564 CAREGiver Application Letter 031412...CAREGiver_Employment_Application_03142012.docx Page 5 of 5...

Home Instead Senior Care of Gainesville4061 NW 43rd Street, Suite 11, Gainesville, FL 32606 Phone: 352-336-3388 Fax: 352-336-0866

AAA Marinelli Home Care Agency, Inc., d.b.a. is an independently owned and operated Home Instead Senior Care franchise serving Alachua,Bradford, Columbia, Levy, Putnum & Union Counties. Lic# 232373

Dear Applicant;

Thank you for applying with us! Home Instead Senior Care of Gainesville may offer wonderful

CAREGiving opportunities for you! We provide services to seniors in Alachua & Bradford Counties.

To be considered for employment, your first step is to complete this application packet and drop it off

along with the following original documents. You may drop-off your packet at Home Instead Senior

Care, 4061 NW 43rd Street, Suite 11, Gainesville, FL 32606 on Monday’s or Tuesday’s, between the

hours of 1:00pm-4:00pm.

Original documents needed at the time of drop-off:

1. Florida Driver’s License (out-of-state licenses not accepted)

2. Social Security card

3. Current Automobile Insurance card

4. Current CPR card (only provide if your CPR card is current and not expired)

Other Requirements to Note:

Because we are a governed by State Regulations, and more importantly because we care very much

about our senior Clients, we require all applicants to pass the following screenings before being placed

in a Clients home. (Please note: Screenings are State Required. There are State fees associated in order

to obtain them.)

State Required Screenings:

1. Level-2 Fingerprint Screening through the Agency for Health Care Administration (AHCA) $51.45

2. 7-year Motor Vehicle Report (MVR) (Suspended License and DUI are disqualifying offenses)

$12.00

Home Instead Requirements:

1. CPR (Please note: CPR is not required at the time of drop-off, however, Home Instead requires

all applicants to be CPR certified prior to employment.)

2. Physician’s Statement of Health and TB Screening (Please note: Physician’s Statement and TB

Screening are not required at the time of drop-off, however, Home Instead requires all

applicants to obtain a physician’s Statement of Health and TB screening prior to employment.)

3. Reliable transportation

4. Pre-employment Drug Testing

What happens next after you apply? You will be contacted either by phone or by mail within 5 businessdays. Our friendly staff is available to assist you if you have any questions.

AAA Marinelli Home Care Agency, Inc., d.b.a. is an independently owned and operated Home Instead Senior Care franchise serving Alachua, Bradford, Columbia,Levy, Putnum & Union Counties. Lic# 232373

CAREGiver_Employment_Application_03142012.docx Page 1 of 5

AAA Marinelli Home Care Agency, Inc.DBA: An independently owned and operated Home Instead Senior Care Franchise

Gainesville Office: 4061 NW 43rd St., Suite 11,Gainesville, Fl. 32606Phone: 352-336-3388

EMPLOYMENT APPLICATION

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify theperson who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

Please read "Applicant Note” below. Complete all pages of this application. Print clearly. Incomplete or illegible applications may not be accepted. If more space is needed to complete any question, use comments section on the back. Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us, anindependently owned and operated Home Instead Senior Care franchise. This is not an employment contract. Please answer allappropriate questions completely and accurately. False or misleading statements during the interview and on this form are groundsfor terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicantswill receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, nationalorigin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs inyour body is required prior to employment.

PERSONAL INFORMATION

Today’s Date: ______________

Positions(s) Applied For: ____________________________________________________

Name: _______________________________ _________________________________ _____________________Last First Middle

Current Address: _________________________________ _______________________ ______ ____________Street City State Zip Code

Home Phone: (______) ___________________ Work Phone: (______) ______________________

Cell Phone: (______) _____________________ Alternate Phone: (______) ____________________

Other Names Previously Used:

____________________________________ __________________________________ ____________________Last Name First Name Middle Name

Emergency Contact(s): ____________________________________ (______) ____________________Name Phone

____________________________________ (______) ____________________Name Phone

Have you ever submitted an application here before? Yes / No If yes, when? _________________________________

Have you ever been employed here before? Yes / No If yes, when? ________________________________________

You have been given a copy of the job description for the position for which you have applied. Are you able to perform the essentialfunctions of the job for which you are applying with or without a reasonable accommodation? Yes / No

How did you hear about our Home Instead Senior Care franchise office? ___________________________________________

Why are you interested in employment with us? _____________________________________________________________

_________________________________________________________________________________________________

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or theamount of hours worked.

