24/7 Home Care Agency of NY, INC Employment
Employment Application (HHA/PCA)


Male Female


Yes No


Yes No


Yes No


Yes No



24/7 Home Care Agency of NY, Inc. does not discriminate because of age, sex, physical handicap, race, creed or national origin. The agency is an equal opportunity employer.

I affirm that information in this application is complete and true. I understand that if employed, false statements will be a case for dismissal.

Confidentiality/ Conflict of Interest Statement

As an employee of 24/7 HomeCare Agency of NY, Inc, and as a condition of my employment I agree to the following:

  1. I understand that I am responsible for complying with the HIPAA policies, which were presented to me upon employment.
  2. I will not access or utilize patient information, unless needed to perform my job duties.
  3. All information received during the course of employment with the agency, will be treated as privileged and confidential information.
  4. I will not log onto any of the agency's computer systems, existing now or the future, using a password other than my own.
  5. I will not email, fax or phone to transmit any patient information unless I am instructed to do so by the Administrator or Director of Nursing.
  6. I will not take patient information from the premises in paper or electronic form without approval from the Administrator or Director of Nursing.
  7. Upon termination of my employment, I agree to maintain confidentiality regarding any information learnt or gained while an employee of the agency and will return all keys, ID cards or any device that would provide continued access to agency or information within the agency.
  8. I understand that all reports, accounting records, research reports, expense accounts, time sheets and other documents must accurately and clearly represent the relevant facts or the true nature of a transaction.
  9. I understand I shall never offer any financial inducement, gift, payoff, kickback, or bribe intended to induce, influence or reward favorable decisions of any government personnel or representative, any customer, contractor or vendor in a commercial transaction or any person in a position to benefit the agency or the employee in any way.

To ensure no conflict of interest The Agency defines "conflict of interest" as those activities or actions which:

  • Conflict with the mission, philosophy of objection of the Agency.
  • Violate local, state or federal regulations.
  • Place the Agency, personnel, clients or their families at risk ethically, financially or legally.
  • To protect the Agency's assets, both material, concepts and publications, as well as to include:
  • Confidentiality of patient diagnosis.
  • Financial matters
  • Staff salaries.
  • Nursing or executive plans that can go to unauthorized agencies.
  • Anything given to staff (e.g. forms, systems, and equipment) that goes to unauthorized people

By signing this document I understand that violation of this agreement will result in disciplinary action, up to and including, termination.


ACKNOWLEDGMENT OF RECEIPT

The Employee Handbook/Code of Conduct/Compliance Program contain important information about the company, and I understand that I should consult the Administrator/Office Manager/General Manager regarding any questions not answered in these documents. I have entered into my employment relationship with the Company voluntarily, and understand that there is no specified length of employment. Accordingly, either the Company or I can terminate the relationship at will, at any time, with or without cause, and with or without advance notice.

Since the information, policies and benefits described herein are subject to change at any time, I acknowledge that revisions to the Handbook/Code of conduct may occur. All such changes will generally be communicated through official notices, and I understand that revised information may supersede, modify, or eliminate existing policies.

I have had an opportunity to read the handbook, Code of Conduct, and Compliance Program and I understand that I may ask my supervisor or any employee of the Human Resources Department any questions I might have concerning the handbook. I accept the terms of the documents described above. I also understand that it is my responsibility to comply with all the policies of 1st Help Homecare, Inc and any revisions made. I further agree that if I remain with the Company following any modifications to the handbook, I thereby accept and agree to such changes.

I have received a copy of the Company's Employee Handbook (Policies and Procedures), Code of Conduct, Compliance Program, Paid Family Leave and Notice of Employee Rights (regarding sick leave), Equal Employment Opportunity Act, Anti-Sexual Harassment notice, Wage Parity, and Fair Labor Standards Act (FLSA) on the date listed below. I understand that I am expected to read the entire handbooks. Additionally, I will sign the two copies of this Acknowledgment of Receipt, retain one copy for myself, and return one copy to the Company's representative listed below on the date specified. I understand that this form will be retained in my personnel file

I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, I agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in by myself or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.

I understand that I may be subject to discipline or other corrective action, up to and including termination of employment or termination of contract, if I violate the standards and requirements set fort in the Code of Conduct, any specific compliance policies or procedures, or any aspect of the 1st Help Homecare, Inc Compliance Program.


HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT

I acknowledge that during the course of performing my assigned duties at 24/7 HomeCare Agency of NY, Inc. I may have access to, use or disclose confidential health information. I hereby agree to handle such information in a confidential manner at all times during and after my employment and commit to the following obligations:

  • I will use and disclose confidential health information only in connection with and for the purpose of performing my assigned duties
  • I will request, obtain or communicate confidential health information only as necessary to perform my assigned duties and shall refrain from requesting, obtaining or communicating more confidential health information than is necessary to accomplish my assigned duties
  • I understand that as an employee of 24/7 HomeCare Agency of NY, Inc. that is a health care provider, the use and disclosure of patient information is governed by the rules and regulations established under HIPAA, the Health Insurance Portability and Accountability Act of 1996, and related policies and procedures of 1st Help Homecare, Inc.
  • I will use and disclose confidential health information solely in accordance with the federal and 24/7 HomeCare Agency of NY, Inc policies and set forth above or elsewhere. I also agree to familiarize myself with any periodic updates or changes to such policies in a timely manner.
  • I will immediately report any unauthorized use or disclosure of confidential health information that I become aware of to the appropriate supervisor.
  • I also understand and agree that my failure to fulfill any of the obligations set forth in this agreement and/or my violation of any terms of this Agreement shall result in my being subject to appropriate disciplinary action, up to and including, termination of employment.

Agreement between 24/7 HomeCare and HHA/PCA Live-In

  1. All PCA/HHA assigned to live-in cases are to be present in the consumer home for 24 hours each working day.
  2. During each live in day, based on a 13 hour day, HHA's/PCA's are to perform tasks in accordance with the verbal or written care plan. HHA's/PCA's may not work in excess of 13 hours in any day and no more than 5 Live in days per week
  3. During each 24 hour day , HHA's/PCA's are to take eleven hours for personal time which will include hours of sleep, meal breaks and other personal time, remaining on premises at all such times.
    • 8 hours of sleep time
    • 2 hours meal breaks
    • 1 hour of personal time- reading, watching television, etc.
  4. If any , HHA's/PCA's finds it impossible to take the specified breaks from work duties because such times are constantly interrupted by the needs of the patient, she/he must call the administrator at 24/7 HomeCare Agency of NY, Inc immediately.
  5. I understand and will abide by the agency's rules stated in this agreement regarding time worked on live-in cases and I understand I will contact my coordinator if I believed I was paid improperly within 5 days. By simply accepting or continuing employment with 24/7 HomeCare Agency of NY, Inc, you agree that you received proper reimbursement for all hours worked and you cannot bring forth any claim/dispute as a plaintiff.
  6. I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, I agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in by myself or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.
  7. My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions. I further agree that, in accordance with 24/7 HomeCare's Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 HomeCare to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 HomeCare. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.

Waiver of Group Health Benefits & Notice of Special Enrollment Rights

For the plan year effective( ) I am waiving coverage for:

Myself
Spouse/Domestic Partner
Dependent (s) Please list names:

I am waiving coverage due to:

My preference not to have coverage
Coverage under my spouse's/domestic partner's plan name of carrier:

Other coverage name of carrier:

This other coverage is: Individual COBRA Medicare TRICARE (formerly CHAMPUS) Medicaid Employer-Sponsored Group Plan

Special Enrollment Notice and Certification - Please review and sign below if you wish to waive coverage

By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage.

I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period.

In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.

Declination of Influenza Vaccination

My employer, 24/7 HomeCare Agency of NY, Inc, has recommended that I receive the influenza vaccination to protect the patients I serve.

I acknowledge that I am aware of the following facts:

  • Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
  • Influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications, and death.
  • If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
  • If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.
  • I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t change, my immunity declines over time. This is why vaccination against influenza is recommended each year.
  • I understand that I cannot get influenza from the influenza vaccine.
  • The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including:
    • All patients in this healthcare facility
    • My Coworkers
    • My Family
    • My Community

I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available.

I also understand that I will need to wear a face mask during flu season while I am on a case with a patient.

I have read and fully understand the information on this declination form. I have also received a flu mask for this flu season

Flu Vaccine Declination

I will NOT be getting the flu vaccine for the 2021-2022 Flu season. I will wear a surgical mask during any time spent with any patients.

I Received the Flu Vaccine for the 2021-2022 Flu Season.

