must be submitted 5 days prior the 1st...

New Employee Packet Checklist

Employee Name: ______________________________________________________________________ Hire Date: ___________________ Submitted to Prime Science Therapy Date:____________________ Welcome aboard! We are excited that you have chosen Prime Science Therapy, Inc. to serve you! Please complete all the items listed below and submit them in order to be ready to begin your employment with us. At the end of this checklist information on how you can submit your documents either by email, fax, or by mailing it via a traceable method. Please submit copies of the following documents:

o Copy of all current Professional Licenses

o Copy of American Heart Association Healthcare Provide BLS/CPR

o Copy of your current certification (OT, SLP, PT, COTA, PTA, SLPA)

o Copy of Driver’s License

o Copy of Green Card (if not a U.S. Citizen)

o Copy of Social Security Card

o Proof of 2 MMR Vaccines or Positive Titer

o Physical examination w/n the last 1 year

o TB Test w/ in last year OR Chest X-ray w/n last 5 years (must also submit proof of a positive TB Test to support x-ray) To be completed by the Employee:

o Employment Application Form o Physical Affidavit

o Background Check Authorization Form o Hepatitis B Vaccinations & Varicella Form

o Job Description Signed & Returned o Tuberculosis Test Record Form

o Form 1-9, Section 1 o Offer Letter Signed & Returned

o Form W-4, Federal Tax Withholding o Acknowledgement of Company Handbook

o Form W-9, Section 1 o Acknowledgement of Orientation(HIPAA)

o Wage Deduction Authorization Form o Payroll Election Form

To be completed by Hiring Manager:

o New Employee Payroll Data Form

o Form I-9, Section 2

MUST BE SUBMITTED 5 DAYS PRIOR THE 1st PAYROLL

Prime Science Therapy, Inc.

91 Gregory Lane | Suite 17 | Pleasant Hill | CA 94523 Phone 415-761-0813 | Fax 925-956-7181

Certified Occupational Therapist Assistant (COTA) - Job Description

POSITION SUMMARY Provides Occupational Therapy services to residents by assisting in the assessment and treatment, development and implementation of programs, and related professional in-services. ESSENTIAL DUTIES AND RESPONSIBILITIES INCLUDE THE FOLLOWING: 1. Provides Occupational Therapy services to residents and initiates referrals under the supervision of an

Occupational Therapist in accordance with state regulations. 2. Assists the Occupational Therapist in the evaluation process as needed or directed. 3. Identifies indications for and assists in evaluations at appropriate intervals under the direction of the

Occupational Therapist. 4. Assists the Occupational Therapist in identifying a problem list, short-term goals, long term goals and

treatment plan. 5. Conducts individual, supervised and group treatment as assigned by the Occupational Therapist and as

outlined in the treatment plan. 6. Monitors resident's response to intervention and consults with Occupational Therapist if modification is

indicated. 7. Adheres to department and resident schedule and modifies as appropriate for treatment regimen. 8. Maintains acceptable resident care rations as determined by the Occupational Therapist. 9. Provides/recommends/fabricates adaptive devices or other equipment; trains resident and caregiver in the

use or application of orthotics and prosthetics. 10. Participates in resident, family and staff education. 11. Confers formally and informally with other team members in coordinating the total rehabilitation program

of the resident. 12. Assumes responsibility for ongoing continuing education and professional development. 13. Adheres to Occupational Therapy Department procedures regarding documentation of Physical Therapy

services. 14. Provides treatment in accordance with established standards of practice, department procedures and

productivity standards. 15. Records billable treatment times according to Occupational Therapy Department procedures and submits

weekly/monthly statistics to corporate office. 16. Reports to work on time and coordinates schedule to achieve maximum productivity and work efficiency

during assigned shift. 17. Maintains safe and clean work area and adheres to facility/company safety standards 18. Complies with all Infection Control, Universal Precautions and OSHA standards for the health care

professional. 19. Maintains positive relationship and rapport with coworkers, residents, family members and facility

personnel 20. Assists with and participates in Quality Assurance Programs as required 21. Adheres to established confidentiality standards. 22. Projects a positive and professional image at all times. 23. Performs other duties as assigned. RECOMMENDED MINIMUM POSITION QUALIFICATIONS: Associates Degree in Occupational Therapy from an accredited program Successful completion of the National Certification for Occupational Therapy Assistant Current state licensure or licensure eligible in states where applicable.



