section 1 personnel folder content part one · current cpr card social security card proof of...

SECTION1

PERSONNELFOLDERCONTENT

PARTONE

EMPLOYMENTCHECKLISTRESUME

APPLICATIONJOBDESCRIPTION

LICENSEVERIFICATIONEMPLOYMENTVERIFICATIONCRIMINALHISTORYCHECK

NURSEAIDEREGISTRY&MISCONDUCTREGISTRYPERSONNELEVALUATIONS

PARTTWO

(ADDITIONALPERSONNELDOCUMENTS)

PARTTHREE

DISCIPLINARYDOCUMENTS

SECTION2


TEXASDRIVER’SLICENSE/IDRNLICENSE

CANCERTIFICATION/HHA/CNACARDCURRENTCPRCARD

SOCIALSECURITYCARDPROOFOFAUTOMOBILEINSURANCE

SECTION3


PARTONE

W-4FORMI-9FORM

PERFORMANCEEVALUATIONSSKILLEDNURSEEXAMS

COMPETENCYEVALUATIONSCNAEXAM

NEWHIREREPORTING

PARTTWO

ORIENTATIONSINSERVICES/MEMOS

CERTFICATEOFEDUCATIONHOURS

SECTION4


AuthorizedPersonnelOnly

TB/CHESTX-RAYAIDS/HEPDOCUMENTS

ALLADDITIONALMEDICALRECORDS

INFUSIONXPERTSPLLCApplicationforEmployment

ApplicantName: DateofBirth: PresentAddress: Phone: SocialSecurityNumber: _______ Areyouatleast18yrsold?□Yes□No PositionApplyingFor: ____________□FullTime□PartTime□PerVisit□PoolShift:□Day□Night□Evening□Weekends SalaryRequirements: DateAvailable: ____ IfyouarenotaUSCitizenhaveyouthelegalrighttoremainpermanentlyintheUS?□Yes□No Doyouhaveadequatemeansoftransportationtogettoworkontimeeachdayandwhencalledinonshortnoticeduringnormalworkinghours?□Yes□No Haveyoubeenconvictedofacrime(excludingmisdemeanorsandtrafficoffenses)and/orreleasedfromconfinementfollowingaconvictionforanycriminaloffensewithinthepast7years?□Yes□NoIfYes,pleasegivedate,placeandnatureofeachsuchconviction.______________________________________________________________________________________________________________________________________Areyoupresentlychargedwithanyviolationofthelawotherthantrafficviolation?□Yes□NoIfYespleasegivedate,placeandnatureofeachsuchconviction._______________________________________________________________________________________________________________________________________

EducationalHistoryTypeofSchool NameandLocationofSchool CircleLast

YearAttendedGraduated Degree

HighSchool 9101112 College 1234 Other From:

To:

Listprofessionallicensesyoupossess.Indicatetypeoflicense,numberandstate ______Listanymembershipinprofessionalorganizations,honorsoractivitieswhichyoufeelwouldenhanceyourapplication,excludingthosethatwouldindicaterace,color,religion,sex,nationaloriginordisability. ______ListlanguagesspokenotherthanEngslish: Listotherskillsapplicabletothepositionforwhichyouareapplying,includingcomputerexperience,typing__speed,etc: Incaseofanemergencynotify: Phone: ______

Itisthisfacility’spolicytoprovideequalemploymentopportunitieswithoutregardtorace,color,religion,sex,nationalorigin,ageordisability.

Name:_ _____

WorkHistory

CompanyName

CompleteAddress PhoneNumber Supervisor’sName

DateStarted:DateLeft:

TypeofBusiness:Salary:□FT□PT□PerVisit

ReasonforLeaving: OktoContactSupervisor?□Yes□No

Describeyourjobtitle,responsibilities,andaccomplishments.CompanyName















Describeyourjobtitle,responsibilities,andaccomplishments.

Attachanadditionalsheetlistingotherworkexperiencepertinenttothepositionforwhichyouareapplyingifthespacebellowisinsufficient.

Name:

PersonalReferencesName Phone Relationship

1. 2. Pleasereviewandsign

Inmakingapplicationforemployment:

• Icertifythattheinformationinthisapplicationistrueandcompleteforallpracticalpurposes.Itmaybeverifiedby the facilityor anyaffiliate. Shouldapositionbeofferedand later it is found that theinformation is significantly untrue, incomplete, ormisrepresented, I understand and agree that thefacility or its affiliates are relieved of all commitments, financial or otherwise pertinent toemployment,andthatIamsubjecttoimmediatedischargewithoutrecourse.

• Iunderstandthataninvestigativereportmaybemadebyaconsumerreportingagencytoincludeastomy character, general reputation, personal characteristics, and mode of living, whichever may beapplicable. If such an investigative report ismade, I understand that I will receive notice that suchreporthasbeenrequested,andthatIwillhavetherighttomakeawrittenrequestforacompleteandaccuratedisclosureofadditionalinformationconcerningthenatureandscopeoftheinvestigation.

• IunderstandandagreethatIamofferedemploymentwillbefornodefinitetermandthateitherI,orthefacilitywillhavetherighttoterminatetheemploymentrelationshipatanytime,withorwithoutcause,andspecificastoallmaterialtermsandissignedbymeandtheAdministratorofthefacility.

• Iunderstand,ifIamanunlicensedpersonwhohasdirectpatientcontact,thattheagencywillperformacriminalhistorycheckperStateRegulations.

Release:Iherebyauthorizeanyprioremployerstoprovidesuchinformationconcerningmyemploymentwith them as may be requested, and also authorize the Registrar/placement Office of all educationalinstitutionsattendedtoreleaseanofficialcopyofmytranscriptand,ifavailable,facultyappraisals.Ialsoauthorizeanyappropriatelicensingboardtoreleasefullinformationconcerningmylicensestatusandmylicensehistory.

