMAIL ADDRESS

Position Title: Direct Care Worker Position Code: 100 Department: Case Management Department: Case Management

Effective Date: 10/17: Rev. 11/18 Essential Functions (assist participant with the following)

i. Self-administration of medication ii. Light housekeeping

iii. Personal care including but not limited to grooming and dressing iv. Meal preparation v. Oral hygiene and dental care

vi. Toileting vii. IADL assistance

viii. Administering emergency first aid ix. Providing or arranging for social interaction

Additional Responsibilities:

i. Document observations and services in the individual participant record. a. Report any change in the participant's mental or physical condition to his,

her or their immediate family, supervisor or agency. ii. Knowledge of, and adhere to, agency policies and procedure.

iii. Apply all training received in all aspects of care to be provided to the participant. a. Follow the plan of care to help the participant maintain good personal

hygiene and maintain a healthy, safe environment and perform ONLY those functions specified for each individual participant.

iv. Must attend all Wyncote Wellness required staff meetings, trainings, etc v. Must perform all duties in a professional and customer-focused manner.

vi. Must respond to ail communications from Wyncote Wellness administration in a timely manner.

Job Conditions: i. On occasion, may be required to bend, stoop, reach and move the participant. Must

be able to lift/carry up to 301bs. ii. Must be able to demonstrate, good communication both verbally and written In

English. Bilingual Spanish is a plus. Equipment Operation.

Civil Rights Compliance AwarenessIn accordance with applicable Federal, State and Local civil rights laws and regulatory requirements, you, as an employee or contractor, engaged in the provision of services, may not directly or indirectly:

Refuse, withhold, or deny services of this facility to any present or prospective client because of race, creed, color, gender, gender identity, gender presentation, age, religion, marital status, national origin (including limited English proficiency), ancestry, disability (including but not limited to mental, physical, HIV status) sexual orientation, citizenship status, military or veteran status, union membership, retaliation or on account of any other reason prohibited by law.

Furthermore, as a staff member of this facility, you have the right:To file a complaint of discrimination if you feel you have been discriminated against

based on your age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation/preference, veteran's/military status, pregnancy, ancestry, disability or religion.

Complaints of discrimination may be filed with any of the following:Wyncote Wellness8480 Limekiln PikeBuilding 3, Suite L20Wyncote, PA 19095

Department of Public Welfare PA Human Relations CommissionBureau of Equal Opportunity Philadelphia Regional OfficeRoom 223, Health &Welfare Building 110 N. 8th Street, Suite 501PO Box 2675

Harrisburg, PA 17105 Philadelphia, PA 19107U.S. Department of Health & Human Commonwealth of PennsylvaniaServices, Department of Public WelfareOffice for Civil Rights Bureau of Equal OpportunitySuite 372, Public Ledger Building Southeastern Regional Office150 South Independence Mall West 801 Market Street, Suite 5034Philadelphia, PA 19106-9111 Philadelphia, PA 19107

Staff Signature ____________________________________________________________________________________Human Resources Director ______________________________________________________________

Required HIPAA Confidentially AgreementEmployee Confidentiality Agreement of Consumer Health Information & Personal Information In accordance with HIPAA RegulationsFor good consideration and as an inducement for Wyncote Wellness Home Care, LLC (employer) to employ (employee/contractor), the undersigned Employee/contractor hereby agree not to directly or indirectly use, manipulate or copy compete any Protected Health Information (PHI), to Include personal health information or personal contact information (address, phone, email address, etc.) With the business of the agency and its successors and assigns during the period of employment. Misuse of PHI or personal contact information will result in termination and report with action to HIPAA federal agencies. Fines related to civil and criminal offences for gross misconduct with the above information are direct responsibility of said employee/contractor.Protestation of Health InformationThere are specific guidelines to ensure consumer's Protected Health Information is kept private. I understand that my employment with the agency involves handling Protected Health Information. I will ensure consumer's records are protected by enforcing the following measures:Consumer Protected Health Information will be transported in a protected travel chart while traveling, if applicable.When transmitting and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area, if applicable.Consumer Protected Health Information will be returned to the agency upon acknowledgement of the consumer being discharged, if applicable.Confidentiality of Protection Health InformationIt is both the agency and the employee's responsibility to ensure that every consumer's health information is always protected, by signing below, you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency's policy regarding consumer's Protected Health Information will be provided to you upon hire. I understand that! 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 rules and regulations. I agree to protect all Electronic Medical Records including passwords as outlined in the HIPAA policy.

Printed Name:______________________________________________________________________________________

Date:_________________________________________________________________________________________________

Signature:____________________________________________________________________________________________

CONFIDENTIALITY AND NON-COMPETITION AGREEMENT

Wyncote Wellness requires that the employee/contractor avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition.The employee/contractor agrees to refrain from prohibited competition with Wyncote Wellness Home Care and to maintain the confidentiality of information regarding employees, consumers and HLHC business.The employee/contractor will have access to information not generally made available to the public, such as identity of consumers, pricing, computer- related programs, etc. Wyncote Wellness Home Care prohibits the utilization of this information for any purpose other than for HLHC's own benefit and prohibits disclosure or unauthorized use during employment or at any time thereafter of any investigations of HLHC's personnel and/or personnel incidents related to any violations of the personnel policies. During employment and for a twelve-month period thereafter the Employee is prohibited from engaging in any of the following: Induce any employee of the employee of Wyncote Wellness Home Care to resign Encourage any consumer or entity to discontinue any relationship with Wyncote Wellness Home Care Solicit any consumer of Wyncote Wellness Home Care (current and within the past twelvemonth period), Enter competitive employment or seek to provide competitive services while employed within twenty-five miles of any office of Wyncote Wellness Home Care Solicit referrals or opportunities from any referral sourceViolation 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. Costs of replacing and training employees improperly solicited for competitive employment, etc. suffered by Wyncote Wellness Home Care. Employees/Contractors will be required to reimburse Wyncote Wellness Home Care for all legal fees, costs and other expenses.This agreement is in effect during the employee's and independent contractor's tenure and for twelve months thereafter. It does not modify the right of the employee/contractor to resign at any time or of Wyncote Wellness Home Care to terminate employment without prior cause, notice or liability and does not modify any other HLHC policy.

Employee Signature: _______________________________________________ Date: _____________________

Policies and Procedures

Acknowledgement

I am a staff member of Wyncote Wellness. I acknowledge the following:I am in receipt of the Policies and Procedures that are related to any aspect of my employment or independent contracting.It is my responsibility to know and abide by all policies and procedures that are related to my employment and scope of work.Wyncote Wellness reserves the right, in its sole discretion, to change, amend, replace, remove, add to and deviate from any policy, procedure or practice at any time, without notice and for any reason.These policies and procedures supersede all prior oral or written statements by Wyncote Wellness concerning any policies, guidelines, etc.I received these policies and procedures on the date indicated below.My signature indicates my acknowledgement of the above statement.

Print Staff Member's Name: _____________________________________________________________________

Staff Member's Signature: __________________________________________ Date: ______________________

Director's Signature: ________________________________________________ Date: ______________________