What date are you available to begin work? ___________

Please complete all areas of availability:

____Full-Time (30 or more hours/week) ____Part-Time (less than 30 hours/week) Hours/Week Desired: _________Mornings ____Afternoon _____Evenings ____Overnights ____Live-In____Weekdays ____Weekends

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

PREFERENCES

Please indicate all areas in which you are willing to work:

Bradford Area: ___ Starke ___ Keystone Heights ___Melrose ___ Lawtey ___ Baldwin ___ Macclenny

Duval Area: ___ Downtown ___Westside ___Northside ___Ortega ___Riverside ___Avondale

Clay Area: ___Middleburg ___Orange Park ___Green Cove Springs ___Lake Asbury ___Penny Farms

Gainesville: (list areas) ______________________________________________________________________

Please indicate the types of services which you are willing to provide:

Companionship Housekeeping (dust/vacuum) Errands/Shopping*Meal Preparation Laundry/Ironing Incidental Transportation*Activities (games/crafts) Medication Reminders Dementia/Alzheimer’s Care

*In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license andcurrent auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required.

Are you willing to provide service to a client with a pet? Yes / No If yes, which ones: ___Cats ___Dogs

Are you willing to provide service to a client that smokes? Yes / No

JOB RELATED SKILLS

Describe any training or life skills you have that apply to caring for a senior: ________________________________________

________________________________________________________________________________________________

Describe any work history you have that would apply to caring for a senior: ________________________________________

________________________________________________________________________________________________

What do you like (or think you would like) most about working with older adults? ___________________________________

________________________________________________________________________________________________

What do you like (or think you would like) least about working with older adults? ___________________________________

________________________________________________________________________________________________

EDUCATION

Please circle highest grade completed:

Grade School: 6 7 8 High School: 9 10 11 12 College: 13 14 15 16 16+

School Type School Name City, State Major/Subject # Yrs Attended Graduate

High School Y / N

Vocational/Technical Y / N

College/University Y / N

WORK HISTORYYour application will not be considered unless all questions in this section are answered. Since we will make every effort to contactprevious employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER

Are you currently working for this employer? Yes / No If yes, may we contact? Yes / No

__________________________________ ________________________ _______ ( _____ )_______________________Company Name City State Phone Number

Dates Employed: From ___________ to ___________ _____________________________ ______________________________________Job Title Supervisor's Name

______________________________________________________________________________________________________________________Duties

$_____________ per __________________ ____________________________________________________________________________Salary (Hour, Week, Month) Reason for Leaving

SECOND MOST RECENT EMPLOYER

____________________________________ ________________________ _______ ( _____ )_____________________Company Name City State Phone Number

Dates Employed: From ___________ to ___________ _____________________________ _______________________________________Job Title Supervisor's Name

______________________________________________________________________________________________________________________Duties

THIRD MOST RECENT EMPLOYER

____________________________________ ________________________ _______ ( _____ )_____________________Company Name City State Phone Number

Dates Employed: From ___________ to ___________ _____________________________ _______________________________________Job Title Supervisor's Name

______________________________________________________________________________________________________________________Duties

BACKGROUND

As a condition of employment all employees must be “Bondable”.

List states and counties of residence for the past seven (7) years:

________________________ ____________________________ ______________________ ____________________________State County State County

Have you had any moving traffic violations? Yes / No If yes, please describe: _______________________________

Have you been convicted of a felony or misdemeanor in the past seven (7) years? Yes / No If yes, please describe:

Incident City/State Result

1) _____________________________________________________________________________________________

2) _____________________________________________________________________________________________

REFERENCES (Do not include relatives)

Please complete all six references (three professional/three personal). Your application will not be considered unless six referencesare provided. Since we will contact these references, please notify them in advance.

