Application form

Step 1 of 15

This field is for validation purposes and should be left unchanged.

TREE'S OF LIFE HOMECARE LLC

Name

Start Date

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

After reviewing your personnel file, we found that you have missing or expired documents that needed to be addressed.Tree's of Life homecare is a licensed provider through the office of Healthcare Facility Regulation Division at Georgia Department of Community Health. Every year our agency is audited to ensure that we meet state guidelines for operating as a Private Home Care Provider. Kindly return

o Copy of Georgia Driver’s License

o Copy of Social Security Card

o CNA Certification

o CPR/First Aid Card

o TB Screening

o Employee Employment Questionnaire signed and dated

o Orientation Check List

o Job Responsibilities

o Company Code of Conduct/Ethics signed & dated

o Confidentiality Statement signed and dated

o Verification of Non-Abuse Statement signed and dated

o Known TB and Hepatitis Statement signed and dated

o Drug and Alcohol Consent/Statement signed and dated

o Name & Address of Emergency Contact

o Copy of Auto Insurance (If Applicable)

o Other: Resume

o Other: ______________________________________________

Please return this cover note with the requested item(s) by

Thank you,

Personnel Officer

Employment & Personal Data Form

Position Applied For :

Personal Information

Name

Preferred First Name

Email address

Mailing address

City/State/Zip

Country

Permanent address (if different from above) :

Phone: H ( )

Phone: W ( )

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Race

Current occupation

Have you ever been convicted of a felony? If yes, please explain

Program Information

Please list any languages that you speak excluding English

Emergency Contact Information

Name

Relationship

Address

Day Phone

Evening Phone

Current and Past Experience

Prior Volunteer Experience:

Employment History: Please attach a resume (Showing 5 years work History)or List below

Education

High School:

Name of Institution

Year Graduated

Field(s) of Study

Undergraduate:

Name of Institution

Year Graduated

Field(s) of Study

Graduate:

Name of Institution

Year Graduated

Field(s) of Study

Post-Graduate:

Name of Institution

Year Graduated

Field(s) of Study

Please describe any other formal, or informal, educational experiences that may be relevant:

Please list All Certifications and Licenses (Attach Copies):

Please list contact information for two professional and one personal references:

Signature of Applicant/Employee

Date

MM slash DD slash YYYY

For Office Use Only

Hired

Yes

Date

MM slash DD slash YYYY

Employers Signature

Date

MM slash DD slash YYYY

Employee Orientation

Date

MM slash DD slash YYYY

Time

Hours

Video or PAPER

COMPLETED

Initial

Date

MM slash DD slash YYYY

Upon completion of the orientation, please signify at the bottom that you fully understand the information provided to you.

Staff Signature

Date

MM slash DD slash YYYY

Person conducting orientation

Position

Date

MM slash DD slash YYYY

Completion Time

Hours

Minutes

Employee Emergency Contact Information

Employee Name

Address

City, State and Zip

Home Phone

Page or Cell Phone

IN CASE OF EMERGENCY CONTACT

1. Name

Address

Relationship

Home Phone

Page or Cell Phone

2. Name

Address

Relationship

Home phone

Page or Cell Phone

3. Name

Address

Relationship

Home Phone

Page or Cell Phone

Signature

Date

MM slash DD slash YYYY

Certificate of Abuse Statement

Employee Name

Date of Hire

MM slash DD slash YYYY

Job Designation

I certify that I have never been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of application.

Employee Signature

Date

MM slash DD slash YYYY

Employers Signature

Date

MM slash DD slash YYYY

Title

Certificate of Ethical Compliance

Employee Name

Date of Hire

MM slash DD slash YYYY

Job Designation

I am CPR & First Aid Certified, I Would Report to Tree's of life Homecare LLC., of Any Exposure to TB & Hepatitis B; Weather The Exposure Occurred On or Off the Job. I Shall Report the Exposure Immediately to Tree's of Life Homecare LLC.

Employee’s Signature

Date

MM slash DD slash YYYY

Supervisor’s Signature

Date

MM slash DD slash YYYY

CODE OF CONDUCT AND ETHICS

Tree's of Life Homecare - Staff Members Must:

• Respect all clients, client premises, and client property.