Certified Occupational Therapist Assistant (COTA) - Job Description

PHYSICAL REQUIREMENTS AND WORK ENVIRONMENT: Physical requirements for this position are classified as medium under the Department of Labor classification. The employee must be capable of exerting 20-50 pounds of force occasionally (less than 1/3 of the time), and/or 10-20 pounds of force frequently (1/2 of the time), and or up to 10 pounds of force constantly (2/3 or more of the time) to move objects, equipment and/or residents. While performing the duties of this job, the employee is regularly required to stand, walk, sit, stoop, kneel, bend, or crouch; use hands to manipulate tools, equipment, or controls; reach with hands and arms, balance, lift, and perform medium to maximum transfer assists with residents. The employee is required to have visual and hearing acuity sufficient enough to assess resident safety and ability. The employee works mostly inside in resident rooms or clinic. This position is classified as a Category 1 for the purpose of exposure to Blood borne Pathogens OSHA Regulations regarding the Standard on Occupational Exposure to Blood borne Pathogens (29 CFR 1910.1030). Category 1 is defined as all procedures or job related tasks that involve an inherent risk for mucous membrane or skin contact with blood, body fluids, or tissues, or a potential for spills and or splashes of blood or body fluids. The use of protective equipment and measures is required for every employee engaged in Category 1 tasks. The essential functions described here are representative of those an employee encounters while performing the basic functions of a Certified Occupational Therapy Assistant. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. __________________________________ ____________________________ Signature Date



Employment Application Form

Personal Information: First Name: Middle Initial: Last Name:

Social Security Number: Date of Birth:

Permanent Address: City: State: Zip: Hm Phone#: Fax#: Cell Phone#: Email:

Temporary Address: City: State: Zip:

Emergency Contact Name: Emergency Contact Phone: Relationship:

Human Resources: How did you hear of Prime Science Therapy? Referral Name:

Are you currently a U.S. Citizen or permanent resident? YES NO

Have you ever been convicted of a crime, other than a minor traffic violation? YES NO

If yes, please explain:

Have you ever worked with Prime Science Therapy in the past? YES NO Education: (Please attach your Resume)

School Name: _________________________________________________________________________

Location: _____________________________________________________________________________

Graduation Date: Diploma/Degree/Certifications:

School Name: _________________________________________________________________________

Location: ____________________________________________________________________________

Graduation Date: Diploma/Degree/Certifications:

Additional Certifications:

Continuing Education in

the last two years:




Professional Information: (Please attach a photocopy of all licenses)

Classification: Specialty(s): Years Experience:

Has any of your Professional License(s) ever been investigated or suspended? YES NO

If yes, please explain:

Desired position: ______________________ Date Available: _____/_____/______

Travel Location Preferences:

License and Professional Certifications:

Specialty (circle one): PT OT SLP COTA PTA SLPA Rehab Aide

All Active Licenses: State: License #: Issue Date: Expiration Date:

Active Certifications: ASHA#: EXPIRATION: FSBPT#: EXPIRATION:

NBCOT#: EXPIRATION: OTHER: EXPIRATION:

ACLS EXPIRATION: OTHER: EXPIRATION:

BLS EXPIRATION: OTHER: EXPIRATION:

NRP EXPIRATION: OTHER: EXPIRATION:

Pending License: State: Application Date: Application Receipt Verified? Board Contact Info:




Acknowledgement (Initial)__________I confirm that the information in this application is true and correct to the best of my knowledge. That providing incomplete or false information can result in my disqualification for employment and can also violate State Laws. I grant permission to Prime Science Therapy, Inc. to inquire & research any current/pending licensure. I hereby authorize Prime Science Therapy, Inc. to thoroughly investigate my references, work record, education, background check, state board information and any other matters related to my qualification for employment. _________________________________________________ ______________________________ Employee Signature Date Voluntary Self-Identification Data The employer may be subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights law and regulations. In order to comply with these laws, the employer invites employees to voluntary self-identify their race or ethnicity, veteran or handicapped status, and sex. Submission of this information is voluntary and refusal to provide it will not subject you o any adverse treatment. The information obtained will be kept confidential and may only be used accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify and specific individual. We are a company that values diversity. Race or Ethnicity

o Hispanic or Latino o White o Black or African American o Asian o American Indian or Alaskan Native o Two or more races o Native Hawaiian or other Pacific Islander