Full Name Phone NumberBest Time ofDay to Call Relationship

Number ofYears Known

1)H ( )W ( )

AM / PMAM / PM

2)H ( )W ( )

AM / PMAM / PM

3)H ( )W ( )

AM / PMAM / PM

4)H ( )W ( )

AM / PMAM / PM

5)H ( )W ( )

AM / PMAM / PM

6)H ( )W ( )

AM / PMAM / PM

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one of this form andthat the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of myknowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may resultin rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including

consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle drivingrecords. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning mybackground and hereby release any said persons, schools, companies and law enforcement authorities from any liability for anydamage whatsoever for issuing this information. I release this company from any liability which might result from making suchinvestigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testingto detect the use of illegal drugs prior to and during employment.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT. I ALSO UNDERSTAND THAT IF HIRED,REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF ANDAAA Marinelli Home Care Agency, Inc. IS TERMINABLE AT-WILL, SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSETO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIPMUST BE MADE IN WRITING.

________________________________________________________ ____________________

APPLICANT SIGNATURE DATE

AAA Marinelli Home Care Agency, Inc., d.b.a. is an independently owned and operated Home Instead Senior Care franchise servingAlachua, Bradford, Columbia, Levy, Putnum & Union Counties. Lic# 232373

Pre-Interview Questionnaire(We want to get to know YOU!)

1. Tell us a little about yourself (e.g. interests, hobbies, likes, dislikes, etc.)

2. Do you consider yourself an extrovert or introvert (outgoing or shy)? Do you talk orlisten best?

3. Do you enjoy cooking? If so, what is your best dish?

4. What emergencies would require you to call and change your schedule?

5. Tell me about your responsibilities in your previous (or current) job. Which did youlike most and why? Also, which did you like the least and why?

6. Why are you considering leaving or why did you leave your current/last job?

7. What attracts you to this job in our company? Why?

8. How would you describe yourself as an employee? What are your strengths? Whatthings do you think you might need to improve?

9. Give me an example of a time when you were under a lot of pressure and stress atwork or school?

10. What type of people do you like best? And least? Why?

11. What do you think will be the most important things to say or do when working withpatients and their families?

12. Describe a situation in which you saw someone “go the extra mile” for a customer ora patient?

AAA Marinelli Home Care Agency, Inc.4061 NW 43rd Street, Suite 11

Gainesville, FL 32606

Phone: 352-336-3388

Name of Service Description Rate of Pay

Assist with walking and light exercise.

meal preparation (client only) and

related clean up, reading & writing

letters, mending, encouraging client by

participating in mind stimulating

activities.

Special Service*4 hour shift

Rise n' Shine or

Tuck-In Service1.5 to 2 hours

Includes Companionship and Home Helper services

listed above.

AAA Marinelli Home Health Agency, Inc., d.b.a. is an independently owned and operated Home Instead Senior Care franchise serving Alachua, Bradford, Columbia,

Levy, Putnam & Union Counties. Lic# 232373

4061 NW 43rd Street, Suite 11, Gainesville, FL 32606 Phone: 352-336-3388 Fax: 352-336-0866

Home Instead Senior Care of Gainesville

Sleep-Over Service8 hour shift

Companionship in addition to assisting client into

bed and throughout the night. Preparation of

morning meal and clean up.

Sleep-Over in addition to being up three or more

times during the night with the client.Long Night Service

The following holidays are paid at time & one-half of the above rates: New Years Day, Easter, Memorial Day,

July 4th, Labor Day, Thanksgiving, Christmas Eve and Christmas Day.

$12.00 addt'l added to flat rate

$7.70 to start

$8.50 per hourAfter training completed/90 day eval.

$20.00 to start

$24.00 Flat RateAfter training completed/90 day eval.

$7.70 per hour8 Hour Shift

Deeper, more detailed housekeeping.

*Please note: Must obtain prior approval from the

office for Special Services pay rate.

CAREGiver Descriptions & Pay RatesDetailed job descriptions can be located in the Home Instead Senior Care CAREGiver Handbook.

Change linens, laundry and pressing, light

housekeeping, pet care, incidental transportation

and running errands. Dusting and polishing

furniture, meal preparation for client's future

comsumption.

Home Helper4 hour shift

Companionship4 hour shift

$7.70 per hour

$7.70 to start

$8.00 per hourAfter training completed/90 day eval.