• Not use a client's phone for personal calls. Obtain permission before using a client's phone to call the office. No smoking and/or alcohol consumption while on duty.

• Depart from the client's home upon completion of duties.

• Complete all assignments before requesting the client to sign or initial time slips, service papers, or forms.

• Not perform any tasks outside of assigned duties.

• Be punctual to work and notify the Tree's of Life Homecare office when necessary.

• Not borrow or lend money, and not accept gifts or gratuities from clients.

• Not release any information or discuss any client with anyone other than a supervisor of services.

• Refrain from confrontational behavior while on duty.

• Refrain from bringing children or unrelated personal belongings to work.

• Obtain written permission from the client and authorization from Tree's of Life Homecare Management before being given a key to enter a client's home.

Acknowledgment:

I acknowledge the receipt of the Code of Conduct and Ethics of Tree's of Life Homecare.

Company Employee Name

Date

MM slash DD slash YYYY

Signature

CERTIFIED NURSING ASSISTANT/PERSONAL SUPPORT AIDE

Criteria-Based Job Description

Employee Name

Date of Hire

MM slash DD slash YYYY

Qualifications:

Current certificate to practice as a Nursing Assistant (Aide) in the State of Georgia; satisfactory criminal records; negative tuberculosis screening; free of communicable diseases; current certification in cardiopulmonary resuscitation (CPR) and emergency first aid; good verbal and written communication skills; and knowledge of the rules and regulations for Person Support Services (PSS).

Job Requirements:

Providing a combination of basic personal care tasks.

RESPONSIBILITY	EXPECTATION
Provide personal care to the client at client's home	- Accessible 24 hours a day - Assist client with bathing - Assisting client with toileting - Assisting client with dressing - Assisting client with general mouth care - Assisting client with grooming and shampooing hair
Provides housekeeper services for the client	- Vacuuming and sweeping client's house - Dusting and mopping client's house - Doing laundry for the client - Cleaning client's room - Changing linens in client's bed - Cleaning client's refrigerator - Cleaning client's stove
Provides Ambulation and Transfer Help	- Assisting client in and out of bed/wheelchair with or without the aid of lifts - Assisting client with walking - Encouraging physical activities
Provides Medically Related Services	- Observing and reporting changes in client's condition - Picking up prescription drugs for the client - Accompany client on medical appointments as time allows - Reminding client to take medication
Provides Home Management Services	- Helping client do grocery shopping - Assisting client in paying bills - Assisting client with food stamp or other application processes - Assisting client with scheduling medical appointments - Assisting in other errands as needed
Performs Other Responsibilities as Indicated	- Works as scheduled - Adheres to Personnel Code of Ethics - Adheres to policies and procedures - Presents neat, professional appearance - Demonstrates positive attitude - Promotes teamwork

Copy of Job Description Reviewed with CNA

Date

MM slash DD slash YYYY

CNA acknowledgement of receipt of Job Description

CNA Signature

Date

MM slash DD slash YYYY

Employer Signature

Date

MM slash DD slash YYYY

CERTIFIED NURSING ASSISTANT & COMPANION/SITTER SERVICES

Criteria-Based Job Description

Employee Name

Date of Hire

MM slash DD slash YYYY

Date of Evaluation

MM slash DD slash YYYY

Qualifications:

Job Requirements:

Companion or sitter positions require the ability to read, write, and follow instructions, and completion of training or passing a competency assessment, as appropriate. Requirements include understanding the needs of populations served, basic meal preparation, provision of transportation services, housekeeping, home safety, handling emergencies in the home, and infection control.