Gender o Male o Female

Veteran Status: o Vietnam Era Veteran o Special Disabled Veteran o Other Eligible Veteran

o I am an individual with Disabilities

o I do not wish to Self-Identify

Signature: _________________________________ Date: ________________

Prime Science Therapy, Inc. 91 Gregory Lane | Suite 17 | Pleasant Hill | CA 94523

Phone 415-761-0813 | Fax 925-956-7181

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Background Check Authorization Form

In connection with my application for employment with Prime Science Therapy, I understand that consumer reports or investigative reports may be requested about me including information about my character, general reputation, personal characteristics and verification of employment record, education, qualifications, criminal record, inquires regarding driving record and credentials. This process may involve a search of public records or various Federal, State, or Local agencies. Reports containing injury and/or medical information may be obtained after a tentative offer of employment has been made. During my employment, I hereby authorize Prime Science Therapy, Inc. or my Worksite Employer to obtain a consumer report and/or investigative consumer report about me for employment related purposes, to the full extent allowed by law. By signing below, I am authorizing Prime Science Therapy, Inc. or my Worksite Employer to obtain consumer reports or investigative consumer reports. I authorize all corporations, employers, co-workers, references, credit reporting agencies, educational institutions, licensing bodies, courts, law enforcement agencies, governmental agencies or departments, and military services to provide information about my background, including but not limited to driving records, court records, criminal records, credit report, academic records, professional license record and employment information or records. I agree to release the aforesaid from any liability for providing that information. I agree that this Disclosure will be valid, now or in the future, in original, faxed, copied or electronic form. Printed Name: Date of Birth:

*If born in the US, please list in which state, or if you were not born born in the US, please list your country of birth:

Social Security #: Driver’s License #: Driver’s License State:

Driver’s License Expiration:

Current Address: ______________________________ ____________________________ Employee Signature Date



Employment Agreement

Prime Science Therapy, Inc. is an Equal Employment Opportunity Company with Worksite Employer clients and employees throughout Northern California. You are an employee of both Prime Science Therapy, Inc., and your Worksite Employer, our customer. Prime Science Therapy, Inc. is a therapy service provider for individuals seeking rehabilitation. Your employment with Prime Science Therapy, Inc. is on an at-will basis, and is for no stated or definite period. This means that either you or Prime Science Therapy, Inc. are free to end the employment relationship for any reason or no reason, and with or without advance notice. Your employment with the Worksite Employer is also an at-will basis. If you are aware of any possible harassment or discrimination (whether directed at you or someone else) you are required to immediately report it to Prime Science Therapy, Inc. You must immediately contact Prime Science Therapy, Inc. if your paycheck does not correctly include all pay or compensation that you believe you are owed. No one is authorized to make you work off the clock. For example, this means that hourly or non-exempt employees cannot be required to work unreported overtime. If you submit a timesheet, you are responsible for ensuring that each timesheet is complete and accurate, and correctly shows all hours you actually worked. While you are required to obtain pre-approval to work overtime hours, any overtime hours actually worked (whether approved or not) must still be reported. To the extent required by state law, Prime Science Therapy, Inc. has agreed to pay your wages, to the extent your wages are timely and accurately reported to us. Prime Science Therapy, Inc. does not offer any bonus plans, commission plans, paid leave plans, profit sharing plans or deferred compensation plans. Drug Testing Co-operation with drug testing is a condition of employment and/or continued employment. Drug and alcohol testing may be required as part of pre-employment screening, randomly, based on reasonable suspicion or after an on-the-job accident or injury. Failure to submit to screening or failure to reasonably cooperate with screening tests will result in termination of employment. Positive test results may result in discipline, up to and including termination of employment. Changes No implied, oral, or written agreement contrary to the express language of this Agreement are valid unless they are in writing and signed by the Chief Executive Officer of Prime Science Therapy, Inc. No supervisor or representative of Prime Science Therapy, Inc., other than the Chief Executive Officer, has any authority to make any agreements contrary to this agreement for at-will employment. This agreement takes the place of all prior and contemporaneous agreements, representations, and understandings between employee and Prime Science Therapy, Inc. Employee Non-Compete Agreement For good and valuable consideration the receipt of which is hereby acknowledged, the employee, hereby agrees not to directly or indirectly compete with the business of Prime Science Therapy, Inc. and its successors and assigns during the period of employment and for a period of 3 years following termination of employment and notwithstanding the cause or reason for termination.