AAA Marinelli Home Care Agency, Inc., d.b.a. is an independently owned and operated Home Instead Senior Care franchise serving Alachua, Bradford,Columbia, Levy, Putnum & Union Counties. Lic# 232373

Drug_Alcohol_Policy_031412.docx Rev.03-14-12

DRUG AND ALCOHOL POLICY

POLICYDrug and alcohol abuse adversely affects the health and safety of employees and compromises theirability to provide services to our clients. Therefore, AAA Marinelli Home Care Agency, Inc., d.b.a. anindependently owned and operated Home Instead Senior Care franchise (“the Company”) is committedto maintaining a work environment free from the adverse impact of employee alcohol and drug abuse.

Prohibitions:

A. The use, possession, sale, transfer, offering or furnishing of illegal drugs or other controlledsubstances (as defined under state and federal law), and the possession of implements andparaphernalia for the illegal use of drugs, while on duty, while on the Company’s premises(including parking lots), while operating a vehicle leased or owned by the Company, or whileperforming services for or on behalf of the Company, is strictly prohibited.

B. Except as provided below, the Company prohibits the use of alcohol by personnel directlybefore or during the workday, including lunch and breaks. The use of alcohol during the workday under Company-related and approved circumstances (whether on or off the Company’sproperty) such as the Company’s representative luncheons or dinners; specific celebrations;while conducting other Company-related business or socializing; or while otherwiserepresenting the Company, is permitted only to the extent that it does not lead to impairedperformance, inappropriate behavior, endanger the safety of any individual, or violateapplicable law.

C. Unless otherwise authorized by this policy, reporting to work, returning to work, being orremaining at work, while under the influence of alcohol, illegal drugs, or any other controlledsubstance (not specifically prescribed by the employee’s medical provider), or having any ofthe substances in your system while on duty, while on the Company’s premises, whileoperating a vehicle leased or owned by the Company, or while performing services for or onbehalf of the Company, is prohibited.

D. Off duty abuse of alcohol which results in excessive absenteeism or tardiness or is the cause ofaccidents or poor performance will result in corrective action, up to and including termination,in accordance with the Company’s policies regarding absenteeism, tardiness, poor performanceand unsafe work practices.

E. Off-the-job illegal drug use or activities, or convictions relating to such illegal drug use oractivities, is also a violation of this policy. Off-the-job illegal drug use or activities orconviction relating to such use is likely to adversely affect the organization in many ways,including without limitation, one or more of the following: adverse effect on job performanceor attendance, jeopardizing the safety or welfare of the employee, fellow employees, and/or theorganization’s clients, risking damage to company business or property.

Prescribed and Over-the-Counter Drugs:

This policy does not prohibit the use of a therapeutic drug unless such therapeutic drug affects theemployee’s capacity to properly perform job duties or creates a danger to him/her or to others in thework place. “Therapeutic Drugs” include legally obtained prescription drugs, controlled substancesand over-the-counter drugs used in accordance with the related prescription and/or directions.

Any employee whose use of any therapeutic drug(s) may affect his/her capacity to properly performjob duties or may create a danger to himself/herself or to others in the work place is required to reportthe therapeutic drug use to the human resources manager. An employee may be allowed to continue towork, even though under the influence of a therapeutic drug, if the Company has determined, afterconsultation, that the employee does not pose a threat to his/her own safety or health or the safety orhealth of other employees, and the employee’s job performance is not significantly, detrimentallyaffected by the therapeutic drug. Otherwise, the employee may be required to take a leave of absenceor comply with other appropriate action determined by the Company.

Administration of Policy:

ReportingEmployees are required to notify their supervisor if they have any evidence or reason to believe thatthe policy and rules set forth above have been, or are being violated. If an employee feels theirsupervisor is involved, they should notify the CEO or the Human Resources Manager. Failure toappropriately notify or report such conduct may also be grounds for appropriate corrective action. Anemployee found to be in violation of this policy may be subject to corrective action up to and includingdischarge.

Drug and Alcohol TestingTo ensure compliance with this policy, The Company reserves the right to require employees toundergo blood tests, urinalysis or other procedures designed to detect the presence of alcohol or theillegal use of drugs under the circumstances described below.

1. Post-Offer/ Pre-Employment Testing: After a conditional offer of employment is extended, alljob applicants will be subject to pre-placement drug and alcohol testing. When the applicanthas an initial screen positive test result for alcohol, an illegal drug, or an unprescribed,controlled substance, the conditional offer of employment will be withdrawn and the applicantwill not be employed by the Company.