I understand that failure to comply with these requirements will put me and the patient I care for at risk, and my employment with 24/7 HomeCare Agency of NY, Inc is conditional on meeting these requirements.

Hepatitis B Vaccination Form

I, (print your name) understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV Infection). I have been given the opportunity by HHA Forms, Inc. to be vaccinated with HBV vaccine at no charge. If you would like to request the Hepatitis B Vaccination please do not sign below and fill out a request form.

PLEASE SIGN ONLY IF DECLINING HEPATITIS B

Declination of Hepatitis B Vaccination

I do not wish to be given the HBV vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. I am aware that I may request to be provided with the vaccination at a later date during my employment with the agency.

SEXUAL HARASSMENT POLICY ACKNOWLEDGMENT

I certify that I have been trained on the NYS Sexual Harassment Policy. I understand that Sexual harassment is a form of workplace discrimination. HHA Forms of NY, Inc has a zero-tolerance policy for any form of sexual harassment, and all employees are required to work in a manner that prevents sexual harassment in the workplace. I also understand that Sexual harassment is against the law and that I have the legal right to a workplace free from sexual harassment, and I can file a complaint internally with, HHA Forms of NY, Inc or with a government agency or in court under federal, state or local anti-discrimination laws. This policy applies to all employees, paid or unpaid interns, and non-employees and all must follow and uphold this policy.

I have been given the Complaint Form and contact information if I ever must file a complaint for sexual harassment.

Acknowledgement of Receipt of Paid Family Leave (PFL) Instructions

Under a new New York state law, working New Yorkers will be able to take time off to care for a loved one while still receiving a portion of their salary. The eligible employees will now be able to take up to 8 weeks of benefits and job-protected leave in any 52-week period at up to 50 percent of their salary.

Employee Eligibility

Full-Time employees (Individuals working 30 or more hours a week): must work 20 or more hours per week for 26 or more consecutive weeks of employment.

Part Time employees (individuals working less than 30 hours a week): must work fewer than 20 hours per week for 175 days in a 52-consecutive week period.

The employee must provide advance notice of 30 days. If providing notice of less than 30 days an explanation must be given.

Types of Leave

  1. Care for a close relative with a serious health condition. A close relative could be your spouse, domestic partner, children, parents, parents' in-law, grandparents, and grandchildren.
  2. Maternity and paternity leave. Employees can take time to bond with their newborn, newly adopted, or a newly placed child, within the first 12 months after the child's birth, adoption, or placement of an adopted or foster child.
  3. Qualifying Exigency Leave: when an employee's spouse, child, domestic partner, or parent is on covered active duty or has been notified of an impending call or order to covered active duty; or to care for a service member with a serious injury or illness, if the employee is the service member's spouse, child, domestic partner, or parents.

Payroll Deductions to Fund Paid Family Leave Benefits

The maximum employee contribution is 0.126 percent of their weekly wage, not to exceed $1,305.92 as per NY DOL.

New York State has more information about the Paid Family Leave program at www.ny.gov/paidfamilyleave

All requests for Paid Family Leave must be made through the Human Resources Department. Please call Sharon at 718-513-1222

I have received the Notice of Employee Rights for the Paid Safe and Sick Leave Law. My questions regarding Paid Safe and Sick Leave have been answered.

I know I can contact 1st Help Homecare, Inc, at the above address or telephone number if I have any other questions regarding this notice.

I understand the following about the Paid Safe and Sick Leave:

  1. I must work 80 hours or more per calendar year (from January 1st to December 31st) in order to be covered by the Paid Sick Leave Law.
  2. I accrue 1 hour for every 30 hours worked, up to a maximum of 40 hours per calendar year.
  3. For new employees: I can use the accrued time after 120 days from my 1st workday.
  4. I am allowed to carry over any unused sick leave to the following year but can only use up to 40 hours of Paid Sick Leave per calendar year.
  5. I am required to provide 24/7 HomeCare with a health care provider's note if I use my sick leave time for four or more consecutive days, no specifics regarding my health is necessary.
  6. I may use Paid Sick Leave for sick leave ONLY and I must be scheduled in order to use sick leave. I must provide 24/7 HomeCare with 7 days of advance notice whenever possible; if I am presented with an unforeseeable situation, then I will provide a notice as soon as possible.
  7. I understand that if I call out or sick the day before or the day after a holiday I am scheduled to work, I will not get paid sick time even if I have it available.

I acknowledge that I have received the necessary information and instructions regarding Paid Family Leave benefits.

Acknowledgement Of
HHA Exchange Time and Attendance
And Duty Codes Training and Responsibilities

I certify that I have been trained on HHA Forms, Inc's automatic time and attendance and duty codes. I understand that my paycheck is generated by the call in and out through HHA Exchange automated telephone system, if I do not clock in and out correctly I will not be paid. When I clock out, it is my responsibility to dial in the duty codes that represent the duties I have performed for my patient that day. I must specify at least five duties performed. The Plan of Care should match the duties I put in. I must immediately inform my supervisor if the client's telephone is not working or if the client refuses the use their telephone.

I understand that my work day must be verified. If I fail to clock in and out correctly (because of circumstances out of my control, ex: telephone is not working) the visit must be verified by the submission of a signed and verified time sheet. If the visit is not verified, then HHA Forms, Inc will not be able to generate a pay check for that unverified work day.

I certify that I have been trained on HHA Forms, Inc "on-call" policy and procedure. I understand that when the office is closed and there is an emergency or if I am unable to make it to work, it is my responsibility to follow the proper procedure. I must reach the answering service. I may not leave a voicemail.

I may be subject to disciplinary actions/investigation and or termination for violation of the agency's policy and procedures, including but not limited to time and attendance.


Acknowledgement of Mandatory Compliance
Regarding Time Sheets and Clock In and Out

I Home Health Aide / Personal Care Aide certify that I have been trained regarding mandatory compliance responsibilities of the agency with the Department of Health. I have been trained and understand the following:

  • I understand that if the patient has a working phone, I MUST CLOCK IN AND OUT or the HHA App.
  • I understand that I will use the patient’s telephone or cell phone, NOT MY CELL PHONE, to clock in and out unless using the app.
  • Timesheets must be filled out according to the time that I serviced the patient. I understand to write down the time that I was with the patient, NOT the scheduled time. Timesheets are only given in emergency circumstances or pre-approved situations.
  • I understand that I can not submit a timesheet if the patient is in care of a third party. Such as Hospital or Hospice or Dialysis Centers including any facilities that are considered 3rd Party.
  • I have been trained and shown how to fill out a timesheet correctly.
  • I understand that I must submit the time sheets by every week Monday the latest.
  • I understand that I may not schedule myself to work for two patients at the same time.
  • I understand that I must not give my clock-in ID # to anyone including the patient.
  • I understand that the patient or anyone else cannot clock me in or out.
  • I understand that I must not send anyone other than myself to work for me.

I acknowledge that I am solely responsible for these requirements in order to continue my employment with HHA Forms, Inc. Violations of these requirements are grounds for immediate termination. I acknowledge that for the safety of the patients whom I will service, I will abide by 24/7 HomeCare policy.

Acknowledgement of Receipt of the
Personnel Policy and Privacy Notice

I have received HHA Forms, Inc, Personnel Policy and Privacy Notice. My questions regarding the Personnel Policy and Privacy Notice have been answered.

I know I can contact HHA Forms, Inc at the above address or telephone number if I have any other questions regarding this form.

I further understand that my employment is at will, and neither HHA Forms, Inc nor I have entered a contract regarding the duration of my employment. Except as otherwise provided in a valid and enforceable collective bargaining agreement, I am free to terminate my employment with the HHA Forms, Inc at any time, with or without reason and HHA Forms, Inc has the right to terminate my employment, or otherwise discipline, transfer, or demote me at any time, with or without reason at the discretion of the Facility. No employee of HHA Forms, Inc can enter into an employment contract for a specified period of time or make any agreement contrary to this policy without the written approval of the Administrator.

Compliance Program

Dear Staff Member:

HHA Forms of NY, Inc is dedicated to conducting its business honestly and ethically wherever HHA Forms of NY, Inc operates. In order to meet this commitment, HHA Forms of NY, Inc as set forth in this Code of Conduct the principles and rules to be followed by all personnel who work with HHA Forms of NY, Inc.

The purpose of this Code of Conduct is to inform all personnel and interested third parties that HHA Forms of NY, Inc is fully dedicated to approaching all of its activities, including compliance with laws and regulations, in an ethical manner. This Code of Conduct will familiarize new personnel with the ethical standards that guide our business and patient relationships in our highly regulated environment. For existing personnel, it will reaffirm our commitment to ethical behavior in all circumstances. Since everyone at HHA Forms of NY, Inc has a personal stake in this important program, we strongly urge each of you to review this information thoroughly and refer to it whenever situations arise requiring you to exercise your judgment.