RESPONSIBILITY	EXPECTATION
Provide personal care to the client at client's home	- Accessible 24 hours a day - Assist client with bathing - Assisting client with toileting - Assisting client with dressing - Assisting client with general mouth care - Assisting client with grooming and shampooing hair
Provides housekeeper services for the client	- Vacuuming and sweeping client's house - Dusting and mopping client's house - Doing laundry for the client - Cleaning client's room - Changing linens in client's bed - Cleaning client's stove
Provides Ambulation and transfer help	- Assisting client in and out of bed/or wheelchair with or without the aid of lifts - Assisting client with walking - Encouraging physical activities
Provides Home Management Services	- Helping client doing grocery shopping - Assisting client in paying bills - Assisting client with food stamp or other application process - Assisting client with scheduling medical appointments - Assisting in other errands as needed
Performs other responsibilities as indicated	- Work as scheduled - Adheres to personnel Code of Ethics - Adheres to policies and procedures - Presents real, professional appearance - Demonstrates positive attitude - Promotes teamwork

Copy of Job Description Reviewed with CNA

Date

MM slash DD slash YYYY

CNA acknowledgement of review of Job Description

CNA Signature

Date

MM slash DD slash YYYY

Employer Signature

Date

MM slash DD slash YYYY

PERSONNEL CODE OF CONDUCT AND ETHICS

POLICY AND PROCEDURE

The manner in which Tree's of Life Homecare employs and conducts business is extremely important to our success. We have corporate responsibilities to ourselves, to our clients and to the community in which we do business in order to effectively provide premiere care and protect our corporate and professional image, we must strive to conduct our business in the most ethical manner possible. Each employee is expected to read, understand, sign, date and comply with the company’s code of ethics. Thus, it is not acceptable to:

Each employee is expected to read, understand, sign, date, and comply with the company's Code of Ethics. Thus, it is not acceptable to:

• Use the client's car for personal reasons.

• Consume the client's food or beverages.

• Use the client's telephone for personal calls.

• Discuss political or religious beliefs, or personal problems with the client.

• Accept gifts or financial gratuities (tips) from the client or client's representative.

• Lend money or other items to the client, or borrow money or other items from the client or client's representative.

• Sell gifts, food, or other items to or for the client.

• Purchase items for the client unless directed in the client care plan.

• Bring visitors to the client's home (children, friends, relatives, etc.).

• Smoke in the client's home, with or without permission.

• Report to duty under the influence of alcohol or drugs.

• Sleep in the client's house unless authorized in the service care plan.

• Remain in the client's home after services have been rendered.

• Falsify client records or timesheets.

• Not report any unusual changes or events with client during work hours

• Breach client/caregiver privacy or confidentiality of information and records in violation of HIPAA regulations.

• Assuming control of the financial or personal affairs, or both, of the client or his/her estate, including power of attorney or guardianship.

• Commit any act of abuse, neglect, or exploitation.

• Use the client's bathroom facilities or eat lunch/snacks without the client's consent.

Employee Responsibility

I understand that Tree's of Life Homecare is not responsible for any damages or cause of action for any injury resulting from use of my automobile to and from work. I also understand Tree's of Life Homecare is not responsible for the use of my automobile to run errands and/or transportation for client.

I understand that Tree's of Life Homecare is not responsible for any damages or cause of action for any injury resulting from use of client’s car to transport the client or go on errands for the client. I also understand Tree's of Life Homecare is not responsible for the use of my automobile to run errands and/or transportation for clients.

I clearly understand and agree that at all times I represent the interest of Tree's of Life Homecare and that I will continue to adhere to company confidentialities and policies.

Signature

Date

MM slash DD slash YYYY

Handling Client Funds

Policies and Procedures

Training shall be provided to all staff involved in handling client funds, including case managers, on their responsibilities. Invite other persons who are representative payees for clients of the agency to attend this training. Financial responsibilities shall be discussed at staff meetings to ensure that all the staff members understand the agency policies and procedures for handling client funds.

Recordkeeping and reporting – If the aide pay bills and purchase items for the client, Tree's of Life Homecare Aide shall maintain written records of client’s funds, and provide written periodic (monthly, quarterly or annual) reports detailing receipt and expenditures of funds, and also provide a copy of the report to clients, guardians, agents or designated representatives.

Record Retention – Keep records for at least three years, and longer if required by an oversight agency.

Signature

Date

MM slash DD slash YYYY

Cobb County Police Department
140 N Marietta Pkwy NE, Marietta, GA 30060
Phone: (770) 499-3900

CRIMINAL HISTORY REQUEST FORM

We are requesting a copy of the criminal history record/ information on the following individual:

Print Full Name

Signature

City, State, Zip

Sex

Race

Date of Birth

MM slash DD slash YYYY

Social Security #

Date

MM slash DD slash YYYY

We understand this information is given to us under the Georgia Open Records Act and we are solely liable for any use of the information.