2. Work-Related Accidents: Employees involved in work-related accidents resulting in anybodily injury (either to themselves or to others) or property damage will be subject to drug andalcohol testing.

3. Reasonable Suspicion: The Company reserves the right to test those employees managementreasonably suspects may be violating any portion of this policy.

4. Post-Treatment/ Post-Rehabilitation Testing: Employees who successfully complete anapproved counseling or rehabilitation program pursuant to this policy may be subject tounannounced testing.

Any employee who (a) fails to cooperate with an investigation into possible violations of this policy;(b) refuses to sign the consent to or to take, a drug or alcohol test; or (c) tampers with any sample ortest result will be subject to corrective action, up to and including termination.

Confidentiality:

Results of drug and alcohol tests will be kept confidential. Only those individuals who need to knowtest results will be notified of or permitted to review the results.

Employee Assistance:

The Company encourages employees with alcohol and/or drug abuse issues that may impact jobperformance to seek assistance from qualified professionals. It is the responsibility of the employee toseek assistance from qualified professionals before alcohol and/or drug problems are discovered by theCompany. Any attempt by an employee to seek such assistance after a violation of this policy hasbeen detected may have no effect on the corrective action, up to and including discharge, which theCompany may determine, in its sole management discretion, is appropriate. The Company mayrequire an employee who has violated any portion of this policy, and whom the Company, in its solemanagement discretion determines will be allowed the opportunity to continue employment, to seekassistance from qualified professionals or participate in a rehabilitation program, at the employee’sexpense, as a condition to any continued employment with the Company.

Searches:

The Company reserves the right to conduct searches of the company’s premises, including work areas,rest areas, parking lots, offices, company vehicles, desks and cabinets. In addition, the Companyreserves the right to conduct searches of employee possessions, including purses, briefcases, or motorvehicles, while the employee is on company property or on duty. The Company also reserves the rightto take custody of and submit for testing any item, article, or substance it discovers during a search thatappears to the company may be evidence of a violation of this policy. Searches may be conducted atany time without advance notice. Any employee who refuses to cooperate with such searches will besubject to corrective action up to and including discharge.

I acknowledge that I have reviewed and received a copy of the Drug and Alcohol Policy. I understandI am responsible for reviewing the information contained herein and will seek clarification orverification where necessary.

___________________________________ _____________________Employee Signature Date

___________________________________ _____________________Supervisor Signature Date

AHCA Form # 3100-0008, August 2010 Section 59A-35.090(3)(b)2, Florida Administrative CodePage 1 of 3 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

Authority: This form may be used by all employees to comply with:

the attestation requirements of section 435.05(2), Florida Statutes, which state that every employeerequired to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting therequirements for qualifying for employment pursuant to this chapter and agreeing to inform the employerimmediately if arrested for any of the disqualifying offenses while employed by the employer; AND

the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which requiresproof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provideror professional licensure requirements of the Agency, the Department of Health, the Agency for Persons withDisabilities, the Department of Children and Family Services, or the Department of Financial Services for anapplicant for a certificate of authority or provisional certificate of authority to operate a continuing careretirement community under chapter 651 if the person has not been unemployed for more than 90 days.

This form must be maintained in the employee’s personnel file. If this form is used as proof of screening for anadministrator or chief financial officer to satisfy the requirements of an application for a health care providerlicense, please attach a copy of the screening results and submit with the licensure application.

Employee/Contractor Name:

Health Care Provider/ Employer Name:

Address of Health Care Provider:

I hereby attest to meeting the requirements for employment and that I have not been arrested for or beenfound guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense,or have an arrest awaiting a final disposition prohibited under any of the following provisions of the FloridaStatutes or under any similar statute of another jurisdiction:

Criminal offenses found in section 435.04, F.S

a) Section 393.135, relating to sexual misconduct withcertain developmentally disabled clients and reporting ofsuch sexual misconduct.

(b) Section 394.4593, relating to sexual misconduct withcertain mental health patients and reporting of such sexualmisconduct.

(c) Section 415.111, relating to adult abuse, neglect, orexploitation of aged persons or disabled adults.

(d) Section 782.04, relating to murder.

(e) Section 782.07, relating to manslaughter, aggravatedmanslaughter of an elderly person or disabled adult, oraggravated manslaughter of a child.