ApplicantSignature: Date:

FOR OFFICEUSEONLY

□Interview(s) □ ReferencesChecked

IfHired:Position:Salary:StartDate:□FT□PT□PerVisit

Pre-EmploymentInterview:

DPSComputerizedCriminalHistory(CCH)Verification(AGENCYCOPY)

I,_________________________________________,havebeennotifiedthataComputerizedCriminalHistory(CCH)verificationcheckwillbeperformedbyaccessingtheTexasDepartmentofPublicSafetySecureWebsiteandwillbebasedonnameandDOBinformationIsupply.

Because the name based information is not an exact search and only fingerprint record searchesrepresent true identification to criminal history, the organization (as listed below) conducting the criminalhistorycheckisnotallowedtodiscussanyinformationobtainedusingthismethod,thereforetheagencymayoffertheopportunitytohaveafingerprintsearchperformedtoclearanymisidentificationbasedonthenamesearch,ifthesearchprovidesacriminalreportIknowcouldnotbemine.

ForthefingerprintingprocessIwillberequiredtosubmitafullandcompletesetofmyfingerprintsforanalysis throughtheTexasDepartmentofPublicSafetyAFIS (automatedfingerprint identificationsystem). Ihavebeenmadeawarethat inorder tocompletethisprocess Imusthavethecorrect fingerprinting (FAST)formfromthisagency,makeanonlineappointment,submitafullandcompletesetofmyfingerprintsandpayafeeof$9.95tothefingerprintingservicescompany,L1EnrollmentServices.

Once this process is completed and the agency receives the date fromDPS, the information onmyfingerprintcriminalhistoryrecordmaybediscussedwithme.

(Thiscopymustremainonfilebyyouragency.RequiredforfutureDPSAudits.)

SignatureofApplicantorEmployee

__________________________________________Date

__________________________________________AgencyName(Pleaseprint)

__________________________________________AgencyRepresentativeName(Pleaseprint)

__________________________________________ SignatureofAgencyRepresentative

__________________________________________ Date

Please:CheckandInitialeachApplicableSpace

CCHReportPrinted:

YES_____NO_____ ______initial

PurposeofCCH:______________________________

Hire________NotHired______ ______initial

DatePrinted:_______________ ______initial

DestroyedDate:____________ ______initial

Retaininyourfiles

INFUSIONXPERTSPLLCStatementofEmployability

Byexecutionof thisdocument, I_______________________________________,herebyacknowledgethat IhavebeeninformedbyINFUSIONXPERTSPLLCthatacriminalhistorycheckwillbeperformedonmyname.Ihaveinformedthisagencyofallnames(i.e.maidennamealiases)thatIhaveusedinthepast.IunderstandthatIhavebeenemployedonanemergencybasisandthatmyemploymentistemporaryorinterimpendingtheresultsofthecriminalhistorycheck.I hereby profess that I have not been convicted of any of the following crimes which are a permanentautomaticbartoemploymentbythisagency:

• AnoffenseunderSection19,PenalCode(criminalhomicide);• AnoffenseunderSection20,PenalCode(kidnappingandfalseimprisonment);• AnoffenseunderSection21.08,PenalCode(indecentexposure);• AnoffenseunderSection21.11,PenalCode(indecencywithachild);• AnoffenseunderSection21.12,PenalCode(improperrelationshipbetweeneducatorandstudent);• AnoffenseunderSection21.15,PenalCode(improperphotographyorvisualrecording);• AnoffenseunderSection22.011,PenalCode(sexualassault);• AnoffenseunderSection22.02,PenalCode(aggravatedassault);• AnoffenseunderSection22.021,PenalCode(aggravatedsexualassault);• AnoffenseunderSection22.04,PenalCode(injurytoachild,elderlyindividualordisabledindividual);• AnoffenseunderSection22.041,PenalCode(abandoningorendangeringachild);• AnoffenseunderSection22.05,PenalCode(deadlyconduct);• AnoffenseunderSection22.07,PenalCode(terroristicthreat);• AnoffenseunderSection22.08,PenalCode(aidingsuicide);• AnoffenseunderSection25.031,PenalCode(agreementtoabductfromcustody);• AnoffenseunderSection25.08,PenalCode(saleorpurchaseofachild);• AnoffenseunderSection28.02,PenalCode(arson);• AnoffenseunderSection29.02,PenalCode(robbery);• AnoffenseunderSection29.03,PenalCode(aggravatedrobbery);• AnoffenseunderSection33.021,PenalCode(onlinesolicitationofaminor);• AnoffenseunderSection34.02,PenalCode(moneylaundering);and• AnoffenseunderSection35A.02,PenalCode(Medicaidfraud);and• AnoffenseunderSection42.09,PenalCode(crueltytoanimals);or• Aconvictionunderthe lawsofanotherstate, federal law,orUniformCodeofMilitary Justice foran

offense containing the elements that are substantially similar to the elements of an offense listedabove.

IalsoprofessthatIhavenotbeenconvictedofanyofthefollowingcrimeswithinthepast5years(applicableonlythosehiredonorafterSeptember1,2007unlessotherwisenoted):

• AnoffenseunderSection22.01,PenalCode(assaultpunishableasaClassAMisdemeanororfelony)[applicabletothosehiredonorafterSeptember1,2003];

• An offense under Section 30.02, Penal Code (burglary) [ applicable to those hired on or afterSeptember1,2003];

FormP-10

• AnoffenseunderChapter31,PenalCode(theftpunishableasafelony)[applicabletothosehiredonorafterSeptember1,2001]

• An offense under Section 32.45, Penal code (misapplication of fiduciary property or property of afinancial institutionpunishableasaClassAMisdemeanororfelony)[applicabletothosehiredonorafterSeptember1,2003]

• An offense under Section 32.46, Penal Code (securing execution of a document by deceptionpunishableasaClassAmisdemeanoror felony) [applicable to thosehiredonorafterSeptember1,2003];

• AnoffenseunderSection37.12,PenalCode(falseidentificationaspeaceofficer);or• AnoffenseunderSection42.01(a)(7),(8),or(9),PenalCode(disorderlyconduct).