Initial_______ Date _______


Phone 415-761-0813 | Fax 925-956-7181

Employment Agreement

Employee shall not own, manage, or operate a business substantially similar to or competitive with, present business of Prime Science Therapy, Inc. or such other business activity in which Prime Science Therapy, Inc. may substantially engage during the term of employment. Employee acknowledges that Prime Science Therapy, Inc. may, in reliance of this agreement, provide Employee access to business information of clients and other confidential data and good will. Employee agrees to retain said information as confidential and not use said information on his or her own behalf or disclose same to any third party. This non-compete agreement shall extend for a radius of 100 miles of Prime Science Therapy, Inc.’s present location and shall be in full force and effect for 3 years, commencing with the date of employment termination. Confidentiality Employee recognizes that Prime Science Therapy, Inc. has and will have information regarding business information which is valuable, special and unique assets of Prime Science Therapy, Inc. Employee agrees that Employee will not at any time or in any manner, either directly or indirectly, divulge, disclose, or communicate any information to any third party without prior written consent of Prime Science Therapy, Inc. Employee will protect the information and treat it as strictly confidential. A violation by Employee of this paragraph shall be a material violation of this agreement and will justify legal and/or equitable relief. Recommendations for Improving Operations Employee shall provide Prime Science Therapy, Inc. with all information, suggestions, and recommendations regarding Prime Science Therapy, Inc.’s business, of which Employee has knowledge, which will be of benefit to Prime Science Therapy, Inc.

Accurate Information I represent that all information I provided on any forums or other documents filled out in connection with my employment, and all information provided in any interview, is complete, true and correct. I have withheld nothing that would, if disclosed, affect my employment relationship unfavorably or might lead a reasonable employer to make further inquiry or to decide against hiring. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed.

I understand that it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete the Form I-9. If you have any questions regarding this statement, please call Prime Science Therapy, Inc. at 415-761-0813 before signing. By signing, you acknowledge that you have read and understood this agreement. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEEMENT AND AGREEMENT ____________________________________________________________________________________ SIGNATURE OF EMPLOYEE DATE SS#



Payroll Election Form

I am electing to be paid (check one): _______ An Independent Contractor/Consultant under 1099 form provided at the end of the year period

_______ An Employee / under a W-2 form provided at the end of the year period

Employee Information: Name: __________________________________________________

Address: __________________________________________________

__________________________________________________

Social Security Number: _________________________________

Date of Hire: _____________________ Date of Birth: ___________________

Employee’s Signature: _________________________ Date: ________________

This election must be made in writing using this form at least one week prior to the first day of work for the school year to which this election applies (e.g. prior to the first day on which the employee must report to Human Resources day of work for the year). The election, once made, is irrevocable for that year. Late submissions cannot and will not be accepted in order to comply with IRS Code 409(A).



Wage Deduction Authorization Agreement I understand and agree that my employer, Prime Science Therapy, Inc., may deduct money from my pay from time to time for reasons that fall into the following categories:

1. my share of the premium contributions to any Company benefits program; 2. any contributions I may make into a retirement or pension plan sponsored, controlled, or

managed by the Company; 3. installment payments on loans or wage advances given to me by the Company, and if there is a

balance remaining when I leave the Company, the balance of such loans or advances; 4. if I receive an overpayment of wages for any reason, repayment to the Company of such

overpayments (the deduction for such a repayment will equal the entire amount of the overpayment, unless the Company and I agree in writing to a series of smaller deductions in specified amounts);

5. the cost of repairing and replacing any Company supplies, materials, equipment, money, or other property that I may damage (other than normal wear and tear), lose, fail to return, or take without appropriate authorization from the Company during my employment (except in the case of misappropriation of money by me, I understand that no such deduction will take my pay below minimum wage, or, if I am a salaried exempt employee, reduce my salary below its predetermined amount);

6. if I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separate from the Company before accruing time to cover such advance leave, the value of such leave taken in advance that is not so covered;

7. the value of any time off for absences to which paid leave is not applied (non-exempt salaried employees will have all such unpaid leave deducted from their salary, while exempt salaried employees will experience salary reductions only in units of a full day or week at a time, depending upon the exact nature of the absence, unless partial-day deductions are specifically allowed under federal law); and

8. if my employer pays any insurance premiums or retirement system contributions (“payments”) on my behalf that I would normally make under the applicable Company benefit plan, the amount of such payments made by the Company, such payments being an advance of future wages payable to me.