Compliance with laws, regulations and out policies require the full commitment of all HHA Forms of NY, Inc personnel. Each of us is personally and professionally responsible for understanding and adhering to this Code of Conduct and the supporting policies and procedures, including those areas covering your specific job responsibilities. The purpose of this Code of Conduct is to provide you with guidance on ethical and compliance issues. However, this Code of Conduct cannot cover every issue you may encounter. If you have a question or encounter a situation which concerns you, you should ask for HHA Forms of NY, Inc through your department supervisor, the Administrator and/or the Compliance Officer.

Compliance Hotline is 718-887-2922 or the email is info@hhaforms.com

JOB DESCRIPTION
Home Health Aide(HHA), Personal
Care Assistant (PCA)
REPORTS TO REGISTERED NURSE / DIRECTOR OF NURSING/REGISTERED NURSE DESIGNEE

SUMMARY

The Home Health Aide is a member of the home care team trained to provide personal care, other unskilled services, and companionship in the home setting, under the direction, instruction, and supervision of a Director of Nursing/Registered Nurse designee and the patient.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

  • Assists the patient in the Activities of Daily Living (ADL) including personal care, hygiene, baths, back rubs, shampoo, skin and nail care, eating, dressing, elimination, exercises, ambulation, and changin^making patient's bed. Plans and prepares meals.
  • Encourages the patient's family to participate in patient's care.
  • Provides companionship to the patient.
  • Assists in the maintenance of a safe and healthy environment Uses equipment and supplies safely and properly.
  • Reminds the client to take, and assists client and/or family, with self-administered oral medications as ordered by the physician, in compliance with the laws in the state of operation.
  • Takes and records accurate patient vital signs when advised.
  • Follows the Home Health Plan as written, approved, and supervised by the Registered Nurse or Physical Therapist.
  • Gives emotional support to the patient and/or family.
  • Informs Registered Nurse (RN)/Director of Nursing/Registered Nurse Designee of changes in patient's condition.
  • Documents activities and findings and submits documentation as required by company procedures.

This job description is not intended to be all-inclusive. The employee will be expected to perform other reasonable related duties as assigned by management.

JOB LIMITATIONS
The Home Health Aide will not function in any manner viewed as the practice of nursing according to the State's Nurse Practice Act Specifically, the home health aide will not administer medications, take physician's orders or perform procedures requiring the mining, knowledge, and skill of a nurse, specifically sterile techniques.

QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

<EDUCATION AND OR EXPERIENCE
High school diploma or general education degree (OED) or equivalent, and meets the training requirement in accordance with state and federal laws. (Effective 8J14/90, a person who has successfully completed a state established or other training program that meets the requirements ofCFR484.36(b), oracompetency evaluation program or state licensure program that meets the requirements of S 484.36(b).) At least one year of experience in home care, nursing, or hospital experience preferred.

LANGUAGE SKILLS
Ability to communicate effectively with patient/client, family members, clinical management, and staff. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.

REASONING ABILITY
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with simple problems in the home setting.

OTHER SKILLS AND ABILITIES
Nurse's Aide skills, observation skills, communication skills, knowledge ofhome health care. Good physical and mental health. Caring attitude, tact, patience, and good personal hygiene.

PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work requires moderately heavy physical exertion on a regular and recurring basis such as: extensive driving, assisting patient in transfer activities (wheelchair, to bed, to tub, to commode) and providing substantial support to individuals in ambulation. While performing the duties ofthisjob, the employee is regularly required to use hands to finger, to handle or feel, and talk or hear. The employee frequently is required to stand; walk; reach with hands and arms' and stoop, kneel, crouch, or crawl. The employee is occasionally required to sit. The employee must occasionally lift and/or move over 100 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

• Patient home setting, exposure to infectious diseases, automobile.

(Signing this document acknowledges that the job description and responsibilities have been reviewed with me, the employee.)

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Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Multiple Hourly Rate Employees

1.Employer Information

1.Notice Given:

At hiring
Before a change in pay rates (s), allowances claimed or payday

3.Employee's rate(s) of pay for each type of work or shift:



4.Allowaces taken:

per hour
per meal

5.Regular payday:

6.Pay is:



7.Overtime Pay Rates(s) for each type of work or shift:

This must be at least 1 1/2 times the worker's weighted average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week. The overtime rate may vary from week to week depending on how many hours you worked at each rate of pay. The overtime rate may vary from week to week.

8.Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given below. I told my employer what my primary language is.

Check one:

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

New York State Department of Health
Criminal History Record Check

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DOH CHRC Form 102: Acknowledgement And Consent Form For Fingerprinting And Disclosure Of Criminal History Record Information

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

SECTION 1 – SUBJECT INDIVIDUAL INFORMATION
Last Name First Name Middle Initial
Date of Birth (mm/dd/yyyy) Mother’s Maiden Name Alias: AKA
Mailing Address(Street) City State Zip Code

SECTION 2 - ATTESTATION

1. I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI).

2. I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI.

3. I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary. In accordance with applicable law, DOH will furnish appropriate summary information to the agency to which i applied for a position to provide direct or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether i have a criminal history, Including convictions of a crime (felony or misdemeanoe) or criminal charges which do not reflect a disposition. the criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history recorde check performed by DCJC. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be discolsed to persons authorized by law. I have been Informed that upon receiving notification from DCJS that three is a subsequent pending criminal action or proceeding or conviction, the DOH shall promptly notify an authorized person(s) of a provider of the additional allegation or new conviction.

4. I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place.

5. I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI. If i beleve an error has been made by DCJS for any New York State conviction/charge or the FBI for a non-New York State conviction/charge, I understand that i should notify DCJS and/or the FBI to repoert and request correction of this error to the addresses below.

NYS Division of criminal Justice Services Criminal History Bureau
Record Review Unit-5th Floor
4 Tower place, Albany,NY 12203
(518) 485-7675

Federal Bureau of investigation
Criminal Justice Information Services (CJIS) Division
1000 Custer Hollow Road, Clarksburg, Wv 26306
(304) 625-5590

6. I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information.

7. I certify to the best of my knowledge and belief that I (check as appropriate):

Have Have not been convicted of a crime in New York State or any other jurisdiction
Do Do not have a final finding of patient or resident abuse.
If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)

8. My current mailing or home address is indicated in Section 1 of this form.

9. I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own.

SECTION 3 - AGENCY AUTHORIZED PERSON INFORMATION

Agency Name: PFI/Operating License Number:
Print Name of Authorized Person: Title:

This form is to be retained by the agency. Do not forword to the DOH CHRC

DOH-102

New York State Department of Health

02/21

Acknowledgement of Receipt
Photo Identification

As an employee of 24/7 HomeCare Agency of NY, Inc, I,, acknowledge receipt of the agency issued photo identification badge. As required by regulation and agency policy, I agree to wear the ID when working where it is visible to the eye immediately by the patient, all the patient's family members and Supervising Nurse.

The identification badge is the property of 24/7 HomeCare Agency of NY, Inc and wiil be returned to the agency upon termination of employment.

I know I can contact 24/7 HomeCare Agency of NY, Inc at the above address or telephone number if i have any other questions regarding this form.

Receipt of 24/7 HomeCare Agency of NY, Inc's
Cellular and Wireless Device In the
Workplace

Please read the policy carefully to ensure that you understand the policy before signing this document.

I certify that I have received a copy of 24/7 HomeCare Agency of NY, Inc's Cellular and Wireless Devices in the Workplace policies. I understand that it is my responsibility to read and comprehend the policy. I have read and understand the content, requirements and expectations of the policy and I agree to abide by the policy's guidelines. I understand that if at any time, I have questions regarding this policy, I will consult with my immediate supervisor or the Corporate Compliance Officer.

I agree to observe and follow this policy. I understand that failure to abide by the policy could result in disciplinary actions and possible termination.

Form

W-4


Department of the Treasury Internal Revenue Service

Employee's Withholding Certificate

► Complete Form W-4 so teat your employer can withhold the correct federal income tax from your pay.

► Give Form W-4 to your employer.

► Your withholding is subject to review by the IRS.

0MB No. 1545-0074

2021


Step 1: Enter Personal Information

► Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

(c)
  Single or Married filing separately
  Married filling jointly(or Qualifying widow(er))
  Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.


Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

  • Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4); or
  • Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
  • If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld ►

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps S-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000 ►
Multiply the number of other dependents by $500 ►
Add the amounts above and enter the total here 3

Step 4(optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other Income you expect this year that won't have withholding, enter the amount of other income here. This may Include Interest, dividends, and retirement income 4(a)
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here 4(b)
(c) Extra withholding. Enter any additional tax you want withheld each pay period 4(c)

Steps: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, conrect, and complete.

Employers Only

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Cat. No. 10220Q

Form

W-4

(2020)

Employment Eligibility Verification
Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS
Form I-9

OMB No. 1615-0047
Expires 10/03/2022

► 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) Last Name (Family Name)
First Name (Given Name) First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name) Address (Street Number and Name)
Apt. Number
City or Town City or Town
State State
ZIP Code ZIP Code
Date of Birth (mm/dd/yyyy) Date of Birth (mm/dd/yyyy)
U.S. Social Security Number U.S. Social Security Number
Employee's E-mail Address
Employee's Telephone Number 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(Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field.(See instructions)

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:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number:

Country of Issuance:

Signature of Employee



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.









Employment Eligibility Verification
Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS
Form I-9

OMB No. 1615-0047
Expires 10/03/2022

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.")

Employee Info from Section 1
List A
Identity and Employment Authorization
OR
List B
Identity
AND
List C
Employment Authorization
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

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)



Section 3. Reverification and Rehlres (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)
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.

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Department of Taxation and Finance
Employee’s Withholding Allowance Certificate
New York State • New York City • Yonkers

IT-2104

First name and middle initial
Last name
Your Social Security Number
Single or Head of household
Married
Married, but with hold at higher single rate
City, village, or post office
State
ZIP code
Note: If married but legally separated, mark an X in the Single or Head of household box.
Are you a resident of New York City?
Yes No
Are you a resident of Yonkers?
Yes No

Complete the worksheet on page 4 before making any entries

1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 20
1
2 Total number of allowances for New York City (from line 35)
2

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 New York State amount
3
4 New York City amount
4
5 Yonkers amount
5

I certify that I am entitled to the number of withholding allowances claimed on this certificate

Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties

Employee: detach this page and give it to your employer; keep a copy for your records.

Employer: Keep this certificate with your records.
Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):
A   Employee claimed more than 14 exemption allowances for NYS ............ A
B   Employee is a new hire or a rehire ... B  First date employee performed services for pay (mm-dd-yyyy) (see instr.):
         Are dependent health insurance benefits available for this employee? ............. Yes No
              If Yes, enter the date the employee qualifies (mm-dd-yyyy):

Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.)
Employer identification number

Instructions

Changes effective for 2018
Form IT-2104 has been revised for tax year 2020. The worksheet on page 4 and the charts beginning on page 5, used to compute withholding allowances or to enter an additional dollar amount on line(s) 3, 4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2018 Form IT-2104 and give it to your employer.
Who should file this form
This certificate, Form IT-2104, is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld.

If the federal Form W-4 you most recently submitted to your employer was for tax year 2019 or earlier, and you do not file Form IT-2104, your employer may use the same number of allowances you claimed on your federal Form W-4. Due to differences in tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.

For tax years 2020 or later, withholding allowances are no longer reported on federal Form W-4. Therefore, If you submit a federal Form W-4 to your

employer for tax year 2020 or later, and you do not file Form IT-2104, your employer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.
Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim Is different from federal Fonn W-4 or has changed. Common reasons for completing a new Form IT-2104 each year Include the following:

  • You started a new job.
  • You are no longer a dependent.
  • Your individual circumstances may have changed (for example, you were married or have an additional child).
  • You moved into or out of NYC or Yonkers.
  • You itemize your deductions on your personal income tax return.
  • You claim allowances for New York State credits.
  • You owed tax or received a large refund when you filed your personal income tax return for the past year.
  • Your wages have increased and you expect to earn $107,650 or more during the tax year.
  • The total income of you and your spouse has increased to $107,650 or more for the tax year.
  • You have significantly more or less income from other sources or from another job.
  • You no longer qualify for exemption from withholding.
Form

8850

(Rev. March 2016) Department of the Treasury Internal Revenue Service

Pre-Screening Notice and Certification Request for the Work Opportunity Credit

► Information about Form 8850 and its separate instructions is at www.irs. Gov/form8850.

0MB No. 1545-1500


Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

If you are under age 40, enter your date of birth (month, day, year)

  1. Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.
  2. Check here if any of the following statements apply to you.
    • I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
    • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
    • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
    • I am at least age 18 but not age 40 or older and I am a member of a family that:
      • Received SNAP benefits (food stamps) for the past 6 months; or
      • Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
    • During the past year, I was convicted of a felony or released from prison for a felony.
    • I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
    • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
  3. Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
  4. Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.
  5. Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
  6. Check here if you are a member of a family that:
    • Received TANF payments for at least the past 18 months; or
    • Received TANF payments for any 18 months beginning after August 5,1997, and the earliest 18-month period beginning after August 5,1997, ended during the past 2 years; or
    • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
  7. Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.

Signature—All Applicants Must Sign


Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Cat. No. 22851L

Form

8850

(Rev.3-2016)

U.S. Department Labor
Employment and Training Administration

0MB Control No. 1205-0371
Expiration Date: January 31,2020

LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM
Work Opportunity Tax Credit (WOTC) Program

Instructions: This Self-Attestation Form (SAF) is to be completed, signed, and dated by the new hire only.Employers or consultants submit this SAF to the State Workforce Agency with IRS Form 8850 or if filed separately, with ETA Form 9061 (or ETA Form 9062) for each certification request filed for the new target group.

Under penalties of perjury, I declare that this information is true and correct to the best of my knowledge.

New Hire's Signature:.

Date
New Hire Name:
Social Security Number:
Employer Name:

Please check the statements below if they apply to you.

I declare that I was In a period of unemployment that Is at least 27 consecutive weeks and for all or part of that period I received unemployment compensation.

I declare that I have been In a period of unemployment since

(Enter start date)

Privacy Act Notice
The Internal Revenue Code of 1986, Section 51, as amended, and its enacting legislation, P.L. 104-188, specify South State Workforce Agendas are the "designated" agents responsible for administering the WOTC certification procedures of this program. The Information you provided completing this form will be disposed by your employer to the State Workforce Agency. Provision of this information Is voluntary; however the Information Is required to determine your employer's eligibility for the federal tax credit.

Public Burden Statement:
Persons are not required to respond to this collection of Information unless it displays a currently valid OM B control number. Respondent's obligation to complete this form Is required to obtain or retain benefits (P.L. 111-5). Public reporting burden Is estimated to average 10 minutes per response, including the time for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of National Programs Tools Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371). Please do not submit completed forms to this address.



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Home Health Aide/ PCA Acceptance Test

Please circle the correct answer for the following questions:

  1. Clients sometimes express religious beliefs with which the home health aide does not agree. In dealing with these situations, which of these understandings should the aide use as a guide?
    • A. Clients have a right to their own beliefs, which should be respected.
    • B. Clients should be told not to discuss their beliefs with aides
    • C. Aides should explain their beliefs to the clients
    • D. Aides should pretend they have the same beliefs that the clients have.
  2. Mrs. Wayne, a home health aide, leaves the home of Mr. David, a terminally ill client. A neighbor stops her and says, "Mr. Davis is sick isn't he? I hear he is dying." What is the best response for the aide to answer?
    • A. "Yes, Mr. Davis is very ill."
    • B. "How do you know Mr. Davis is so sick?"
    • C. "I'm sorry, I can't discuss Mr. Davis"
    • D. "Mr. Davis is doing as well as can be expected"
  3. Miss Ferri, a home health aide, is assigned to care for Mr. Conway. Miss Ferri notices that she feels very angry when she is with the patient. What should Miss Ferris do because she feels this way?
    • A. Tell Mr. Conway how she is feeling.
    • B. Find out if other aides have felt this way.
    • C. Try to pretend Mr. Conway is someone she likes.
    • D. Talk with the agency supervisor about the situation.
  4. A client accuses a home health aide of stealing five dollars. The aide has not taken the clients' money, but the client does not believe the aide. What should the aide do?
    • A. Ask the other aides who care for the client if they took the money.
    • B. Ask the client why the aide is being accused.
    • C. Offer to give the client five dollars.
    • D. Notify the agency supervisor.
  5. Which of these actions is the home health aide permitted to take in relation to drug administration?
    • A. Recording and reporting the client's reaction to the medication.
    • B. Giving nonprescription medications whenever the client asks for them.
    • C. Adjusting the dosage of the medication given to the client.
    • D. Adjusting the times medications are given to fit into the client's scheduled.
  6. The home health aide is helping Mrs. Elden with her bed bath. Mrs Elden requests to wash her genital and rectal areas herself. Which of these measures should the aide take?
    • A. Have Mrs. Elden use cold water only in washing her genitals.
    • B. Have Mrs. Elden use no soap when washing her rectal area.
    • C. Remind Mrs. Elden to wash from the vaginal area toward the rectal area.
    • D. Tell Mrs. Elden she cannot wash herself.
  7. A patient who has been on bed rest is too weak to get up in a chair. The home health aide helps the client to sit on the edge of the bed. The client says "I am dizzy". What should the aide do?
    • A. Rub the client's feet.
    • B. Help the client to a standing position.
    • C. Put a cool compress on the clients head.
    • D. Support the client in sitting position and wait a minute or two to see if the dizziness goes away.
  8. Pressure ulcers are most likely to be prevented if:
    • A. The patient is turned on each side every 2 hours
    • B. Clients sleep all day
    • C. Clients eat well.
    • D. Clients shower frequently.
  9. An aide is taking care of a patient who becomes aggressive. The patient is cursing and yelling. What should the aide do?
    • A. Yell back at the patient.
    • B. Tell the patient to calm down.
    • C. Move away from the patient and give the patient a few minutes to calm down.
    • D. Leave the patient and go home.
  10. A fall risk patient asks the aide to go to the supermarket to buy some groceries. What should the patient do?
    • A. Leave the patient alone and go to the supermarket.
    • B. Tell the patient she cannot leave him alone and ask if he wants to go with her or order in delivery.
    • C. Put the patient to sleep and then go to the supermarket.
    • D. Tell the patient she doesn't want to go.
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Commuter Benefits Participation Form

