Apply for Home Health Aide

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

Summary
Title:Home Health Aide
ID:1004
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:
CNA/HHA Pre Hire Interview Questions - MA
* If CNA/HHA do you have a current certificate or License?
Yes   No
* Have you ever worked in home care? If yes, where?
* Is the prospective employee currently working anywhere?  If yes where?
Field Interview Questions - MA
* What would you do if you arrive at a client’s home and he/she refused to allow you to enter?
* What would you do if your client fell and insisted that you do not call for help and insists that
they are all right?
* How would you respond if the Administrator calls you in to give you a written warning for
something she has discovered happened?
Application for Employment
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

*
Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

*
*
*
*
*
*
*
*
*
Yes   No
*
*

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

*
*
*
*

Reference 2

*
*
*
*

Reference 3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

Conflict of Interest
* POLICY:
No employee or member of the Board of Directors, Advisory Committee, or other individual, committee, or entity shall derive any profit or gain directly or indirectly by reason of their association with the agency, without the prior knowledge and approval of the Board of Directors. All board members and/or employees, at the discretion and specific request of the board, will be required to submit a disclosure statement annually.
If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Administrator and Board of Directors.
In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the agency and a board member shall not participate in discussions unless requested by the board nor vote on such transactions. The abstention and the reason for it shall be recorded in the minutes.
Field staff in any capacity understands that all clients are clients of the Agency not personal clients of the field staff. Clients may never be serviced privately by an employee of Our Agency for the financial gain of the employee. Should an employee terminate employment with A Caring Heart Nursing Services LLC, the field staff understands that the client may not be encouraged or otherwise moved from our Agency to another agency.

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST.

I have read and am fully familiar with the agency’s policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other matter in which I would profit or gain directly or indirectly as a result of my membership on the agency’s board of Directors or its committees or my employment.
Furthermore, I agree to disclose any such interest which may occur in accordance with the requirements of the policy and agree to abstain from any vote or action regarding the agency’s business that might result in any profit or gain directly or indirectly myself.

I also work for another home care agency
Yes
No
If yes, I am disclosing the name of the agency/agencies
Acknowledgement Consent Form - MA

Statement Of Driving Status

* I am currently licensed to drive a motor vehicle in the state of MA. If I am unable to drive, I
will find other forms of transportation to get to my scheduled visits (i.e. public transportation)
Yes   No

Attorney General’s Fair Labor And Business Practice Notice

* I acknowledge that I received a copy of the Attorney General’s Fair Labor and Business
Practice notice. This notice includes the MA minimum wage, who is covered, deductions,
minimum daily hours and overtime. I received this as part of my application from A Caring
Heart Nursing Services LLC.
Yes   No

False Claims Act Policy

* I have received the aforementioned policy, and I understand that it is my responsibility to
read and comply with the content and provisions contained in this policy and any revisions
made to it. I further understand that it is my responsibility to seek clarification if I do not
understand its content.
Yes   No

Equal Opportunity Policy

* I acknowledge that I read and received a copy of the Equal Opportunity Policy and I am fully
aware of the procedure to follow should I ever feel there is a discrimination issue to be resolved
or discussed.
The Administrator, the president and the vice president for human resources of the company
fully support this equal employment opportunity policy and specifically require each employee
to act in accordance with its principles.
Yes   No

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
*
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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