I agree that the Company may deduct money from my pay under the above circumstances, or if any of the above situations occur. I further understand that the Company has stated its intention to abide by all applicable federal and state wage and hour laws and that if I believe that any such law has not been followed, I have the right to file a wage claim with appropriate applicable state and federal agencies. _________________________ ____________ Signature Date _________________________ Employee’s Name - Printed _________________________ ____________ Company Representative Date



Direct Deposit Authorization Form

PLEASE ATTACH YOUR

VOIDED CHECK HERE

Please PRINT and complete ALL the information below.

Employee Information Name: __________________________________________

Address: __________________________________________

City, State, Zip Code: __________________________________________

Bank Information

Name of Bank: ______________________________________________________

Account #: ______________________________________________________

9-Digit Routing #: ______________________________________________________

Amount: $ _____________ ____________% or Entire Paycheck

Amount: Checking Savings (Check One)

Prime Science Therapy, Inc. is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

Employee’s Signature: _________________________________________

Date: _________________________________________



No Physical Limitations Affidavit I, ___________________________________ (Employee Name) have not sustained any injuries nor

have any limitations that would prevent me from successfully completing an assignment with Prime

Science Therapy, Inc. (Company) starting ____________________ (date).

_______________________________________ ___________________________ Employee Signature Date

Acknowledgement of Entitlement to Rest & Meal Periods All employees who work more than 3.5 hours are entitled to, and should be scheduled for, a rest period (break) as close to the middle of every 4 hour work period (or major fraction thereof) as is operationally possible. This rest period must be at least 10 minutes, but no more than 15 minutes in length. All employees who work more than 5 hours are entitled to, and should be scheduled for, a 30 minute uninterrupted meal period. I understand and acknowledge that in the event I am unable to take my breaks and/or meal period due to business necessity, I must notify my supervisor immediately. My supervisor will ask me to complete and sign a letter/note explaining the reason(s) for my missed break(s) and/or meal period. The intent of a rest period is to provide time away from work to make personal phone calls, take restroom breaks, use vending machines and/or any other time that is not deemed work time. I also understand and acknowledge it is my responsibility to maintain my own time record and each pay period attesting the hours worked and paid are true and correct. Violation of this Company policy and state law, will result in written disciplinary action up to and including termination. _______________________________________ Print Employee Name _______________________________________ ___________________________ Employee Signature Date



Hepatitis B Vaccination OSHA requires that all health care workers get the opportunity to have the Hepatitis B vaccination offered to them by their employer. Please check the box next to one of the following statements that best applies to you and your decision regarding the Hepatitis B vaccine. ________ I understand the OSHA guidelines and I still need # __________ or booster in the series. I will make arrangements with AMPS to receive this dose of the vaccine series. ________ I understand the OSHA guidelines and I decline because I have already completed the Hepatitis B Vaccination Series. **(If you select this option you are required to submit proof of your vaccination records or a positive titer) ________ I understand the OSHA guidelines and I have declined. I am not interested in having the Hepatitis B vaccination series. __________________________________________ ___________________________ Employee Signature Date

Varicella (Chickenpox) History In following the CDC Guidelines, health care workers are required to have either a reliable history of Varicella, two vaccines 4-8 weeks apart or an existing titer showing immunity. Please indicate below what is applicable in your case: ________ I have had (Chickenpox) Varicella disease as a child ________ I have had the Varicella Vaccines (please attach/fax records for proof) ________ I have had Positive Varicella Titers (please attach/fax records for proof) __________________________________________ ___________________________ Employee Signature Date



Health Statement – Physical Record

____________________________________________ ____________________________ Name of MD, NP or PA Date

____________________________________________ ____________________________ Name of Patient (Please Print!!) Job Title ____________________________________________ ____________________________ Signature of Patient / Social Security # Phone #

Fit to Work/No Restrictions No Communicable Diseases Restrictions – see comments section below

I examined the individual named above, and to the best of my knowledge, he/she is physically and medically qualified to perform the essential functions of the above referenced means of employment and has no health condition, including any communicable diseases, which would create a direct threat to patients. Comments: Office Address:

