Apply for AFC Caregiver

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:AFC Caregiver
ID:1007
Location:Massachusetts
Department:Client Services
Resume
Resume:
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* D.O.B :
* SSN:
* Emergency Contact Name:
* Emergency Contact Phone Number:
AFC Caregiver Questionnaire
* Role
Caregiver
Backup Caregiver
* How did you hear about our program?
* What is the name of the AFC member you are applying for?
* What is the relationship with the AFC member?
* Do you have any physical limitations or diagnoses' that might prevent you from rendering hands on care?
Yes
No
If yes, please specify
* Do you have special training e.g. Alzheimer's or Behavioral Health training?
Yes
No
* Do you have a diagnosed drug or alcohol abuse disorder?
Yes
No
* Have you previously worked in homecare or as a caregiver?
Yes
No
* Do you provide services to any other AFC client?
Yes
No
* Please list all family members and non relatives in your home, including yourself. Include Age and Relation to Caregiver

REFERENCE 1

* Full Name
* Phone Number
Relationship

REFERENCE 2

* Full Name
* Phone Number
Relationship

REFERENCE 3

* Full Name
* Phone Number
Relationship
MA AFC Pay Schedule
* Caregiver for Level 1 Client: $31.75 per day
Caregiver for Level 2 Client: $54.56 per day
I have read the above rates and agree that these rates are satisfactory and acceptable to me.
I have read the above rates and I do not accept these rates, therefore, do not desire employment with A Caring Heart Nursing Services LLC at this time.
* Signature
* Date
MA AFC Caregiver Consent Form

Criminal Background Check Consent

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that a Criminal Background Check will be performed with my personal information in the State of Massachusetts. I hereby acknowledge and provide permission to A Caring Heart Nursing Services, LLC or its authorized agent to submit a background check. This authorization is valid for the entire tenure of my employment with this organization.
Yes   No

Abuse Registry Consent Check

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current
licensee, I understand that an Abuse Check will be submitted for my personal information. I
hereby acknowledge and provide permission to A Caring Heart Nursing Services, LLC or its
authorized agent to submit an abuse check for my information. This authorization is valid for
the entire tenure of my employment with this organization.
Yes   No

Sex Offender Registry InvestigationConsent

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current
licensee, I understand that a Sex Offender Registry Investigation (SORB) will be submitted
for my personal information. I hereby acknowledge and provide permission to A Caring
Heart Nursing Services, LLC or its authorized agent to submit a SORB check for my
information. This authorization is valid for the entire tenure of my employment with this
organization.
Yes   No

Office of the Inspector General (OIG) Investigation

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that A Caring Heart Nursing Services or its authorized agent will conduct an initial and monthly checks of the OIG’s List of Excluded Individuals/Entities (LEIE). I hereby acknowledge and provide permission to A Caring Heart Nursing Services, LLC or its authorized agent to submit such periodic checks with my information. This authorization is valid for the entire tenure of my employment with this organization.
Yes   No

System for Award Management Check (SAM Check)

* A Caring Heart Nursing Services, LLC is registered under the provisions of M.G.L. c.6, § 172 to receive SAM for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, and current licensees.
Yes   No
* By signing below, I provide my consent to all required pre-hiring background checks and subsequent checks for MA regulations and affirm that the information provided on this acknowledgment Form is true and accurate
* Date
Employee Documents Required for Hire
Please review the list and present it to the office with the attached documents

Social Security Card

Government Issued ID or Massachusetts Driver's License
Documents must be current and not expired

Tuberculosis Test
A negative blood/ skin test within 1 year must be on file prior to orientation
If History of a positive TB Test, please provide Chest X-ray completed less than 10 years.

Physical Exam Letter
A Physical Exam Date within the past 12 months
A letter from your provider that clears you to work without restrictions

Proof of Auto Insurance
Not applicable if you do not drive

Immigration Documents
Documents must be current and not expired

* By signing below, I attest that I have been made aware of the required hiring documents mentioned above and I will not be able to attend an orientation without the required documents.
*
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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