Under NYC's Commuter Benefits Law, certain employers must offer commuter benefits to existing full-time employees beginning January 1, 2016 or four weeks after an employee begins full-time work, whichever is later. For more information, please call 311 or visit nyc.gov/commuterbenefits to read Frequently Asked Questions about the Commuter Benefits Law.

Note to Employees:
Your employer is required by law to offer you a commuter benefits program; however, your participation is voluntary. You may decline to enroll in the program, or you may cancel your participation at any time. You may also choose to enroll in the program at a later date.

EMPLOYER INFORMATION
Employer Name
Address
City/State/ZIP Code
Phone Number
EMPLOYEE INFORMATION
Name (First/Middle/Last)
Address
City/State/ZIP Code
Phone Number
Email Address
Date of Hire

I (Employee's printed name) Accept Decline
my employer's offer to use pre-tax income to pay for qualified transportation benefits to the extent permitted under federal law

If you have questions about your employer's obligations under NYC's Commuter Benefits Law or to report non-compliance, please contact the Department of Consumer Affairs (DCA) at nyc.gov/commuterbenefits. Email commuterbenefits@dca.nyc.gov. or contact 311 (212-NEWYORK outside NYC).

FACT-FINDING AND ISSUE RESOLUTION ("FAIR") PROGRAM

Purpose of the FAIR Program. The Agency values each employee and looks forward to good relations with and among all of its employees. Occasionally, however, disagreements may arise between you and our agency or between employees in a context that involves the Agency We believe that the resolution of such disagreements will be best accomplished by internal dispute resolution and, where that fails, by external binding arbitration that is conducted by a neutral arbitrator. For these reasons, the Agency has adopted this Fact-Finding and Issue ResolutionProgram (the "FAIR Program"). The FAIR Program is effective immediately upon your execution of this document (the "Effective Date").

The FAIR Program is an essential element of Your employment and/or continued employment with the Agency.Although the FAIR Program Is a binding agreement between you and the Agency, It does not create a contract of employment for a specific term or otherwise affect the at-will nature of Your employment. You Indicate your agreement to be bound by the FAIR Program's terms and conditions by beginning or continuing your employment with the Agency.

What does the FAIR Program cover? The FAIR Program applies to any and all Claims, regardless of when those claims arose or accrued or were first asserted, between You and the Agency (as these terms are defined below). For the avoidance of doubt, the FAIR Program applies to claims that accrued, arose, or were asserted before execution of this agreement and to claims that accrued, arose, or were asserted after execution of this agreement. The FAIR Program also applies to Claims that arise or are asserted after your employment with the Agency ends.

For purposes of the FAIR Program and this document, the following terms have the following meanings:

"The Agency" means 24/7 Homecare Agency of NY, Inc., each of its subsidiaries, affiliates, and successor entities, as well each of their partners, principals, owners, directors, agents, and employees against whom a Claim is asserted by You.

"You" and "your" refers to you and any other person who may assert your rights.

"Claim" includes any claim, dispute, allegation, controversy or action between you and The Agency that in any way arises from or relates to your employment with The Agency or the termination of your employment with The Agency, and that is based on a legally protected right (i.e., statutory, regulatory, contractual, or common-law rights). The term Claim includes, for example, any employment, labor, wage and hour, overtime, or compensation related claims. As further examples, the term Claim includes, without limitation, claims, disputes, demands or actions that may arise under the following laws (all as amended):

  • Title VII of the Civil Rights Act of 1964
  • The Civil Rights Act of 1991
  • the Age Discrimination in Employment Act of 1967
  • the Americans with Disabilities Act of 1990
  • the Fair Labor Standards Act of 1938 or any state wage and hour laws, such as the New York Labor Law and the Domestic Workers Bill of Rights
  • New York Public Health Law Section 3614- c, also known as the Wage Parity Law
  • any other federal, state, or local wage parity, living wage, or prevailing wage law
  • the Equal Pay Act of 1963
  • the Rehabilitation Act of 1973
  • the Older Workers Benefit Protection Act employment, compensation, breach of contract, or defamation
  • any common law theories, such as tort, contract, or quasi-contract, including, but not limited to, claims of breach of an expressed or implied contract, tortious interference with contract or prospective business advantage, breach of the covenant of good faith and fair dealing, unjust enrichment, promissory estoppel, detrimental reliance, retaliation.
  • the Family and Medical Leave Act of 1993
  • the Occupational Safety and Health Act of 1970
  • the Worker Adjustment and Retraining Notification Act of 1988
  • any state anti-discrimination, anti-retaliation, or whistleblower laws (including, without limitation, the New York State Human Rights Law and the New York State Whistleblower Law)
  • any other federal, state, or local statute, regulation, or common-law doctrine regarding employment, employment discrimination, harassment, terms and conditions of employment, termination of violation of public policy, invasion of privacy, nonphysical injuiy, personal injury or sickness or any other harm, wrongful or retaliatory discharge, fraud, defamation, slander, libel, false imprisonment, or negligent or intentional infliction of emotional distress
  • disputes about the validity, enforceability, coverage or scope of the FAIR Program or any part thereof

The above list is not exclusive, and is only provided to illustrate examples of Claims. All Claims, whether listed above or not, must be resolved through the FAIR Program.

Are any Claims excluded from the FAIR Program? Yes. The term "Claim" does not include the following, which are for a court or an agency and not an arbitrator to decide:

  • controversies, claims or other disputes for injunctive relief for unfair competition or unauthorized use or disclosure of confidential information or trade secrets
  • claims for workers' compensation (except that claims for interference with or retaliation for filing a workers' compensation claim will be considered a Claim subject to arbitration under the FAIR Program)
  • claims for unemployment compensation benefits
  • claims for employee welfare benefits (e.g., medical, health, dental)
  • claims for retirement benefits under the Employee Retirement Income Security Act ("ERISA") (except that claims for interference with or retaliation for exercising protected rights under ERISA shall be considered Claims subject to arbitration under the FAIR Program)
  • unfair labor practice charges under the National Labor Relations Act

The FAIR Program also does not prevent You from pursuing a claim based on alleged violations of any applicable collective bargaining agreement grievance procedure. Claims that are independent of rights under the CBA and/or that can be resolved without interpreting the collective bargaining agreement are not excluded from the FAIR Program. For instance, a claim alleging a violation of New York Labor Law, the Fair Labor Standards Act, or any other federal or state law is subject to the FAIR Program.

The FAIR Program also does not prevent You from filing a charge, testifying, assisting, or otherwise participating in any investigation or proceeding conducted by the equal employment opportunity commission, or another government agency to the extent You have a protected right to do so. But if You take such action in relation to a claim, controversy, or other dispute that would constitute a Claim and you have not fully pursued such dispute through the FAIR Program, The Agency may request the agency in question to defer its processing or investigation of such charge until the FAIR Program has been completed. Notwithstanding Your rights under this subsection. You agree that, to the maximum extent permitted by law. You may recover monetary relief with respect to a Claim only through the FAIR Program.

