EMPLOYEE ACKNOWLEDGMENT
Confidentiality: The Agency maintains confidentiality of operations, activities, and business affairs of the Agency and the patients/clients according to 1996, Health Information Portability and Accountability Act (HIPAA Due to the nature of our work, each employee will gain, directly or indirectly, sensitive and confidential information on patients/clients and staff members. The health care professional safeguards the patient's/clien right to privacy by judiciously protecting information of a confidential nature including medical treatment information, diagnosis, medical records, personal patient/client information, etc. This information should be shared only with those persons who, due to their position, have a need to know. Sensitive or confidential information must never be used as the basis for social conversation or gossip. If an employee is in doubt as to whether or not certain information may be shared, s/he should consult with his/her supervisor.
Drug Testing Policy: The Agency maintains a drug free workplace policy with regard to the possession, use, distribution and sale of drugs or alcohol. All employees are prohibited from the unlawful or unauthorized manufacture, distribution, dispensing, possession or use of a controlled substance or any alcoholic beverages while in the workplace or on Company paid time. Violation of this policy can result in disciplinary action, up to and including termination of employment. I acknowledge I have received a copy of the agency's policy on drug testing.
Harassment Policy: The Agency is committed to providing a work environment, that is free from all forms of discrimination and unlawful harassment including sexual harassment. This policy applies to all employees including management personnel. Sexual harassment is any unwelcome sexual advances either explicit or implicit as a term or condition of employment. Improper behavior may be verbal, visual, or physical in nature and/or the creation of a hostile environment. Management will investigate complaints of sexual harassment promptly, impartially and without fear of retaliation to the employee. An employee should report the alleged incident immediately and confidentially to the appropriate manager or Human Resources.
Non Solicitation/Illegal Remuneration: The Agency does not reimburse or provide incentives to physicians, durable equipment providers, family or other referral entities for patient/client referrals for home health services. Employees may not solicit patients/clients for the agency. Employees found in violation of this non-solicitation policy will be subject to discipline up to and including termination of employment.
Non-Discrimination: The Agency does not discriminate against employees based on race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. The employee may file a report of a grievance or complaint regarding discrimination with the Office of Civil Rights within 180 days of when the employee knew of the situation.
Non-Discrimination: The Agency does not discriminate in patient/client provision of services with respect to race, color, national origin, age, sex, disability, marital status, religion, or source of payment according to Title VI of the Civil Rights Act.
Abuse, Neglect, and Exploitation: Agency employees will report suspected abuse, neglect and/or exploitation to the Texas Department of Family and Protective Services, Texas Health and Human Services, and Agency management. Agency employees suspected of abuse, neglect, or exploitation will be suspended immediately, an investigation will be conducted, and if the investigation validates the claim, the employee will be terminated.
Workers' Compensation The Agency is a non-subscriber to workers' compensation insurance. An employee who incurs an injury on the job that requires emergency medical treatment or is life threatening should proceed to the nearest emergency room. Emergency medical treatment (non life threatening) or non-emergency treatment should be referred to the agency's designated clinic. Notify the agency of an injury within 24 hours to complete paperwork. Medical expenses for injuries are covered with the exception of the following: employee's willful intent to hurt self or others, intoxication or drug use, horseplay, acts of God, and/or acts of a third party.
Progressive Discipline Policy: Agency utilizes a progressive discipline process in cases of misconduct or unacceptable performance. This includes verbal warning, written warning and final warning. Disciplinary action may begin at an advanced stage of the process or may result in immediate termination based upon the nature and severity of the offense, employee's past record and other circumstances.
Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.
Employee
Date
Month Day Year
ALLBRIGHT HEALTH CARE SERVICES INC
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
Applicant Name (last, first, middle)
Email Address
example@example.com
Address
Present Address
Street Address Line 2
City/State/Zip State / Province
Postal / Zip Code
Home Phone
Area Code Phone Number
Mobile Phone
Area Code Phone Number
Are You at Least 18 Years Old?
Yes No
Shift Requesting
Full Time Part Time Per Visit Shift Day Night
Position Applying For
If you are not a US Citizen, do you have the legal right to remain permanently in the US?
Yes No
Salary Requirements
Date Available to Start
Month Day Year
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
Yes No
List professional licenses you possess. Indicate type of license, number and state
List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law
List languages spoken other than English
List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc
Work History
Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient:
Company Name
Complete Address including City/State/Zip
Part Time Yes Per Visit Full Time
Describe your job title, responsibilities and accomplishments
Phone Number
Area Code Phone Number
Supervisor's Name
OK to contact Supervisor?
Yes No
Reason For Leaving
Company Name
Complete Address including City/State/Zip
Part Time Yes Per Visit Full Time
Describe your job title, responsibilities and accomplishments
Phone Number
Area Code Phone Number
Supervisor's Name
OK to contact Supervisor?
Yes No
Reason For Leaving
Company Name
Complete Address including City/State/Zip
Full Time
Part Time Yes No Per Visit
Describe your job title, responsibilities and accomplishments
Phone Number
Area Code Phone Number
Supervisor's Name
Reason For Leaving
PERSONAL/BUSINESS REFERENCES:
Name
First Name Last Name
Phone
Area Code Phone Number
Address
Relationship
Name
First Name Last Name
Phone
Area Code Phone Number
Address
Relationship
Emergency Contacts
Name
First Name Last Name
Phone Number
Area Code Phone Number
Relationship:
Name
First Name Last Name
Phone Number
Area Code Phone Number
Relationship:
Please review and sign