I understand that Ihavebeenplacedondeferredadjudicationcommunity supervision foranoffense listedabove, successfully completed the period of deferred adjudication community supervision, and received adismissal and discharge according to Section 5 (c), Article 42.12, Code of Criminal Procedure, I am notconsideredconvictedoftheoffense.IacknowledgethatifIamfoundtohavebeenconvictedofanyotheroffense(s),thattheseoffensesmayalsobarmyemployment.I understand that all information obtained by this agency regarding any criminal history will remainconfidential.Icertifythattheinformationonthisformcontainsnowillfulmisrepresentationandthattheinformationgivenistrueandcompletetothebestofmyknowledge._________________________________________SignatureofApplicant_________________________________________PrintedName_________________________________________Date

INFUSIONXPERTSPLLC

STAFFEVALUATION

StaffPerson’sName:______________________________________DateofEvaluation:__________________

□Annual□3Month□6Month□Probation□Other:________________

Strengths: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________GrowthAreas:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CommentsonClientCare:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CommentsonDocumentation: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CommentsonClinicalSkills:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CommentsonInfectionControl,Safety:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________GeneralComments/Recommendations:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Evaluator:________________________________________________Date:____________________________

INFUSIONXPERTSPLLCSUBJECT:SECURITYINSPECTIONSANDPOSSESSIONOFPROHIBITEDARTICLES NUMBER:330POLICYSTATEMENT

Ø INFUSIONXPERTSPLLCwishestomaintainaworkenvironmentfreeofillegaldrugs,alcohol,firearms,weapons,explosives,orother impropermaterials.To thisend, INFUSIONXPERTSPLLCprohibits thepossession,transfer,sale,oruseofsuchmaterialsonitspremises.INFUSIONXPERTSPLLCrequiresthecooperationofallemployeesinadministratingthispolicy.

Ø Desksandotherstorageareasmaybeprovidedfortheconvenienceofemployees,butremainthesolepropertyofINFUSIONXPERTSPLLC.Accordingly,they,aswellascontainersorarticlesfoundinthem,canbeinspectedbyanyrepresentativeofINFUSIONXPERTSPLLCatanytime,eitherwithorwithoutpriornotice.Containersaresubjecttosearchwhetherornottheyarelocked.

Ø Additionally, employeesmaybe asked to submit to a searchof any vehiclebroughtonto INFUSIONXPERTSPLLCorINFUSIONXPERTSPLLCclients’premises.

Ø AnyemployeewhowishestoavoidinspectionsofanyarticlesormaterialsshouldnotbringsuchitemsontoINFUSIONXPERTSPLLCorINFUSIONXPERTSPLLCclients’premises.

Ø Refusal to consent to a search or inspection will result in disciplinary action, up to and includingdischarge.Thepossession,transfer,sale,oruseoftheaforementionedprohibitedmaterials,assetoutinthispolicywillalsoresultindisciplinaryaction,uptoandincludingdischarge.

PURPOSE:

Ø Toprovideasafeworkingenvironmentforemployees.PROCEDURE:

Ø Uponhiring,thenewemployeewillbeinformedofthepolicyandgivenacopyofthepolicy.Ø The disciplinary procedure will be utilized for any violations of the policy. Suspension without pay

and/orimmediateterminationmaybeutilized.

______________________________________________ ________________________________NameofEmployee Date______________________________________________SignatureofEmployee

INFUSIONXPERTSPLLCANEQUALOPPORTUNITYEMPLOYER

ItisthepolicyofINFUSIONXPERTSPLLCtoprovideemploymentopportunitieswithoutregardtorace,religion,sex,nationalorigin,age,handicap,orveteranstatus.

PROFILEName:____________________________________________________________________________________Address:__________________________________________________________________________________Phone:____________________________________ Fax:______________________________________Mobile:___________________________________ Alt#:_____________________________________

ALTERNATECONTACTINFORMATIONName:____________________________________________________________________________________Address:__________________________________________________________________________________Phone:____________________________________ Fax:______________________________________Mobile:___________________________________ Alt#:_____________________________________

EMPLOYEESORIENTATION Initial DateMISSIONSTATEMENT,PHILOSOPHY,OBJECTIVE _____ _____WELCOMELETTER _____ _____ CERTIFICATION&CONTRACTAGREEMENT _____ _____BUSINESSCARDS _____ _____COMPANYHANDBOOK _____ _____RULESOFCONDUCT _____ _____CONFIDENTIALITYAGREEMENT _____ _____SCOPEOFSERVICES _____ _____COMMUNICATIONW/CLIENTPOLICY _____ _____NON-COMPETEPOLICY _____ _____SUBSTANCEABUSEPOLICY _____ _____

FormP-1

ABUSENEGLECT&EXPLOITATIONACKNOWLEDGEMENT

I,________________________________,acknowledgereadingandunderstandingthepolicyandprocedureofINFUSIONXPERTSPLLC,regardingAbuse,Neglect,andExploitationandagreetocomplywithandbeboundby,thepolicy.INVOLUNTARYTERMINATIONPOLICYPOLICY:AllterminationwillbedonebytheAdministrationbasedonrecommendationsfromsupervisor.PURPOSE:TomaintaincompliancewithagencypoliciesPROCEDURE:

1) Disciplinarypolicymustbefollowed2) Allviolatorsandreprimandswithemployeemustbedocumentedinemployeefile.3) EmployeefileanddocumentationmustbesubmittedtotheAdministrator.4) AttachmentmustbecompletedandsubmittedtotheAdministrator.