The FAIR Program does not require the Agency to begin arbitration proceedings or initiate any other procedure whatsoever before taking any action regarding your employment with which you might disagree, such as coaching, counseling, warning, reprimand, suspension, investigation, discipline, demotion, changing your days or hours of work, or termination.

Can a Claim be resolved in court? No. Under the FAIR Program, You and the Agency each waive your respective rights to have a Claim decided by a court, judge, jury and, where permitted by law, an administrative agency. Instead, You and the Agency agree that the internal dispute resolution (if any) and arbitration under the FAIR Program are the sole and exclusive methods for resolving Claims. If either You or the Agency files an action in court or another forum not contemplated by the FAIR Program asserting one or more Claims and the other party successfully stays such action andMr compels arbitration of such Claim, the arbitrator may assess reasonable costs and expenses, including an award of reasonable attorneys' fees, incurred in seeking such stay and/or order compelling arbitration against the party that filed the action in court or such other forum.

How should You Raise a Claim under the FAIR Program? If You believe You have a Claim against the Agency, You should first give the Agency a chance to investigate and resolve the Claim before You file a demand for arbitration (the arbitration process is explained further below). You do not need to use any specific form to submit a Claim. Simply write a letter explaining your Claim and the relief sought, and submit the letter to the Compliance Officer listed in your Compliance Training Module. As part of this process, a Agency representative might meet with you to discuss your Claim. Or, depending on the nature of the Claim, the Agency will investigate the Claim on its own, such as by reviewing its records. If You do not receive a satisfactory response from the Agency within 30 days of the date that you submitted Your letter or if you disagree with the response from the Agency, You must follow the arbitration procedure set forth below if you wish to pursue the Claim.

The Arbitration Process

How much time do You have to file a Claim? An arbitration proceeding under the FAIR Program must be commenced within the time period prescribed by the statute of limitations applicable to the Claim being asserted. For purposes of statute of limitations, an arbitration proceeding is deemed commenced when a demand for arbitration is filed with ADR Systems. Filing an internal Claim under the FAIR Program will not extend the time period within which You must file a demand for arbitration.

How does the Arbitration process begin? To start the arbitration process, the party wishing to file a Claim must file a written demand in accordance with the rules of ADR Systems ("ADR") for starting the arbitration process. More information about the ADR may be obtained at www.adrsystems.com or by calling 312-960-2260.

How is the Arbitrator selected? All arbitrators must be licensed attorneys or retired judges selected from the ADR's regional Employment/Commercial Dispute Resolution Roster, or an equivalent list if such list is unavailable. Unless the parties agree otherwise, the arbitrator must be a retired or former Judge or a lawyer who has at least 5 years of experience with employment-related claims. No person may serve as an arbitrator unless that person has confirmed in writing that he or she is bound by and will adhere to the requirements of the FAIR Program.

Can an attornev represent You? Yes. Any party may be represented by an attorney. If you need assistance finding an attorney, there may be resources available to you, such as the American Bar Association (www .amcricanbar.oru and 800-285-2221 or 202-662-1000) or the Legal Aid Society (www.legal-aide.org or 212- 577-3300 or 718-722-3100). Alternatively, You must represent Yourself.

When and where will Arbitration take place? The arbitration will be conducted by the arbitrator in whatever manner will most expeditiously permit full presentation of evidence and arguments of the parties. The arbitrator will set the time, date, and place of the hearing, notice of which must be given to the parties at least 30 calendar days in advance, unless the parties agree otherwise. In the event the hearing cannot be reasonably completed in one day, the arbitrator will schedule the hearing to be continued on a mutually convenient date. Any arbitration hearing will take place within the County of Kings, State of New York, unless the parties agree otherwise or the arbitrator, for the convenience of the parties, selects an alternative location.

What rules and law applv to the Arbitration? Arbitration under the FAIR Program will be conducted pursuant to the ADR's Employment/Commercial Arbitration Rules and Mediation Procedures. If there is any conflict between the FAIR Program and the ADR rules and procedures, the FAIR Program terms will govern unless application of such terms would cause the ADR to decline to provide its services, in which case the ADR rules and procedures will govern (except that under no circumstance will an arbitrator have the authority to hear or decide any Claim on a class, collective, or other group or representative basis). The arbitrator must apply the substantive law, including the applicable burdens of proof and persuasion, that would be applied by a court hearing the Claim in the venue of the arbitration. The arbitrator may grant relief that could be granted by a court hearing the Claim, including an award of attorneys' fees and costs, but will not have any authority to grant any other relief.

Can claims be heard or decided on a class, representative, or collective basis? No. Notwithstanding anything to the contrary, this is not permitted under any circumstance. Notwithstanding anything to the contrary: (a) no arbitrator is permitted to hear or decide any Claim on a class, collective, or other group or representative basis; (b) all Claims between You and the Agency must be decided individually; and (c) the ADR's Supplementary Rules for Class Action Arbitration (and any similar rules) will not have any applicability to any Claim. This means that if You have a Claim, neither You nor the Agency will have the right, with respect to that Claim, to do any of the following in court or before an arbitrator: (a) pursue or obtain any relief from a class, collective, or other group or representative action; (b) act as a private attorney general; or (c) join or consolidate a Claim with the Claim of any other person. Thus, the arbitrator shall have no authority or Jurisdiction to process, conduct, or rule upon any class, collective, private attorney general, or other representative or group proceeding under any circumstances. If there is more than one Claim between You and the Agency, those Claims may be heard in a single arbitration hearing.

Who pays for the arbitration? The party claiming to be aggrieved is responsible for paying the first $200.00 of any applicable filing fee in effect and established by the ADR at the time the demand for arbitration is made. The Agency will pay the remainder of any applicable filing fee and will pay any administrative or hearing fees and the arbitrator's fees (except postponement fees or additional hearing fees resulting from actions or inactions of the employee or employee's representative). Each party will be responsible for its own attorneys' fees, witness fees, expenses and costs, but the arbitrator may award either party reasonable attorneys' fees and costs, to the extent a court hearing such Claim would award attorneys' fees under applicable law. However, if the arbitrator finds that the employee's or the Agency's demand for arbitration is frivolous or vexatious, or was not filed in good faith, the arbitrator may require the offending party to reimburse the other party for the arbitrator's expenses and fees. Any amounts required to be paid by You under this paragraph may be adjusted or eliminated to the extent necessary for the FAIR Program to be enforceable.

Will there be discovery or deDositions? Yes. All discovery will be governed by the ADR's rules.

Can You have witnesses testify at the arbitration? Yes. At the hearing, the parties will have the right to present proof through testimony and documentary evidence, and to cross-examine witnesses who testify at the hearing. The arbitrator will require all witnesses to testify under oath. The arbitrator(s) will also have the authority to decide whether any person who is not a witness may attend the hearing.

The Arbitrator's Decision/Award. The Arbitrator will issue his or her award promptly after the arbitration hearing concludes or post-hearing briefs are received. The arbitrator's award will set forth the factual and legal basis for the award, including his or her legal reasoning, and contain a summary of the facts, the issues, the governing law applied, and the relief requested and awarded. It should also identify any other issues resolved and the disposition of any statutory claims. The arbitrator's award will be final and binding on the parties.

How Long Does the FAIR Program Apply to You? The FAIR Program will remain in effect and survive the cessation of Your employment relationship or affiliation with the Agency, regardless of the reason for such cessation.

Miscellaneous Provisions

Choice of Law. The FAIR Program and the terms of this document shall comply with and be governed by the provisions of the Federal Arbitration Act ("FAA") and not by any state law concerning arbitration. The parties acknowledge and agree that the FAIR Program evidences a transaction involving interstate commerce.

Severability. If any part or provision of the FAIR Program or this agreement is held to be invalid, illegal, or unenforceable, such holding will not affect the legality, validity, or enforceability of the remaining parts, and each provision of the FAIR Program and this agreement will be valid, legal, and enforceable to the fullest extent permitted by law. However, in the event the provision prohibiting class, collective, or representative actions is found to be unlawful or unenforceable, then the entire FAIR Program and this agreement will be considered null and void.

Notices. Any notice required to be given to You will be directed to Your last known address as reflected in the records of the Agency. Any notice required to be given to the Agency will be directed to the Agency's principal location in Brooklyn, New York.

Amendment. The Agency reserves the right to amend or terminate the FAIR Program. Such amendments may be made by providing notice to You, electronically or otherwise, of such amendment or termination. Your continuation of employment after receiving notice of any amendment to or termination of the FAIR Program will be deemed agreement to such amendment or termination.

