REFERENCE #1

REFERENCE #2

REFERENCE #3

If yes, please describe the date and nature of the offense.

EMERGENCY CONTACT #1

EMERGENCY CONTACT #3

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize URGENT HOME CARE to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.

I agree not to do business directly with any individual or business entity that URGENT HOME CARE has introduced to me or by entering into employment with such individuals or businesses.

You need to report to your supervisor if your member is hospitalized, you can accompany your member to the hospital and stay until your hours are over or your time automatically ends when your member is admitted. When your member returns home you cannot go back to work without your supervisor’s permission. Even if the member calls you and tells you they are from the hospital, you cannot go back to work until your supervisor tells you to. Please call your supervisor.

• Your supervisor is the only person who can change or add to your hours. If your member’s hours change please call your supervisor before making any changes in your hours.
• You need to notify the supervisor of any changes in your member’s condition for example skin changes; member falls; changes in the member’s speech; medications etc.
• Report any injuries to you or your member, and immediately call the supervisor on duty.
• You are not allowed to change bandages, cleanse wounds, call in prescriptions or pick- up over-the-counter medicine such as aspirin, Advil, suppositories, cough medicine, etc.
• You can only be in your member’s home when your member is there.
• Affectionate relationships with your member or their family are not allowed. Carrying any type of weapon on the job is not allowed. Having keys to your member’s home is allowed only when an agreement is signed by your member, your supervisor and you, otherwise having keys to your member’s home is not allowed. The above can cause disciplinary action up to and including termination.
• You are required to wear your badge and dress according to the dress code policy, attend training, or whenever you come into the office.
• You need to be on time with your member. If you are going to be late even ten minutes you must call your member to let them know, then call the office and leave your supervisor a message if you are a NO CALL OR NO SHOW to your member it can cause disciplinary action, up to and including termination.
• You are required to give Urgent Home Care, 2 hours’ notice when calling off. Please call the office at (602) 687-9625 between 8:00 am – 5:00 pm Monday through Friday and the same number for after-hours calls.
• If someone is dropping you off please have him or her leave immediately or if picking you up, please have him or her come at the end of your shift no sooner.
• All cell phones must be put on vibrate. Only emergency phone calls can be returned, please inform your member or your need to return the phone call. Step outside when returning a personal call. If you need to use the member’s phone please ask their permission.
• Do not give out your personal numbers to your member or their family. Please keep your personal problems to yourself.
• Expect unannounced visits from your supervisor.
• You are not to eat the member’s food. Please bring your food with you.
• Some member’s are sensitive to certain smells, such as perfume, lotions, etc. Please use caution when using these products.
• You cannot bring family, children, or pets to work.
• You may not borrow anything from your member or their family this includes money, food, appliance, clothing, etc.
• You may not drive your member's car.
• You cannot smoke in your member’s home, even if the member does.
• You do not move furniture, clean, ceiling fans, wash walls or clean the outside of windows, clean up after animals, babysit children, do any kind of yard work, or clean up after family members.
• Remember you’re a caregiver, not a maid. Your job makes a difference in a member’s life. When you have a problem we need to know so we can assist you in solving the problem. We care about you. Please report by way of your member Care Supervisor any problems or concerns you have. Always show respect for your members and their family.