SUBSTANCEANDABUSEPOLICYNOTIFICATIONPOLICY:INFUSIONXPERTSPLLCdoesnotdrugtestitsemployees:however,theagencyprohibitsemployeestopossess,distributeand/orusealcoholicbeveragesorcontrolledsubstances,includinginhalantswhileonpremisesofpropertycontrolledbyINFUSIONXPERTSPLLC,orwhileinthecourseofconductingcompanybusinessorengagedinanycompanysponsoredactivity.Further,itshallbeprohibitedforanyclientorvisitortopossess,distributeand/oralcoholicbeveragesorcontrolledsubstanceswhileonthepremisesofthepropertycontrolledbyINFUSIONXPERTSPLLC.PROCEDURE:Anyemployeewhohasknowledgeofpersonviolatingthepolicymustreportittohis/hersupervisorimmediately.Basedonreasonablecause,thecompanymayconductsearchesorinspectionsofanemployeepersonorpersonaleffect.TheSubstanceUseandAbusePolicyandProcedureabovehasbeenpresentedandexplainedtome.IherebyacknowledgethatI,_________________________________(printemployee’sname)understandandagreetocomplywiththeSubstanceUseandAbusePolicy.

SAFETYPOLICYI,__________________________________________,havesuccessfully&thoroughlyreadtheDepartmentSafetyManualand/orgeneralinformationonsafety.IamawarethatINFUSIONXPERTSPLLC,policyrequiresannualretainingonallnewpolicies/revisionsrelatedtotheDepartmentSafetyManual.________________________________________ ________________________EmployeeSignature Date________________________________________ ________________________Orientation/SafetyCoordinatorSignature Date

FormP-1

GROUNDSFORIMMEDIATETERMINATION

1) Forgeryorfalsificationofanydocument(i.e.,license,healthcard,charting,etc.)2) Workingundertheinfluenceofdrugsandalcohol.3) Forgeryoftimesheets.4) ViolationofCodeofEthics.5) Theftorpropertyfrompatient,co-worker,orcompany6) Unsatisfactoryjobperformance.7) Neglectofperson(client)propertyorinjuryofpatient.8) Acceptingmoney.9) Disclosinganyinformationconcerningapatientcondition,treatment,personalaffairs,orrecordsto

anyoneotherthanauthorizedusers.10) Carryingaweapon.11) Abuseofservicetimeorproperty.12) Insubordination13) Arrestorconvictionoffelony,drugpossession14) Misrepresentationoftheservice15) Discussionoffellowemployeeswithpossession.16) Failuretosatisfypoorjobperformancewithinreasonabletimeframe.17) Malpractice18) Performanceoutsideofjobdescription19) Solicitationofemploymenttopatientsbyemployee.

Thislistisnotall-inclusive,INFUSIONXPERTSPLLC,reservestherightofimmediatedismissalforanyreasonablecause.

EMPLOYEEPOLICIESANDPROCEDURES

Iunderstandthatcopiesofpolicyandproceduresmanualsareavailableandthatitismyresponsibilitytoread,andunderstandandconformtoallapplicableAgencypoliciesincludingpersonnelpolicies.Itisalsomyresponsibilitytocomplywithperiodicchangesandrevisions.IhavereadtheAgency’sPolicyandProcedureandAbuse,Neglect,andExploitationandagreetocomplywithandbeboundbythePolicy.IunderstandthatinformationcontainedinanyAgencymanualdoesnotconstituteacontractualrelationshipbetweentheAgencyanditsemployees,norisitanexpressionofmytermofemployment.IaffirmthatIhaveautoinsurancecoverageasrequiredbythisstateandtheAgencyandIagreetokeepitfullyinforceofanyvehicleIusefortheconductionofAgencybusinessduringthetermofmyemployment.TheagencyhastherighttorequestproofofinsuranceatanytimeduringthetermofemploymentandthatIamrequiredtofollowallAgencyrequirementsandStateandlocallaws.IunderstandthatonlytheAgencyhastheauthoritytoadmitclientsandwillsupervisewithappropriatepersonnelallservicesprovided.Asacaregiver,Iwillcarryouttheplanoftreatment,submittime-sheets,clinicalandprogressnotesasappropriateand,ataminimum,onaweeklybasis,Iwillparticipateindevelopingandreviewingplansofcare,periodicclientevaluationsandcareconferences,dischargeplanningandschedulecoordination.IwillprovideserviceswithinthegeographicareacoveredbytheAgency.Iwillattendrequiredstaffmeetingsandin-servicetraining.HomeHealthAidesarerequiredtohave12hoursofin-servicetrainingannually.

FormP-1

IunderstandthatImustsubmitdocumentationofservicesperformedpriortopaymentforthoseservicesandthatpayrollproceduresrequiretimelyandaccuratecompletionofdocumentationthatmustbesubmittedpriortopaymentforservicesprovided.Iunderstandthatallinformation,bothwrittenandverbal,regardingclientandemployeehealthconditionsisstrictlyconfidentialandprotectedunderfederalandstatelaw.Thepresenceofacommunicableorvenerealdisease;testing,resultsorknowninfectionbyHIV,Hepatitis,Tuberculosis,informationconcerningchildabuse,mentalhealth,drugoralcoholabuseisprotectedunderlaw.Allinformationinconnectionwiththeexamination,careorprovisionofservicestoanyclientwillnotbedisclosedwithouttheindividualswrittenconsentexceptasmaybenecessarytoprovideservicesasrequiredbylaw.Informationmaybeusedinstatisticalorothersummaryformorforclinicalpurposesonlyiftheidentityoftheindividualisnotdisclosed.Iunderstandtheviolationofclient/employmentconfidentialityissubjecttocivilandcriminalpenalties.CONFIDENTIALITYANDNON-DISCLOSUREAGREEMENTToinsuretheAgencyisincompliancewiththeHIPAAregulationsandtoensuretheprotectiontoProtectedHealthInformation(PHI)andthepreventionofunauthorizedusetheAgencywillauthorizethosepersonsallowedhavingaccesstoPHI.TheAgencymustbewhatisminimallynecessarytoperform/carryoutthejobduty/function.Bysigningthisagreement,IagreetocomplywiththeAgency’spoliciesandprocedurespertainingtoPHI.Failuretodosowillresultinprogressivedisciplinaryactionincludingterminationasapplicable.EMPLOYEESIGNATUREIDENTIFICATIONFORCLINICALRECORDS EmployeeName:__________________________________________________________ PrintName:______________________________________________________________ ScriptSignature:___________________________________________________________ PrintInitials:_______________________ ScriptInitials:______________________