Waiver. No waiver may be granted by either party, except in writing. No waiver of any provision of the FAIR Program will constitute a waiver of any other provision of the FAIR Program (whether or not similar), nor will such waiver constitute a continuing waiver unless otherwise expressly provided in such writing.

By signing below, You confirm that You have read and understand the terms and conditions of the FAIR Program, which require You to submit all Claims to binding arbitration on an individual basis.

120 DAYS HHA PERFORMANCE REVIEW
BY: Staffing Coordinator ONLY

Employee
CC #
JOB TITLE:
Rating: NI=Needs Improvement S = Satisfactory VG=Very Good E=Excellent
Longevity on assignments NI S VG E
Informs Staffing Coordinator of changes in schedule in a timely manner,
including client appointm ents or overtime."		 NI S VG E
Accepts assignments to meet the needs of the program. NI S VG E
Uses HHA EXCHANGE for recording time appropriately. NI S VG E
Inputs tasks as required. NI S VG E
Reports incidents in a timely manner. NI S VG E
Calls for replacements in a timely manner. NI S VG E
Appearance is appropriate. NI S VG E
Demonstrates concern for assigned clients' well being. NI S VG E
Attends sched uled appointments including medical,in-service and competency." NI S VG E
Works alternate weekend. NI S VG E
Overall attendance (call outs/cancellations) NI S VG E
Punctuality NI S VG E
Works well with other staffing coordinators NI S VG E

HHA/ PCA Initial Competency

Home Health Aide Name:
Competency Assessment Method
D = Direct Observation and/or Demonstration
0 = Oral Question and Answer
(Circle the appropriate method below)
Skills Supervisor Assessment Method Supervisor Evaluation Competency
Understand/Follow Plan of Care D or O  MET    NOT MET
Observation, reporting and documentation of patient
status and the care of services provided		 D or O  MET    NOT MET
Reading and recording temperature, pulse and respiration D or O  MET    NOT MET
Universal Precautions (Standard Prec, Handwashing) D or O  MET    NOT MET
PPE, TB, HEB B , HIV and Infection Control D or O  MET    NOT MET
Follows HIPAA and HIV confidentiality D or O  MET    NOT MET
Understands PT Rights and Adv. Directives D or O  MET    NOT MET
Follows Emergency Procedures D or O  MET    NOT MET
Assists with Medication D or O  MET    NOT MET
Basic elements of body functions and changes in condition that must be reported D or O  MET    NOT MET
Maintainig a clean,safe and health environment D or O  MET    NOT MET
Ability to recognize emergency situations D or O  MET    NOT MET
Ability to recognize physical and emotional needs and client and respect the pt's privacy and property D or O  MET    NOT MET
Appropriate and safe techniques in personal hygiene and grooming D or O  MET    NOT MET
Bed Bath D or O  MET    NOT MET
Sponge Bath, Tub, Shower D or O  MET    NOT MET
Shampoo (sink, tub or bed) D or O  MET    NOT MET
Nail Care D or O  MET    NOT MET
Skin Care D or O  MET    NOT MET
Oral Hygiene D or O  MET    NOT MET
Toileting and elimination (Bedpan, Diaper,Commode D or O  MET    NOT MET
Safe transfer techniques D or O  MET    NOT MET
Safe Ambulation (Wheelchair,Walker, Cane D or O  MET    NOT MET
Ability to recognize adequate nutrition and intake D or O  MET    NOT MET
Position/Prevent Bedsores D or O  MET    NOT MET
Range of Motion D or O  MET    NOT MET
Hoyer Lift D or O  MET    NOT MET

ORIENTATION CHECKLIST

Name:
TitIe:
SS#
Welcome to 24/7 HomeCare Agency
A Tax Forms from TAXOA YES NO N/A
B 1-9 Form, Wage form, W-4
C Employee Handbook
1.Employment Requirements and Agency Policies
2.Continuous Employment
3.Job Description
4.HIV Confidentiality Policy
5.Infection Control. Universal Precaution
6.TB Policy/Precautions
7.Emergency Disaster Preparedness
8.HIPAA/Privacy Rights
9.Required E V V, (clock in/out)
10.Case Acceptance
11.Absences and Lateness Policy
12.Patient Abandonment Policy
13.No Call No Show Policy
14.Dress Code
15.Cellular/Wireless Device Policy
16.Employee Counseling
17.Grievances/Complaints
18.Equal Employment Opportunity Policy
19. Pregnancy Accommodations
20. Anti-Harassment Policy
21.Sexual Harassment Policy
22.Protection Against Retaliation
D Code of Conduct
E a. Fraud and Abuse
b. Professional Standard
c. Confidentiality
F HHA/PCA Activity -- DUTY CODES/Timesheets
G HHA Exchange App
H Picture IDs
I Missing Documentation from Application Process

I have read my job description and understand that I will be evaluated based on the performance criteria in my job description. I acknowledge having completed all of the orientation in service curriculum.


WORK AVAILABILITY

Saturday

AM

PM

Sunday

AM

PM

Monday

AM

PM

Tuesday

AM

PM

Wednesday

AM

PM

Thursday

AM

PM

Friday

AM

PM


Yes No

Are pets OK?

Yes No

Is smoking OK?

Yes No

Kosher experience?

Yes No

Is vehicle available for work?

Yes No


4 hour     8 hour     12 hour     Live-In


Brooklyn     Queens     Bronx     Manhattan     Long Island


Tel:

Fax:

PRE-EMPLOYMENT REFERENCE CHECK
EMPLOYMENT VERIFICATION:

Release of Information: I hereby authorize the institution or person being contacted to release all information pertaining to my employment with them. I release them from all liability regarding this reference check.

Job Title:
Dates of Employment From: To:
Reason For Leaving:
Eligible for Rehire? Yes NO Not allowed to disclose N/A

How would you rate the following?

Excellent Good Fair Unsatisfactory
Denendable
Punctuality
Good Attendance
Quality of Work
Cooeration
Communication Skills

Sleep and Meal Period Agreement for 24-Hour Caregivers

24-hour patient cases refer to cases involving patients whose medical professional has determined that the patient needs assistance over a 24-hour period, but that the patient's condition permits a Caregiver working with that patient to receive at least 3 hours of breaks and 8 hours of uninterrupted sleep time during the 24-hour period. Therefore, during 24-hour shifts, Caregivers are expected to provide care to the patient for only 13 hours of the 24-hour case/shift and to receive a total of 11 hours of rest/breaks. This Sleep and Meal Period Agreement ("Agreement") outlines the terms and conditions of 24-hour shifts. Caregivers who wish to work on 24-hour shifts should carefully read this Agreement. No Caregiver will be forced to work a 24-hour case and any Caregiver who wishes to work a 24-hour case must sign this Agreement, to indicate their understanding of what 24-hour cases require and consent to work under those conditions.

Terms of 24-Hour Cases: Caregivers who accept 24-hour cases will be paid for all hours worked on each 24-hour/live-in shift. As state above, however, during each 24-hour shift, it is expected that Caregivers will only be required to work for 13 hours. It is expected that Caregivers will receive a total of at least 3 hours of "Bona Fide Meal Periods" and a 8-hour "Bona Fide Sleep Period," as those are defined below, for each full 24-hour shift. The hours spent in Bona Fide Sleep Period and Bona Fide Meal Periods (total of 11 hours per 24-hour shift) will not count as hours worked. For purposes of this Agreement, the following terms are defined:

  1. "Bona Fide Meal Periods" are meal periods (e.g., one each for breakfast, lunch, and dinner) that are uninterrupted, duty free, and at least 30 minutes in duration. So, on each 24-hour shift, Caregivers can take either six (6) Bona Fide Meal Periods of 30 minutes each, or Caregivers can take three (3) one-hour Bona Fide Meal Periods, on each 24-hour shift. The Bona Fide Meal Periods.

    While Caregivers may not leave the patient's home during a 24-hour shift, Caregivers may leave their work area during each Bona Fide Meal Periods. Caregivers are not required to eat with the patient during their meal period or take their meal period at the same time that the patient eats his/her meal. If a Caregiver is interrupted during his/her meal periods (e.g., the patient has an emergency and calls the Caregiver for assistance), the Caregiver must note any such interruptions on his/her timesheet. The Caregiver will identify the duration of the interruption and when the interruption started and ended.
  2. "Bona Fide Sleep Periods" are regularly scheduled sleep periods, which include at least 5 consecutive hours that are not interrupted by a call to duty, in adequate sleeping facilities. Caregivers will receive an 8-hour scheduled sleep period for each 24-hour shift. Caregivers are expected to be relieved of all duties and work during such scheduled 8-hour period. Caregivers are expected to receive at least 5 consecutive hours of sleep during the 8-hour scheduled sleep period.