(f) Section 782.071, relating to vehicular homicide.

(g) Section 782.09, relating to killing of an unborn quickchild by injury to the mother.

(h) Chapter 784, relating to assault, battery, and culpablenegligence, if the offense was a felony.

(i) Section 784.011, relating to assault, if the victim of theoffense was a minor.

(j) Section 784.03, relating to battery, if the victim of theoffense was a minor.

(k) Section 787.01, relating to kidnapping.

(l) Section 787.02, relating to false imprisonment.

(m) Section 787.025, relating to luring or enticing a child.

AFFIDAVIT OF COMPLIANCE WITHBackground Screening

Requirements

(n) Section 787.04(2), relating to taking, enticing, orremoving a child beyond the state limits with criminal intentpending custody proceedings.

(o) Section 787.04(3), relating to carrying a child beyond thestate lines with criminal intent to avoid producing a child at acustody hearing or delivering the child to the designatedperson.

(p) Section 790.115(1), relating to exhibiting firearms orweapons within 1,000 feet of a school.

(q) Section 790.115(2)(b), relating to possessing an electricweapon or device, destructive device, or other weapon onschool property.

(r) Section 794.011, relating to sexual battery.

(s) Former s. 794.041, relating to prohibited acts of personsin familial or custodial authority.

(t) Section 794.05, relating to unlawful sexual activity withcertain minors.

(u) Chapter 796, relating to prostitution.

(v) Section 798.02, relating to lewd and lascivious behavior.

(w) Chapter 800, relating to lewdness and indecentexposure.

(x) Section 806.01, relating to arson.

(y) Section 810.02, relating to burglary.

(z) Section 810.14, relating to voyeurism, if the offense is afelony.

(aa) Section 810.145, relating to video voyeurism, if theoffense is a felony.

(bb) Chapter 812, relating to theft, robbery, and relatedcrimes, if the offense is a felony.

(cc) Section 817.563, relating to fraudulent sale of controlledsubstances, only if the offense was a felony.

(dd) Section 825.102, relating to abuse, aggravated abuse,or neglect of an elderly person or disabled adult.

(ee) Section 825.1025, relating to lewd or lasciviousoffenses committed upon or in the presence of an elderlyperson or disabled adult.

(ff) Section 825.103, relating to exploitation of an elderlyperson or disabled adult, if the offense was a felony.

(gg) Section 826.04, relating to incest.

(hh) Section 827.03, relating to child abuse, aggravatedchild abuse, or neglect of a child.

(ii) Section 827.04, relating to contributing to thedelinquency or dependency of a child.

(jj) Former s. 827.05, relating to negligent treatment ofchildren.

(kk) Section 827.071, relating to sexual performance by achild.

(ll) Section 843.01, relating to resisting arrest with violence.

(mm) Section 843.025, relating to depriving a lawenforcement, correctional, or correctional probation officermeans of protection or communication.

(nn) Section 843.12, relating to aiding in an escape.

(oo) Section 843.13, relating to aiding in the escape ofjuvenile inmates in correctional institutions.

(pp) Chapter 847, relating to obscene literature.

(qq) Section 874.05(1), relating to encouraging or recruitinganother to join a criminal gang.

(rr) Chapter 893, relating to drug abuse prevention andcontrol, only if the offense was a felony or if any other personinvolved in the offense was a minor.

(ss) Section 916.1075, relating to sexual misconduct withcertain forensic clients and reporting of such sexualmisconduct.

(tt) Section 944.35(3), relating to inflicting cruel or inhumantreatment on an inmate resulting in great bodily harm.

(uu) Section 944.40, relating to escape.

(vv) Section 944.46, relating to harboring, concealing, oraiding an escaped prisoner.

(ww) Section 944.47, relating to introduction of contrabandinto a correctional facility.

(xx) Section 985.701, relating to sexual misconduct injuvenile justice programs.

(yy) Section 985.711, relating to contraband introduced intodetention facilities.

(3) The security background investigations under thissection must ensure that no person subject to this sectionhas been found guilty of, regardless of adjudication, orentered a plea of nolo contendere or guilty to, any offensethat constitutes domestic violence as defined in s. 741.28,whether such act was committed in this state or in anotherjurisdiction.

Criminal offenses found in section 408.809(4), F.S

(a) Any authorizing statutes, if the offense was a felony.