TheaboveinformationisstrictlyfortheuseoftheClinicalRecordDepartmentandwillbemaintainedionthatdepartment.

REQUIREDDOCUMENTSTheagencyrequirescopiesofthefollowingdocumentspriortoprovidingpatientassignment.Driver’sLicenseSocialSecurityCardProofofAutoInsuranceSkilledLicensureCertification(In-serviceRecords)AdditionalDocumentstocompleteNotLimitedto:I-9,W-4,W-9AVAILABILITY

WeekDaysPreferencesSunday Monday Tuesday Wednesday Thursday Friday Saturday

□Part-Time □Full-Time □Days □Evenings □Nights

FormP-1

EMPLOYMENTHISTORYIMPORTANT!LISTINCONSECUTIVEORDERALLEMPLOYMENTYOURPRESENTORMOSTRECENTEMPLOYER.ALLSECTIONSMUSTBECOMPLETED.ADDITIONALEMPLOYMENTMAYBELISTEDONSEPARATEPAGE(S)IFNECESSARY.MUSTHAVETWO(2)GOODREFERENCESPRESENTORMOSTRECENTEMPLOYER

PREVIOUSEMPLOYER

OTHEREMPLOYMENTSKILLS

_________________________________________ ________________________________________FULLNAMEOFCOMPANY TELEPHONE EMPLOYEDFROM TO_________________________________________ ________________________________________STREETADDRESS STATE ZIPCODE BEGINNINGSALARY ENDINGSALARY_________________________________________ ________________________________________NAME&TITLEOFSUPERVISOR DEPARTMENT TITLEOFYOURPOSITIONREASONFORLEAVING

_________________________________________ ________________________________________FULLNAMEOFCOMPANY TELEPHONE EMPLOYEDFROM TO_________________________________________ ________________________________________STREETADDRESS STATE ZIPCODE BEGINNINGSALARY ENDINGSALARY_________________________________________ ________________________________________NAME&TITLEOFSUPERVISOR DEPARTMENT TITLEOFYOURPOSITIONREASONFORLEAVING

LISTPART-TIMEEMPLOYMENTWHILEINSCHOOL,INCLUDINGCOMPANYNAME(S)ADDRESSES,DATESOFEMPLOYMENT:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HAVEYOUEVERBEENSUSPENDED,PLACEDONPROBATION,ASKEDTORESIGN,DISCHARGEDORTERMINATED?__________IFYES,PLEASEEXPLAIN:__________________________________________________________________________________

IndicateExperienceinYearsorMonthsforEachArea:(√)TITLE YEARS/MTHS TITLE YEARS/MTHS TITLE YEARS/MTHS□ACCOUNTING_____________ □BILLING________________ □MEDIARELATION_____________□BOOKKEEPING___________ □ICD-9CODING__________ □ADVERTISING________________□PAYROLL________________ □MARKETING____________ □MANAGEMENT_______________ListAllOtherSkillYouHaveThatMayBeofValuetoTheCompanySuchasProgramming,Etc.______________________________________________________________________________________________________ComputerSkills □Yes □No □Hardware □Software WPM__________IndicateShort-TermGoal(s)________________________________________________________________________________IndicateLong-TermGoal(s)_________________________________________________________________________________DescribeYourIdeal/DreamJob_____________________________________________________________________________

PERSONALINFORMATIONLastNameFirstInitial SocialSecurity#

StreetAddress HomeTelephone#

City,State,Zip Cellular/Alternate#ReferredBy IndicateTitle(√)□RN□LVN□Aide

□Other(indicate)AreyoulegallyabletobeEmployedintheUnitedStates?□Yes□No

DoyouhaveaCriminalHistory?□Yes□No

Ifyes,Explain

GENERALINFORMATION

EDUCATIONINFORMATIONSCHOOLS/EDINSTITUTIONS YEARSATTENDED GRADUATED INDICATEONE MAJORSTUDIESHIGHSCHOOL

□YES□NO

CERTIFICATIONDIPLOMADEGREE

COLLEGE/UNIVERSITY □YES□NO


VOCATIONAL,BUSINESS,OTHER □YES□NO


LISTANYSCHOLARSHIPS,ACADEMICHONORS,AWARDSORSPECIALACHIEVEMENTS:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FormP-1

PositionofInterest__________________________ DesiredSalary________________ PossibleStartDate____________HOWDIDYOUHEARABOUTCOMPANY?_____________________________ ADVERTISEMENT(specify):____________________PLACEMENTFIRM(firmname):_______________________________________OTHER:____________________________________AREYOUWILLINGTOWORKANYSHIFT,INCLUDINGNIGHTSANDWEEKENDS?□YES□NOHAVEYOUEVERBEENEMPLOYEDBYTHECOMPANY?______IFSO,WHEN?______________POSITION______________________AREANYRELATIVES,INCLUDINGIN-LAWS,EMPLOYEDATTHECOMPANY?_______________________________________________IFYES,GIVENAME,REALTIONSHIP,POSITIONANDLOCATION:_________________________________________________________HAVEYOUEVERPREVIOUSLYAPPLIEDFOREMPLOYMENTATTHECOMPANY?______IFSOWHEN?(MO.)_______(YR.)_________