Authorizing Signature

Date

MM slash DD slash YYYY

Form W-4 (2018)

Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply:

1. For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and
2. For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.

If you're exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Taxto learn more about whether you qualify for exemption from withholding.

General Instructions

If you aren't exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you're having withheld compares to your projected total tax for 2018. If you use the calculator, you don't need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.

Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you're married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P.

Nonresident alien. If you're a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions

Personal Allowances Worksheet

Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.

Line C. Head of household. Please note: Generally, you can claim head of household filing status on your tax return only if you're unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.

Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.

Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don't qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet.On the worksheet, you will be asked about your total income. For this purpose, total income includes all of

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Employee's Withholding Allowance Certificate

Whether you're entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

1. Name

First Middle Last

2. Your social security number

Home address (number and street or rural route)

City or town, state and ZIP code

3. Martial Status

Single

Married

Married, but withhold at higher Single rate

Note: If married filing separately, check "Married, but withhold at higher Single rate."

If your last name differs from that shown on your social security card. You must call 800-772-1213 for a replacement card.

5. Total number of allowances you're claiming (from the applicable worksheet on the following pages)

6. Additional amount, if any, you want withheld from each paycheck($0.0)

7. I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption:

1. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
2. This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write "Exempt" here

N/A

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

Employee's signature

(This form is not valid unless you sign it.)

Date

MM slash DD slash YYYY

8. Employer's name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9. First date of employment

MM slash DD slash YYYY

10. Employer identification number (EIN)

BANK DIRECT DEPOSIT INFORMATION

Name of Employee

Type of Account

Savings

Checking

Name of Bank

Routing Number

Account Number

Email Address

Signature

Date

MM slash DD slash YYYY

Upload Documents

DRIVER'S LICENSE

Max. file size: 512 MB.

RESUME

Max. file size: 512 MB.

CPR Card

Max. file size: 512 MB.

TB TEST

Max. file size: 512 MB.

RN REGISTRY

Max. file size: 512 MB.

CPR CERTIFICATE

Max. file size: 512 MB.

PPD TEST SCREENING WITHIN THE YEAR

Max. file size: 512 MB.

VALID DRIVER'S LICENSE

Max. file size: 512 MB.

SOCIAL SECURITY CARD

Max. file size: 512 MB.

FINGERPRINT BACKGROUND CHECK

Max. file size: 512 MB.

Application form

TREE'S OF LIFE HOMECARE LLC

Employment & Personal Data Form

Personal Information

Program Information

Emergency Contact Information

Current and Past Experience

Education

For Office Use Only

Employee Orientation

TOPICS

COMPANY POLICY & PROCEDURE

Job Description/Duties

Procedures for reporting client progress and problems to supervisors

Service Papers & Daily log

Reporting client progress

Procedures for handling medical emergencies and incidents

Client Rights and responsibilities

Reporting known exposure to TB and hepatitis.

Code of Conduct/Dress Code

Infection Control

Confidentiality of Client information.

Procedure for reporting & handling complaints

Miscellaneous:

Employee Emergency Contact Information

IN CASE OF EMERGENCY CONTACT

Certificate of Abuse Statement

Certificate of Ethical Compliance

CODE OF CONDUCT AND ETHICS

CERTIFIED NURSING ASSISTANT/PERSONAL SUPPORT AIDE

Criteria-Based Job Description

CERTIFIED NURSING ASSISTANT & COMPANION/SITTER SERVICES

Criteria-Based Job Description

PERSONNEL CODE OF CONDUCT AND ETHICS

POLICY AND PROCEDURE

Employee Responsibility

Handling Client Funds

CRIMINAL HISTORY REQUEST FORM

Form W-4 (2018)

General Instructions

Specific Instructions

Personal Allowances Worksheet

Employee's Withholding Allowance Certificate

BANK DIRECT DEPOSIT INFORMATION

Upload Documents

Schedule Consultation

Let's Talk