In making application for employment:
I certify that the information in this application is true and complete for all practical purposes. It may be verified by the Agency or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the Agency or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
I understand and agree that if I am offered employment by the Agency, my employment will be for no definite term and that either I, or the Agency will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the Agency.
Applicant Signature
Clear
Date
Month Day Year
Statement of Employability
By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check per TXH&SC 250.006. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. As required, I agree to a search of the Texas Health and Human Services Commission's OIG List of Excluded Individual/Entities, prior to being hired and monthly thereafter, the HHS - OIG Excluded Individuals/Entities Search Database and SAM Exclusion List.
I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will barmefromemployment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253. I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check and that I may not have face-to-face patient/client contact until results are returned. I will be notified of results.
I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this Agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.
Name (last, first, middle)
Date of Birth
Maiden, alias, if applicable
Signature of Applicant
Clear
Date
Month Day Year
Date
CONVICTIONS BARRING EMPLOYMENT
A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection: An offense under Chapter 19, Penal Code (criminal homicide); An offense under Chapter 20, Penal Code (kidnaping, unlawful restraint, and smuggling of persons); An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children) or Section 21.11, Penal Code (indecency with a child); An offense under Section 22.011, Penal Code (sexual assault); An offense under Section 22.02, Penal Code (aggravated assault); An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual); An offense under Section 22.041, Penal Code (abandoning or endangering a child); An offense under Section 22.08, Penal Code (aiding suicide); An offense under Section 25.031, Penal Code (agreement to abduct from custody); An offense under Section 25.08, Penal Code (sale or purchase of a child); An offense under Section 28.02, Penal Code (arson); An offense under Section 29.02, Penal Code (robbery); An offense under Section 29.03, Penal Code (aggravated robbery); An offense under Section 21.08, Penal Code (indecent exposure); An offense under Section 21.12, Penal Code (improper relationship between educator and student); An offense under Section 21.15, Penal Code (improper photography or visual recording); An offense under Section 22.05, Penal Code (deadly conduct); An offense under Section 22.021, Penal Code (aggravated sexual assault); An offense under Section 22.07, Penal Code (terroristic threat);
An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual); An offense under Section 33.021, Penal Code (online solicitation of a minor); An offense under Section 34.02, Penal Code (money laundering); An offense under Section 35A.02, Penal Code (Medicaid fraud); An offense under Section 36.06, Penal Code (obstruction or retaliation); An offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to nonlivestock animals); or A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection. An offense the Agency determines to be contraindicated to employment with the consumers the Agency serves. (B)Aperson may not be employed in a position the duties of which involve direct contact with a patient/client in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is
(C)
An offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony); An offense under Section 30.02, Penal Code (burglary); An offense under Chapter 31, Penal Code (theft) that is punishable as a felony); An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or An offense under Section 32.46, Penal Code (securing execution of a document by deception) that is punishable as a Class A misdemeanor or a felony. An offense under Section 37.12, Penal Code (false identification as a peace officer; misrepresentation of property); or An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted: Of an offense under Section 30.02, Penal Code (burglary); or Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under
(D)
For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with, Article 42A.111 Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.
For Agency Use Only: Criminal History, Employee Misconduct Registry (EMR), Nurse Aide Registry (NAR), and OIG Exclusion Lists checks completed reason for hiring in Comments below
Criminal History Check completed on-line EMR Registry Other Convictions Identified on Criminal History (Document the reason for hiring in comments below) OIG Exclusion List Applicant Employable Applicant not employable (see comments below)
COMMENTS
Verified By
Date
Month Day Year
Date
PRO / Statement of Employability Rvd. 050120
Hepatitis B Vaccination