I HEREBY CERTIFY thatmyanswers to the foregoingquestions are true and complete and that I havenot knowinglywithheld any facts, circumstances or other information, which would, if disclosed, affect my application. I furtherunderstandthatanyfalseormisleadingstatementoromissionofpertinentinformationwillresultintherejectionofmyapplication,orindismissalifdiscoveredsubsequenttomyemployment.I HEREBY AFFIRM that by execution of the application, I acknowledge that the Company has disclosed tome that aCriminalHistorycheck,includinginformationastomycharacter,generalreputation,personalcharacteristics,andmodeoflivingmaybemade;andthatI,uponwrittenrequesttotheCompanymadewithinareasonabletimeafterthedateofthisapplication,mayobtainacompleteandaccuratedisclosureofthenatureandscopeoftheinvestigationrequested.IHEREBYAUTHORIZE theCompanytorequest,and IALSOAUTHORIZEANDREQUESTeachformeremployer,schoolattended,andeachperson,firm,orcorporationgivenasreferencesabove,tofurnishatanytime,anyinformationwhichmay be sought concerning me and my work habits, character or skill, and any other data required, whether inconnectionwiththisapplicationonforpurposesofcomplyingwithsuretycompanyrequirementsorotherwise.I HEREBY AFFIRM that by submitting this application I agree to submit tomedical evaluations and/or examinations,including tests for the presence of illegal drugs or alcohol, prior to and during employment, within a tie periodprescribedbytheCompanyandasoftenasdirectedduringemployment.IUNDERSTANDthatshouldIbegivenemployment,suchemploymentshallbeforanindefiniteperiodoftimeandmaybe terminated, at will, at any time, for any reason, by me or by the Company without notice or without liabilitywhatsoever, except for unpaid wages or salary earned by the date of termination. I further understand that onlyINFUSIONXPERTSPLLChastheauthoritytoenterintoanyagreementforemploymentforaspecifiedperiodoftimeortomakeanyagreementcontrarytothisatwillstandardandthatanysuchagreementmustbeinwriting.IUNDERSTANDthatifIamemployed,thisapplication,theCompany’sTermsofEmployment,andPolicyandProcedureswillgovernthetermsandconditionsofmyemployment,asamendedfromtimetotimebytheagency.TheCompanyoperatesundertheprinciplesofaffordingequalemploymentopportunitythroughaffirmativeactionforqualifiedhandicappedindividuals,qualifiedveteransoftheVietnameraandqualifieddisabledveterans.Allapplicantswhobelievetheytobemembersofoneormoreofthesegroups,andwhowishtoidentifythemselvesassuchforthepurposeofaffirmativeactionconsiderationareinvitedtodoso.Submission of this information is voluntary and refusal to provide itwill not subject you to discharge or disciplinarytreatment. Information obtained concerning individuals shall be kept confidential, except t hat (1) supervisors andmanagersmay be informed regarding disabled veterans and handicapped individuals, as necessary, (2) first aid andsafety personnel may be informed, when and to the extent appropriate, if the condition might require emergencytreatment,and(3)governmentalofficialsinvestigatingcompliancewillbeinformed.Iwishtovolunteerthefollowinginformation(checkone)_____Idonotqualify Idoqualifyunderthefollowing:_____Handicapped _____VietnamEraVeteran _____DisabledVeteran___________________________________________________________ ___________________Signature DateThankyouforcompletingthisapplication.Itwillremainunderconsiderationforsixmonths.Itwillnotbenecessaryforyoutoreapplyduringthissix-monthperiod.YourinterestinINFUSIONXPERTSPLLCisappreciated.

FormP-1

INFUSIONXPERTSPLLCREFERENCECHECK

PHONE:(832)369–6811FAX:(713)981–1811

_________________________________________ _______________________________ApplicantName SS#Company:________________________________ Contact:________________________ EmploymentDates:_____________________________________________________________________EligibleForRehire?□YES□NOPositionHeld:________________________________ Salary:____________________________Terminated/Separationdueto___________________________________________________________________

Pleaseindicatedbelowwitha(√)Qualityofwork □Exceptional□Satisfactory□PoorAttitude □Exceptional□Satisfactory□PoorAttendance □Exceptional□Satisfactory□Poor________________________________________ ______________________________CompletedBy Date

INFUSIONXPERTSPLLCtoCompleteBelowthisLine MethodofVerification:□Telephone□Fax□Mail ______________________________ ________________________ ______________________ VerifiedBy Title Date

FormP-1

INFUSIONXPERTSPLLCREFERENCECHECK

PHONE:(832)369–6811FAX:(713)981–1811

_________________________________________ _______________________________ApplicantName SS#Company:________________________________ Contact:________________________ EmploymentDates:_____________________________________________________________________EligibleForRehire?□YES□NOPositionHeld:________________________________ Salary:____________________________Terminated/Separationdueto___________________________________________________________________

Pleaseindicatedbelowwitha(√)Qualityofwork □Exceptional□Satisfactory□PoorAttitude □Exceptional□Satisfactory□PoorAttendance □Exceptional□Satisfactory□Poor________________________________________ ______________________________CompletedBy Date

INFUSIONXPERTSPLLCtoCompleteBelowthisLine MethodofVerification:□Telephone□Fax□Mail ______________________________ ________________________ ______________________ VerifiedBy Title Date

FormP-2

INFUSIONXPERTSPLLCSUBJECT:EMPLOYEESAFETY NUMBER:513

POLICYSTATEMENT

Duringorientationandatleastannually,thereafter,staffmemberswillbeinstructedontheappropriatesafetymeasurestobeusedduringhomevisits.