    The Caregiver will receive a Bona Fide Sleep Period at a regularly scheduled time on each 24- hour shift, and a 12-hour "window" within which the Bona Fide Sleep Period should start. For example, the Caregiver will receive a sleep period window of 8 pm to 8 am, and the 8-hour sleep period will be regularly scheduled to occur at 10 pm to 6 am. If the Caregiver's Bona Fide Sleep Period start time has to be adjusted due to work flow issues on the shift, the Caregiver must indicate on their timesheet the actual start and end time of their Bona Fide Sleep Period.
  3. "Adequate sleeping facilities" means that Caregivers have access to basic sleeping amenities (e.g., a bed and linens); enjoy reasonable standards of comfort (e.g., heat); and have access to
    2414 Ralph Avenue Brooklyn, NY 11234 • T: 718-887-0782 • F: 718-874-2778 • Email: info@247nyhomecare.com basic bathroom and kitchen facilities, which may be shared (e.g., bathing and toilet facilities, refrigerator, stove, sink, utensils).

Sleep and Meal Period Agreement for 24-Hour Caregivers

Recordkeeoing: Should Caregivers not receive a Bona Fide Meal Period and/or Bona Fide Sleep Period during a 24-hour shift, it is critical that the Caregiver report this on his/her timesheet so that the Company can pay the Caregiver for all work time. Caregivers must document any interruption of meals or sleep on their timesheet or in writing/email and given to their coordinator within 10 days of the incident. The Caregiver should document they had adequate sleeping facilities on the 24-hour shift and confirmation that the Caregiver received at least 5 consecutive and uninterrupted hours of sleep during his/her Bona Fide Sleep Period; confirmation that the Caregiver's Bona Fide Meal Periods were not interrupted by a call to duty; if a Caregiver's Bona Fide Meal Period was interrupted, the total duration of such interruption; and if a Caregiver's Bona Fide Sleep Period was interrupted, the length of the interruption, and the times that the interruption(s) started and ended. If there are other circumstances or work time that a Caregiver believes should be paid, the Caregiver must write that on the timesheet so that he/she can be paid for all their work time. If no interruptions are reported on a timesheet or written on a document/email it should be assumed that the caregiver took the appropriate meals and sleep time as per the plan of care and this agreement

If a Caregiver believes that he/she was not paid for all hours worked, the Caregiver must contact the Human Resources Department immediately and report the actual hours that he/she worked so that the Caregiver can be compensated for all hours of work.

No Retaliation: No employee will be subject to any reprisal or other adverse action for reporting missed or interrupted meal or sleep periods. But any employee who knowingly submits a false report of work time will be subject to disciplinary action, up to and including termination of employment.

By my signature on the below line, I certify that I have read, understood, and agree to the terms of this Agreement.

-->

2414 Ralph Avenue Brooklyn, NY 11234 • T: 718-887-0782 • F: 718-874-2778 • Email: info@247nyhomecare.com

Acknowledgement of Receipt of the
Paid Safe and Sick Leave Notice of Employee Rights

I have received the Notice of Employee Rights for the Paid Safe and Sick Leave Law. My questions regarding Paid Safe and Sick Leave have been answered.

I know I can contact 24/7 Home Care Agency of NY, Inc, at the above address or telephone number if I have any other questions regarding this notice.

I understand the following about the Paid Safe and Sick Leave:

  1. I must work 80 hours or more per calendar year (from January 1st to December 31st) in order to be covered by the Paid Sick Leave Law.
  2. I accrue 1 hour for every 30 hours worked, up to a maximum of 40 hours per calendar year.
  3. For new employees: I can use the accrued time after 120 days from my 1st workday.
  4. I am allowed to carry over any unused sick leave to the following year but can only use up to 40 hours of Paid Sick Leave per calendar year.
  5. I am required to provide 24/7 HomeCare with a health care provider's note if I use my sick leave time for four or more consecutive days, no specifics regarding my health is necessary.
  6. I may use Paid Sick Leave for sick leave ONLY and I must be scheduled in order to use sick leave. I must provide 24/7 HomeCare with 7 days of advance notice whenever possible; if I am presented with an unforeseeable situation, then I will provide a notice as soon as possible.
  7. I understand that if I call out or sick the day before or the day after a holiday I am scheduled to work, I will not get paid sick time even if I have it available.

NYC Temporary Changes To Work Schedule Law
Acknowledgement Of Receipt

The NYC Temporary Schedule Change Law, allows employees to temporarily change their schedule. A Temporary Change means an adjustment on the employees' usual calendar.

Employee Eliaibility

Any employee, who have been employed for 120 days or more and have worked 80+ hours per calendar year, is qualified.

The aides could make changes to up to:

-Two separate occasions of 1 business day each

Or

-One occasion for up to Two business days

You may use PTO or Sick and Safe Leave, if they have it available, you can also take leave without pay.

You must submit your request in writing before your leave or on the 2"^ day of your return.

Employees can take the Temporary Schedule Change for:

Personal event, which could be to care for a child under age of 18, to care for a person with disability who is a family or household member and relies on the employee for medical care or to meet the needs of daily living, the need to attend a legal proceeding, any other reason for the employee to use Paid Safe and Sick Leave.

Family member, any individual whose close association with the employee is the equivalent of family; child (biological, adopted, or foster, legal ward, or loco parentis), grandchild, spouse, domestic partner, parent, grandparent, child or parent of an employee's spouse or domestic partner, sibling, any other individual related by blood to the employee.

All requests for Temporary Schedule Change must be made through the Coordination Department.

I acknowledge that I have received the necessary information and instructions regarding the Temporary Schedule Change Law

CORPORATE COMPLIANCE / CONFLICT OF INTEREST
NON-SOLICITATION AND NONCIRCUMVENTION

As an employee of 24/7 Home Care Agency of NY, Inc I, ,understand that any attempt on my part to provide services to a patient without the knowledge of the agency would be harmful and damaging to the agency. I agree that during the term of my employment with the agency and for a period of ninety (90) days after the end of myemployment:

  1. I will not in any way, directly or indirectly, offer to provide services to any of the agenc/s patients without the agency's actual knowledge, authorization and consent.
  2. I will not in any way, directly or indirectly, accept a patient's offer to hire me directly without the agency's actual knowledge, authorization and consent.
  3. I will not in any way, directly or indirectly, actually provide services to any of the agency's patients without the agency's actual knowledge, authorization and consent.

I recognize that a breach of this agreement can result in harm to the agency and agree that in the event of such a breach, I will be liable to pay the agency a minimum of the full payment the agency would have earned had I not circumvented the agency, plus further damages to the extent allowed by law and that the agency shall be entitled to and may seek any and all additional remedies to the extent available by law.

LS 62 Notice to Wage Parity Home Care Aides - (cont'd)
Benefit Portion of Minimum Rate of Home Care Aide Total Compensation

Hourly Rate
Type of Supplement
Name & Address of Provider
Agreement/ Plan information
Supplement Number
$xxx
(Pension, Welfare, or Other)
Insert Name and Address of Company or Organization Providing Benefit
Identify plan or agreement that creates the benefit, e.g., Union Local No. 1 Collective Bargaining Agreement or Insurance Company X Benefit Plan
Supplement Number 1
Health & Welfare
Benefit & Risk Management Services P.O. Box 2140 Folsom, CA 95763
Summary Plan Description for the 2417 Home Care Agency of New York
Supplement Number 2
Annual Physical Compliance
Mobile Health 229 W 36th St. #10, New York, NY 10018
MEC Employee Benefit Plan
Supplement Number 3
Employer Paid Reimbursement Card
Ameriflex 2508 Highlander Way Carrollton, TX 75006
Amenflex Administrative Service Agreement
Supplement Number 4
JNS Benefit Management
J.N. SavastaCorp. 1350 Broadway NY. NY 10018
J.N. Savasta Corp. Administrative Service Agreement

*If wage supplements are paid as a single payment awed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

List any additional benefits and attach listing to this document.

Copies of the above listed agreements or summaries may be obtained by:

J.N. Savasta Corp.


Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate, allowances, supplements/benefits, and designated payday provided on this form (LS 62) attached and this addendum on the date given below.

My primary language is I have been given this notice in my primary language Yes No

Preparer's Name and Title:

Note 1: Benefit eligibility and costs outlined on separate provided grid and can also be found at JN Savasta

Note 2: Amounts accrue weekly, but enrollment in benefits is based on total monthly accruals from a month prior.

For example, total accruals in January determine eligibility and enrollment for March benefits. Costs for benefits outlined in previously referenced grid


LS 62 (9/20)