Due to your occupational exposure to blood or other potentially infectious materials, you may be at risk for acquiring hepatitis B viral (HBV) infection. The vaccination series is available, at no cost, to you. Please indicate below your declination or acceptance to receive the vaccine.
Hepatitis B is a blood borne virus which can cause a range of symptoms from mild to serious, and possibly result in fatal liver damage to health care workers who become infected. The virus can be transmitted through contact with infectious fluids of a patient who has hepatitis B virus. You have been taught the concepts of Universal Precautions concerning safe patient care and the use of equipment to avoid
Synthetic hepatitis B vaccine is derived from yeast cells. It is not composed of human blood or plasma. It is given as a series of three injections into the arm muscle at prescribed intervals (initial shot, one month later, and six months later It has proven to be over 80-90% effective in protecting against the disease. There may be hypersensitivity to the vaccine, and there may be soreness and swelling of the injection arm. Other side effects may occur at an incidence of under 3% of injections.
The vaccine will not be given to persons with known sensitivity to aluminum hydroxide, thimerosal, yeast or hepatitis antigen and will only be given with your personal physician's recommendations in the cases of pregnancy or presence of other infection of immunosuppressive state. The vaccine does not grant 100% assurance of immunity.
Acceptance: I have read the above information describing the risks and benefits of receiving the vaccination. I understand that the decision to receive the vaccination series is mine and I wish to receive the hepatitis B vaccine.
Employee Signature
Clear
Date
Month Day Year
Date
Witness
Declination: I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. I decline the vaccination series. I understand that by declining this vaccine, I continue to be at risk for acquiring hepatitis B. If I continue to have occupational exposure to blood or other potentially infectious material (OPIM) and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
I have already received the hepatitis vaccine at an earlier date. I am providing a copy of the record to the agency
Employee Signature
Clear
Date
Month Day Year
Date
Witness
ALLBRIGHT HEALTH CARE SERVICES INC
Contract Staff Signature
Clear
Date
Month Day Year
Date
CONFIDENTIALITY OF PATIENT/CLIENT INFORMATION
I plan to utilize electronic documentation of patient care.
I will ensure confidentiality and security of patient information by password protecting the device or program utilized.
I agree to change the password at least quarterly or following a breach of security.
I will not provide my password to anyone.
I will use an electronic signature, if acceptable to payor source. Authentication will be available if requested by the Agency.
I have been informed of the Agency's Confidentiality Policy and Safeguarding of Medical Records Policy and I agree to abide by these policies.
Printed Name
Signature
Clear
Date
Month Day Year
Date
CONFIDENTIALITYICONFLICT OF INTEREST DISCLOSURE STATEMENT
CONFIDENTIALITY/NON-DISCLOSURE OF COMPANY OR PATIENT/CLIENT INFORMATION:
The Health Information Portability and Accountability Act (HIPAA) ensures the patient/client's right to privacy of Protected Health Information to be maintained at all times. Any information related to the care of patient/clients through this Agency will be held as confidential. All information, written or verbal, will be disclosed only to appropriate health care personnel, appropriate staff, those with a "need to know basis", or to individuals the patient/client requests.
CONFLICT OF INTEREST DISCLOSURE STATEMENT:
I acknowledge I have read the policy and procedure regarding conflict of interest and the procedure for disclosure. I understand that if I have an outside relationship that is personal, professional, or otherwise, with a patient/client, vendor, or potential business associate, I must disclose the nature of that relationship to my supervisor, or Administrator as soon as the relationship is established. I also understand that I forfeit any voting privileges, decision making capacity, and input from any activities associated with said relationship.
I have no conflict of interest to report, or
I,________________________________, as a staff member, member of the Governing Body, or member of any Advisory Committee, am providing the following disclosure as a potential conflict of interest: ____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Name (Please Print)
Signature
Clear
Date
Month Day Year
Date
Reported conflict of interest reviewed by the Governing Body with the following decision(s) made
Signature of Governing Body Member
Clear
Date
Month Day Year
Date
Drivers License/Identification
Browse Files
Cancelof
Social Security Card
Browse Files
Cancelof
ALLBRIGHT HEALTH CARE SERVICES INC
Should be Empty:

EMPLOYEE ACKNOWLEDGMENT

Work History

PERSONAL/BUSINESS REFERENCES:

Emergency Contacts

Statement of Employability

(C)

Hepatitis B Vaccination