Ø Whenmakinghomevisits,staffmemberswillnotcarryvaluablesorlargesumsofmoneyontheirpersonsorintoclienthomes.Anynecessarypersonalidentificationwillbelockedinthetrunkoftheautomobile,ofpossibleorcarriedinabeltpack.

Ø Staffmemberswillnotgounescortedintoareaswherethereareknowndrugtraffickingorotherknownorsuspectedunsafeareas.

Ø Staffmembersshouldrequestescortserviceforvisitsonwhichtheyfeelunsafe.Thesupervisorwillarrangeforabuddysystemsorotherescortasappropriate.

Ø Staffmemberswillnotcarryconcealedweapons.However,theymaycarrypepperspraysorotherdeterrentsasdesired.

Ø Staffmemberswillcarrymapsandhavecleardirectionsforlocationsofhomevisits.Ø Staffmemberswillcarrymedicalsuppliesoutofvisualsight,suchasinthetrunkoftheautomobile.Ø Staffwilllocktheirvehicleduringhomevisitstomaintainsecurityofsuppliesandconfidentialityof

clientinformation.Ø Staffwillrequestthatclientsandfamilymemberskeepdangerousanimalschainedduringhomevisits

ifanimalsarenotadequatelyrestrainedorifthepatientrefusestodoso,ahomevisitwillnotbemade.

Ø Homevisitswillnotbemadetopatients’homeswherethereareweaponsissight;iftheclientand/orafamilymemberthreatenstafforareverballyabusive;orifthestaffmemberfeelsunsafe.

Ø Whenmakingon-callvisitsafterdark,staffmemberswillnotifytheansweringservice,asupervisor,orafamilymemberoftheirpresenceandexpectedreturn.

Ø StaffmemberswearINFUSIONXPERTSPLLCidentificationandappropriateattireforallhomevisits.PURPOSE:

Ø Toprovideguidelinestostaffmembersfortheirsafetywhilemakinghomevisits.PROCEDURE:

Ø Safetymeasuresforusebystaffmembersarepresentedduringthegeneralorientationforeachnewemployee.

Ø Specificsafetymeasuresforaparticularbranchareincludedinthatbranch’sorientation.Ø Annualin-servicesareofferedforallstaffmembers.Ø Occasionalarticlesregardingsafetypoliciesandprocedureareincludedintheemployeenewsletter.

______________________________________________ ________________________________NameofEmployee Date______________________________________________SignatureofEmployee

INFUSIONXPERTSPLLC

CONFIDENTIALITYOFPROTECTEDHEALTHINFORMATION(PHI)

It is both the agency and employees’ responsibility to ensure that every patient’s health information isprotectedatalltime.BysigningbelowyouareindicatingtheacknowledgementofHIPAAandunderstandthata thoroughorientationof theagency’spolicy regardingpatient’sProtectedHealth Information (PHI)willbeprovidedtoyouuponhire.IunderstandthatImaybehandlingProtectedHealthInformation.Ifurtherunderstandthattherearespecificguidelinesassociated for sueanddisclosureofProtectedHealth Information.TheagencyhassanctionsandfinesforallindividualsfailingtocomplywithHIPAARulesandRegulations.

PROTECTIONOFHEALTHINFORMATION

There are specific guidelines to ensurepatient’s ProtectedHealth Information is keptprivate. I understandthatmy employeewith the agency involves handling Protected Health Information. I will ensure patient’srecordsareprotectedbyenforcingthefollowingmeasures:

Ø PatientProtectedHealthInformationwillbetransportedinanenclosedenvelopwhentraveling.

Ø When transmitting and receiving a fax involvingProtectedHealth Information, Iwill ensure that it’sconductedinaprivatearea.

Ø Patient Protected Health Information will be returned to the agency upon acknowledgment of thepatientbeingdischarged.

Ipledgetomakeeveryefforttokeeppatient’sPHIprotectedatalltimes._________________________________________ _____________________________EmployeeName Date_________________________________________ EmployeeSignature

INFUSIONXPERTSPLLC

ORIENTATIONDOCUMENTATIONONHIPAACOMPLIANCE

It is the policy of this agency to ensure that every employee understands that guidelines of contact withProtectedHealthInformation.ThisagencystrictlyenforcesrulesandregulationsofHIPAA.SigningthisformindicatesthatyouhavebeenorientedonHIPAApertheagency’spolicy._________________________________________ _____________________________EmployeeName Date_________________________________________ EmployeeSignature

INFUSIONXPERTSPLLCSUBJECT:NON-DISCRIMINATIONPOLICY NUMBER:325

POLICYSTATEMENT

INFUSIONXPERTSPLLCwillcomplyandincorporatethenon-discriminationprotocolontoitspoliciesandprocedures.PURPOSE:

Ø ToensureINFUSIONXPERTSPLLCpolicystatementmeetstheDADSrequirements.Ø ToensurecompliancewiththeU.S.DepartmentofHealth&HumanServicesRequirements.Ø INFUSIONXPERTSPLLCwillcomplywithTheDepartmentofAging&DisabilityServicesfor

developmentandtheimplementationofanondiscriminationpolicystatement.Ø INFUSIONXPERTSPLLCwillimplementTheDepartmentofAging&DisabilityServicesrequirementsas

outlined.

NON-DISCRIMINATIONPOLICY

Ø InaccordancewithTitleVIoftheCivilRightsActof1964andtheimplementationoftheregulations,(Nameoftheagency)willnot,directlyofthroughcontractualarrangements,discriminateonbasisofrace,color,ornationalorigininitsadmissionsoritsprovisionofservicesandbenefits,includingassignmentsortransfersorreferralstoorfromINFUSIONXPERTSPLLC.Staffprivilegesaregrantedwithoutregardtorace,color,ornationalorigin.