Office Tele #: ______________________________________ ____________________________ Signature of MD, NP or PA Date



Name: _______________________________________________________

Please Print Clearly TB Step One

Address: Date Placed: __________________ Signature: ____________________

Time Placed: __________________ AM/PM

(circle one) Address:

Date Read: __________________ Signature: ____________________

Time Read: __________________ AM / PM

(circle one)

Results: ______________ mm Negative Positive (circle one) **Note: If a two-step is required, the 2nd test cannot be placed any sooner than 8 days after the first read date** TB Step Two

Address: Date Placed: __________________ Signature: ____________________

Time Placed: __________________ AM/PM

(circle one) Address:

Date Read: __________________ Signature: ____________________

Time Read: __________________ AM / PM

(circle one)

Results: ______________ mm Negative Positive (circle one) **For any positive results, please send a copy of your most recent chest X-ray and complete the information below. Positive Tuberculosis History Exam Results: Office Address: Chest X-ray Date: __________________ Doctor’s Signature: ____________________________ Have you experienced any of the following? 1. Chronic (recurring) cough? Yes No 5. Unexplained weight loss? Yes No 2. Unexplained recent fevers? Yes No 6. Unexplained chronic fatigue? Yes No 3. Current Night Sweats? Yes No 7. Been advised that you are Yes No 4. Coughed or spit up blood? Yes No immunosuppressed for any reason?

The above statements and answ ers are true to the best of my know ledge.

Employee Signature: _____________________________ Date: _______________________

Tuberculosis Test Record



HIPAA OVERVIEW WHAT IS HIPAA?

• The Health Insurance Portability and Accountability Act (HIPAA) enacted by Congress in 1996. • A Federal law that protects patient’s health coverage and information • Regulations promulgated by the Department of Health and Human Services • Guidelines implemented in April, 2003 • Goal: improve the efficiency and effectiveness of the nation’s health care system by encouraging

the widespread and secure of electronic data interchange in health care. TITLE I of HIPAA

• Protects and provides ability to carry health insurance coverage for workers and their families when they change or lose their jobs

• Limits restrictions that a group health plan can place on benefits for pre-existing conditions • Prohibits health plans from creating eligibility rules, assessing premiums for individuals in the plan

based on health status, medical history, genetic information or disability Title II of HIPAA

• Known as the Administrative Simplification (AS) provisions, established national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers

• Defines numerous offenses relating to health care and sets civil and criminal penalties for infractions

• The most significant provisions for providers are the Administrative Simplification rules. These rules apply to “covered entities” including health plans, health care clearing house such as billing services and community health information systems, and health care providers that transmit data in any way regulated by HIPAA

What information must you protect?

• Information you create or receive in the course of providing treatment or obtaining payment for services or while engaged in teaching and research activities, including

o Information related to the past, present, or future and/or mental health or condition of an individual

o Information in ANY medium whether spoken, written or electronically stored including videos, photographs and x-rays.

• This information is called PROTECTED HEALTH INFORMATION (PHI) Title II of HIPAA The Department of Health and Human Services has established five rules within the Administration Simplification provisions

• The Privacy Rule • The Security Rule • The Unique Identifiers Rule • The Transactions & Code Sets Rule • The Enforcement Rule



The Privacy Rule • Establishes regulations for the use and disclosure of Protected Health Information (PHI) • PHI is ANY information about health status, provision of health care or payment for health care

that can be linked to an individual whether paper or electronic. • Requires covered entities to:

o Notify individuals of use of their PHI o Document privacy policies and procedures o Train all members of their workforce in procedures regarding PHI o Establishes regulations for the use and disclosure of Protected Health Information (PHI) o PHI is ANY information about health status, provision of health care or payment for health

care that can be linked to an individual Notice of Privacy Practices This form describes how a facility may use and disclose the patient/resident’s PHI and advises the patient of his/her privacy rights

• Most facilities will attempt to obtain a signature acknowledging receipt of the Notice, if patient/resident refuses then the reason must to be documented

HIPAA Requirements for Authorization:

• Describe the PHI to be released • Identify who may release the PHI • Identify who may receive the PHI • Describe the purpose of the disclosure • Identify when the Authorization expires • Be signed by the patient/patient representative

Patient Specific Rights

• The right to request restriction of PHI uses and disclosures • The right to request confidential forms of communications • The right to access and receive a copy of one’s own PHI • The right to an accounting of the disclosures of PHI • The right to request amendments to the medical record