URGENT HOME CARE, Inc. (“the Company”) does not discriminate in hiring or employment on the basis of race, color, religion, sex, gender identity, sexual orientation, national origin, age, disability, veteran status or status within any other protected group. No questions on this application are intended to secure information to be used for such discrimination. Pursuant to the Americans With Disabilities Act, it is the Company’s policy to hire qualified individuals with a disability as long as the individual can perform the essential functions of the job, with or without reasonable accommodation. In connection with the Company’s consideration of me for employment, continued employment, promotion, or reassignment or as part of an investigation, I understand that the Company or persons acting on its behalf may conduct investigative inquiries into my background that will include information regarding job reference, personal reference, criminal, consumer credit, driving, and other reports pertaining to me. These inquiries may include personal conversations with persons possessing knowledge relevant to these categories. These background inquiries will be conducted and reports obtained to provide the Company with job-related information regarding my character, general reputation, personal characteristics, work record and characteristics, skills and abilities, education and training, employment and experience, past job performance, reasons for termination of previous employment and other pertinent information. I hereby consent to the Company, or persons acting on its behalf, obtaining the above stated information, I authorize, without reservation, any person or entity contacted by the Company or anyone acting on its behalf to furnish the above-stated information, and I release any such person or entity from any and all liability for furnishing such information. I also release the Company from any and all liability for conducting such an investigation. I understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of the investigation(s). In addition to authorizing the release of any information regarding my employment and background, I hereby fully waive any rights or claims that I have or may have against my former employers, their agents, employees and representatives regarding the release of information and release them from any and all liability, claims, or damage that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the Company or persons acting on its behalf to make these investigations, and to use job-related information obtained in its employment decision, including but not limited to, the truthfulness of my responses to the Company’s employment inquiries. I hereby state that all information that I provide on this application and in any interview is true and accurate. I am aware that false statements, misrepresentations of facts, or material omissions may be sufficient to disqualify me for employment, or if employed, may result in my termination. I have not signed any employment agreement or other agreement which limits the type of job I might accept in the future, or which limits for whom I might work in the future, with any employer by whom I have been employed at any time during the past two (2) years. If a job offer is extended, my initial and continued employment will be conditioned upon execution of agreements, if appropriate, with regard to invention, patent, confidentiality and non-competition. If employed, I will be required to provide proof of identity and legal work authorization, and I must meet the minimum age requirements of applicable laws. I understand and acknowledge that there have been no oral or written representations made promising or guaranteeing employment or continued employment. I understand that the Company is required to comply with Electronic Visit Verification implemented by the State of Arizona. To comply with the EVV requirements, the Company has implemented Sandata, an electronic application to record hours worked and tasks/visits completed. I agree to fully and accurately use the Sandata system and understand that, if hired, my compensation is based on the information I enter into Sandata and confirmed by the member as accurate and correct. I understand that nothing contained in this application, offer letter, or in the interview process is intended to create an employment contract between the Company and me. If I am employed, I have a right to terminate my employment at any time and for any reason. Similarly, the Company may terminate my employment at any time, with or without notice and with or without cause. The Company is an at-will employer. I further understand that no representative of the Company has any authority to enter into any agreement with me for any specified period of time or to guarantee some other benefit, other than the President and any such agreement must be in writing to be effective. Supervisors do not have the authority to make oral agreements guaranteeing employees’ future promotions, pay raises, benefits, reassignments or transfers. Any such assurances must be in writing and signed by the President to be enforceable. This statement applies to the period prior to or after I may be employed. I understand that my application for employment will be considered active for 60 days. After the expiration of 60 days, and, if I still desire to be considered for employment, it will be necessary for me to complete a new application.

URGENT HOME CARE INC. provides care and companionship services to members. While we provide a broad range of services URGENT HOME CARE DOES NOT provide transportation services. Employees are strictly prohibited from transporting members in the employee’s personal vehicle or in the member's vehicle or any other vehicle. You may accompany the member as a passenger if the member is being transported by an independent transportation service to doctor’s appointments or other appointments, but employees are strictly prohibited from driving members while on working hours for any reason. Driving or transportation is not a service offered by URGENT HOME CARE INC. and URGENT HOME CARE INC. does not have any liability or responsibility to the employee or member if employee violates the policy. Employee may be held liable for all damages and expenses involved if they are transporting a member in violation of this policy and are in an accident. Employees who are providing care and companionship to family members are subject to this policy and may not transport members during working hours. If the family member employee provides transportation to a family member during working hours, it is a violation of this policy and grounds for disciplinary action, up to and including termination of employment.

EMPLOYMENT ACKNOWLEDGMENT 

I understand and agree that I am not permitted to transport members during my working hours, either in my personal vehicle, the members, or any other vehicle, I agree not to drive the member around for any reason while on working hours. I understand and agree that if I provide transportation or driving services to a member in violation of this policy, I will be solely liable for any damages and the Company will not be liable for any damages or costs that may result from my violations of this policy. If I am providing care and companionship services to a family member, I understand that any transportation of my family member should be done outside of working hours. I expressly understand and agree that when transporting a family member for any reason, I am acting as a family member of the member, not as an employee of URGENT HOME CARE INC. I understand and agree that I will be solely liable for any damages and the Company will not be liable for any damages or costs that may result from my violations of this policy. I understand and agree to comply with the Company’s policies, and procedures. I further understand and agree that I am an at-will employee, meaning that the Company or I can terminate my employment at any time, for any reason, with or without notice and with or without cause.