Ø Inaccordancewithsection504oftherehabilitationActof1973andtheimplementationoftheseregulations,INFUSIONXPERTSPLLCwillnot,directlyorindirectlythroughanycontractualarrangements,discriminateonthebasisofdisabilityinadmissions,accesstreatmentoremployment,DirectorofNursing,hasbeendesignatedasthecoordinatorfortheimplementationofthispolicy.

Ø InaccordancewiththeAgeDiscriminationActof1975anditsimplementingregulation,INFUSIONXPERTSPLLCwillnot,directlyorthroughcontractualorotherarrangements,discriminateonthebasisofageintheprovisionofservices,unlessageisfactornecessarytonormaloperationsortheachievementofanystatutoryobjective.

Ø Incaseofquestionsconcerningthispolicy,orintheeventofadesiretofileacomplaintallegingviolationsoftheabove,pleasecontactINFUSIONXPERTSPLLC’sadministrator,____________________,at_____________________.

Ø AcopyofINFUSIONXPERTSPLLCnondiscriminationpolicyispostedinitsfacilityforvisitorsandclientstoview.

Ø INFUSIONXPERTSPLLC’snondiscriminationpolicyisprintedinthecompanyadmissionbookletandisroutinelydistributedtopatients,referralsourcesandthecommunity.

Ø AcopyofINFUSIONXPERTSPLLC’snondiscriminationstatementisavailableuponrequest.Ø INFUSIONXPERTSPLLCpostsitsnondiscriminationpolicyinallcompanybrochuresand

advertisements.Date:________________________NameofEmployee:___________________________SignatureofEmployee:_______________________ Title:______________________________

INFUSIONXPERTSPLLC

HEPATITISBVIRUS(HBV)VACCINATIONCONSENTFORM/STATUSRECORD

INITIALEACHAPPLICABLESTATEMENT:

□ I understand that the nature of my jobmakes it reasonably anticipated that I may have percutaneous,mucousmembrane or non-intact skin exposure to blood or other potentially infectious body fluids in thecourseofmywork.Therefore,IamentitledtoreceivetheHBVvaccineseriesatnocosttome,atareasonabletime and place, and during work hours. I understand that taking the HBV vaccine will reduce the risk ofdevelopingseriousliverdiseaseasaresultofoccupationalexposuretoHBV.

□ I understand that my decision to accept or decline HBV vaccine will not affect my employment or anybenefitsavailabletomethroughmyemployment.

□ I elect to receive the HBV vaccination series provided to me by Name of Agency I understand that byreceivingthevaccineseriesIhavea90percentassuranceofimmunityagainstthevirus.

□ IhavereceivedtrainingontheriskofinfectionwithHBVonthejobandhavegiventheopportunitytobevaccinatedwithHBVvaccine.However,IdeclineHBVvaccinationatthistime.Iunderstandthatbydecliningthisvaccine,IcontinuetobeatriskofacquiringHBV,aseriousdisease.IfinthefutureIcontinuetobeatriskofoccupationalexposuretobloodorotherpotentiallyinfectiousbodyfluids,andIwanttobevaccinatedwithHBVvaccineIcanreceivethevaccineatnochargetome.

□Ihavepreviouslyreceivedthecomplete3-doseseriesofHBVvaccine.Mythirdinjectionofvaccinewason____________________.

□Antibodytesting(anti-HBsoranti-HBc)hasrevealedthatIamimmunetoHBV.

□TheHBVvaccine iscontraindicatedformedical reasonsasevidencedbytheattachedstatement frommyphysician.

□Antibodytesting(anti-HBs)aftertheprimaryseriesofHBVvaccineandatleastoneboosterindicatesthatIamanon-respondertoHBVvaccine.

________________________________________________________________________________________ EmployeeSignature Date

________________________________________________________________________________________ WitnessSignature Date

INFUSIONXPERTSPLLC

NameofEmployee_____________________________________________hadachestxrayDate________________________ _________Negative _________PositiveforTBHaveyouhadanysymptomsof:_____Excessivesneezeorcough_____Excessivesweat_____Excessivechills_____Excessivefever_____Excessivelossofweight_____Excessivepaininthechest_____Weaknessorfatigue_____Noappetite_____Coughingbloodorgreensputum_____________________________________ ________________________________ EmployeeSignature Date

_____________________________________ ________________________________ SupervisorSignature Date

INFUSIONXPERTSPLLC

ANNUALAFFIRMATIONOFCOMPLIANCEANDDISCLOSURESTATEMENT

IhavereceivedandcarefullyreadtheConflictofInterestPolicyfortrustees,employees,consultants,vendorsandvolunteersof INFUSIONXPERTSPLLCandhaveconsiderednotonlythe literalexpressionof thepolicy,butalso its intent.Bysigningthisaffirmationofcompliance, Iherebyaffirmthat IunderstandandagreetocomplywiththeConflictofInterestPolicy.ExceptasotherwiseindicatedintheDisclosureStatementandattachments,ifany,below,IherebystatethatIdonot, tothebestofmyknowledge,haveanyconflictof interest thatmaybeseenascompetingwiththeinterests of the INFUSION XPERTS PLLC, nor does any familymember or business associate have such anactualorpotentialconflictofinterest.IfanysituationshouldariseinthefuturewhichIthinkmayinvolvemeinaconflictofinterest,Iwillpromptlyand fully disclose the circumstances to the Chairman of the Board of Trustees or to the Administrator ofINFUSIONXPERTSPLLCasapplicable.IfurthercertifythattheinformationsetforthintheDisclosureStatementandattachments,ifany,istrueandcorrecttothebestofmyknowledge,informationandbelief.________________________________Name(PleasePrint)________________________________Signature________________________________Date