Incidental uses and disclosures of PHI “Incidental” means a use or disclosure that cannot reasonably be prevented, is limited in nature and occurs as a by-product if an otherwise permitted use or disclosure. **Incidental uses and disclosures are permitted, so long as reasonable safeguards are used to protect PHI and minimum necessary standards are applied. The Security Rule Complements the Privacy Rule but deals specifically with Electronic Protected Health Information (EPHI) Identifies three types of security safeguards required for compliance:

• Administrative Safeguards – Policies and procedures designed to clearly show how the entity will comply with the act



• Physical Safeguards – Controlling physical access to protect against inappropriate access to protected data

• Technical Safeguards – Controlling access and security to computer systems containing PHI The Five Rules of Title II The Unique Identifiers Rule – Covered entities, particularly third party payers, are assigned a National Provider Identifier (NPI) alphanumeric code for use in all electronic transactions The Transactions and Code Sets Rule – Applies a unique code to health care claim and billing information, particularly for retail pharmacy chains. The Enforcement Rule

• Oversight of all HIPAA Rules falls under the Department of Health and Human Services (HHS) • Within HHS the responsibility of enforcement of the Privacy Rule by the Office of Civil Rights

(OCR) Protecting Your Patient’s PHI When preparing care plans or other course required documents take extra care to:

• Identify the patient/client by initials only • Use other demographic data only to the extent necessary to identify the patient and his/her

needs to the instructor • Protect the computer screen, PDA, clipboard, or notes from other individuals who do not have a

‘need to know’ • Protect your printer output from other who do not have a ‘need to know’

HIPAA FINES & PENALTIES

• HIPAA penalties can be Civil and/or Criminal • Under "General Penalty for Failure to Comply with Requirements and Standards, “The Secretary

can impose fines for noncompliance as high as $100 per offense, with a maximum of $25,000 per year on any person who violates a provision of this part

• A person who knowingly uses or causes to be used a unique health identifier; obtains individually identifiable health information relating to an individual; or discloses individually identifiable health information to another person shall be fined not more than $50,000, imprisoned not more than 1 year, or both

• If the offense is committed with intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm, be fined not more than $250,000, imprisoned not more than 10 years, or both

HIPAA Do’s & Don’t

• Treat all patient information as if you were the patient. Do not be careless or negligent with PHI in any form, whether spoken, written or electronically stored.

• Shred or properly dispose of all documents containing PHI that are not a part of the official medical record. Don not take the medical record off facility.

• Use secure networks for e-mails with PHI and add a confidentiality disclaimer to the footer of such e-mails.

• Set a protocol to provide for confidential sending and receipts of faxes that contain PHI and other confidential information.

• Discuss PHI in secure environments or in a low voice so that others do not overhear.


Phone 415-761-0813 | Fax 925-956-7181

HIPPA Compliance Pledge o I understand that I require information to perform my duties at a hospital or healthcare facility.

This information may include, but is not limited to, information on patients, employees, students, other workforce members, donors, research, and financial business operations. Some of this information made confidential by law (such as “protected health information” or “PHI” under the federal Health Insurance Portability and Accountability Act) or by hospital policies. Confidential information may be in any form, e.g., written, electronic, oral overheard or observed. Access to all confidential information is granted on a need to know basis. A need to know basis is defined as information access that is required in order to perform my work.

o I will not disclose confidential information to patients, friends, relatives, co-workers or anyone else except as permitted by hospital policies and applicable law and as required to perform my work as a consultant, contractor, subcontractor, employee or vendor for hospital.

o I will protect the confidentiality of all confidential information, including PHI, while at a

healthcare setting and after I leave healthcare setting. All confidential information remains the property of healthcare setting and may not be removed or kept by me when I leave healthcare setting except as permitted by healthcare setting policies or specific agreements or arrangements applicable to my work as a consultant, contractor, subcontractor, employee or vendor for hospital.



HIPAA Overview

I have read and understand the information provided by Prime Science Therapy, Inc. on HIPAA Overview. ______________________________________ ________________________________________ Employee Signature Date

PSTI Handbook Receipt of Acknowledgement

I have read and understand the information I was given regarding Prime Science Therapy, Inc.’s policies and procedures. ______________________________________ ________________________________________ Employee Signature Date