• To be treated with dignity, respect, and consideration;
• To not be treated unfairly because of your race, religion, gender, age, disability, or financial status;
• To have all personal information about you kept confidential, including but not limited to financial and social information;
• To have all medical and treatment information and records kept confidential;
• To receive care of the highest quality;
• To request a change in care providers;
• To have private conversations and communication with the Member Lead Care Coordinator or other management and support staff of URGENT HOME CARE; and
• To be given information regarding the complaint process and to file a complaint without fear of reprisals or interference with service, and to be provided information about the disposition of any complaint.

RESPONSIBILITIES AS A MEMBER (EMPLOYEE) OF URGENT HOME CARE INC.: 

• To treat URGENT HOME CARE personnel with respect and consideration;
• To provide a safe home environment in which your care can be provided and received; • To participate in planning the care and in planning changes in the care provided by your caregiver and receive an explanation of any proposed services;
• To provide accurate and complete information about matters related to your health and any changes to your medical condition;
• To call the Member Lead Care Coordinator, if you have any problems with our caregiver or if there is a misunderstanding or confusion over the caregiver’s duties.
• To notify your Member Lead Care Coordinator as soon as possible, if you are not going to be home for your visit; and

• To notify your Member Lead Care Coordinator as soon as possible of any change of address or phone number.

Caregiver must complete DCW training within 90 days of their effective date of employment. The DCW class is a state mandatory class. DCW classes are held in our office. If you have any questions regarding DCW classes please contact our office. During the DCW class you will cover the following:

• Roles and Responsibilities within the Agency and Community
• Ethical and Legal Issues
• Communication and Cultural Competency
• Job Management Skills/Time Management
• Infection Control
• Safety and Emergencies Nutrition and Food Preparation
• Home Environment Maintenance
• Chronic Diseases and Physical Disabilities
• Philosophy and Values of Providing Care and Support
• Physical and Emotional Needs of an Individual
• Transfers and Positioning
• Personal Care
• Activities and Activity Planning
• Dementia-Specific Care
• Grief and End-of-Life Issues

I understand and agree that it is my responsibility to become proficient in the competencies listed above. I agree to comply with all company policies, practices, and procedures. I further understand that violations of the company’s policies, practices, and procedures may lead to disciplinary action up to and including termination of employment.

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

Some employees. Eligible employees are all full-time employees. Full-time employee is defined as an employee who works an average of 30 hours or more per week or 130 hours or more per month.

With respect to dependents: We do offer coverage. Eligible dependents are children up to age 26 and spouses: this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

Acknowledgment Of Receipt

In compliance with the Electronic Visit Verification requirements from the State of Arizona, the Company requires all DCWs to use the Sandata app to record all hours worked and all visits and activities with clients. Employees must be 100% honest and accurate recording their hours of work. Employees are required to clock in at the beginning of each shift and clock out at the end of each shift. Failure to accurately clock in and out on Sandata may result in disciplinary action, up to and including separation of employment. The Company’s payment for the services you provide, and your payment from the Company, are dependent on the information in Sandata, as verified by the member. Therefore it is essential that it be absolutely correct. All employees using the Sandata App must sign and agree to comply with the following acknowledgment:

1. I understand that I must accurately record all hours worked, including accurately recording the exact time that I start work and the exact time that I stop work and all meal breaks, and I agree to be 100% accurate in recording my time every day in Sandata.
2. I understand that by submitting my time in Sandata, I am representing and confirming that I worked all of the hours that I recorded in Sandata.
3. I understand that if I am not 100% accurate on my time record, I am subject to disciplinary action, up to and including termination of my employment.
4. I understand that failing to clock in or failing to clock out may result in disciplinary action, up to and including termination of my employment. I further understand that failure to accurately clock in and clock out may delay my paycheck.
5. I understand that I must accurately record all the hours that I work, including any overtime hours, whether or not I have received approval for overtime and will report to Human Resources if anyone tells me not to accurately record my hours of work.
6. I agree to review my time cards and paycheck within 14 days after receiving my paycheck and contact Human Resources or Payroll if I have any questions or concerns about my pay.
7. I understand and agree to comply with all Company policies, practices and procedures. I understand that any violation of Company policies, practices, and procedures may result in disciplinary action, up to and including termination of employment.
8. I understand that I am employed at will and that I and the Company both have the right to terminate my employment at any time, for any reason or no reason, with or without notice, and with or without cause.