(b) This chapter, if the offense was a felony.

(c) Section 409.920, relating to Medicaid provider fraud.

(d) Section 409.9201, relating to Medicaid fraud.

(e) Section 741.28, relating to domestic violence.

(f) Section 817.034, relating to fraudulent acts through mail,wire, radio, electromagnetic, photoelectronic, or photoopticalsystems.

(g) Section 817.234, relating to false and fraudulentinsurance claims.

(h) Section 817.505, relating to patient brokering.

(i) Section 817.568, relating to criminal use of personalidentification information.

(j) Section 817.60, relating to obtaining a credit cardthrough fraudulent means.

(k) Section 817.61, relating to fraudulent use of creditcards, if the offense was a felony.

(l) Section 831.01, relating to forgery.

(m) Section 831.02, relating to uttering forged instruments.

(n) Section 831.07, relating to forging bank bills, checks,drafts, or promissory notes.

(o) Section 831.09, relating to uttering forged bank bills,checks, drafts, or promissory notes.

(p) Section 831.30, relating to fraud in obtaining medicinaldrugs.

(q) Section 831.31, relating to the sale, manufacture,delivery, or possession with the intent to sell, manufacture,or deliver any counterfeit controlled substance, if the offensewas a felony.

If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) inthe last 5 years and have not been unemployed for more than 90 days, please provide thefollowing information. A copy of the prior screening results must be attached.

Purpose of Prior Screening:

Screened conducted by: Date of Prior Screening:

Agency for Health Care AdministrationDepartment of Health

Agency for Persons with Disabilities

Department of Children and Family Services

Department of Financial Services

Affidavit

Under penalty of perjury, I, , hereby swear or affirm that I meet the

requirements for qualifying for employment in regards to the background screening standards set forth in

Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested

or convicted of any of the disqualifying offenses while employed by any health care provider licensed

pursuant to Chapter 408, Part II F.S.

Employee/Contractor Signature Title Date

Release authorization and Request for Criminal History, SSN verification, National SexOffender Registry, Super Criminal check and MVR check.

Disclosure to Employment Applicant Regarding Procurement of a Consumer Report

Name: Last _________________ First: _______________, Middle _________________Previous / Maiden Name (s): ________________________________________________

Date of Birth: ___________________ Social Security #: __________________________Race: _______________ Sex: ________________Home Phone: ____________ Cell Phone: _______________ E-Mail: _______________

Emergency Contact: ________________________ Emergency Ph: _________________

Current Address: Street: _______________________________ City: _______________State: _______ Zip: _______ Florida. Drivers License # __________________________Previous State(s) and Counties Lived: _____________________, __________________,___________________, ___________________________, ________________________In connection with your application for employment, AAA Marinelli Home Care Agency, Inc.,dba Home Instead Senior Care, may obtain consumer reports on you as part of our process forconsidering you for employment. These reports may include public record information such asyour driving records, criminal history and personal reputation, mode of living, character andworkers’ compensation claims. Private information such as your credit history may also beobtained.The Fair Credit Reporting Act gives you specific rights in dealing with consumer reportingagencies.I hereby authorize AAA Marinelli Home Care Agency, Inc., dba Home Instead Senior Care toobtain consumer reports about me as described above for the purpose of qualifying me foremployment. I release AAA Marinelli Home Care Agency, Inc.,., dba Home Instead Senior Careas well as Florida MVR Services, Inc., IntelliCorp and all other search entities from which theconsumer reports are obtained from any claim or liability related to obtaining, compiling orreleasing such reports. I also agree that this authorization and release will remain on file for theterm of my employment and will serve as an ongoing authorization to obtain consumer reportsrelated to my employment. I understand and agree to a yearly Authorization and Request forCriminal History and MVR, which I fully understand to be paid by me. I agree to pay all relatedfees.The SSN Verification, Criminal Super Search, Nationwide Sex Offender Registry, EmploymentVerification and MVR processing fee is based on the number of states and counties you lived inthe past 7 years. MVR checks as dictated by your driving record. Each county and state livedmust be searched. All related fees for searches are to be paid by me, the applicant / employee

__________________________________________________ ____________________Applicant Signature Date

Note to Applicant: This release form must be completed and signed foryour application to be considered.

AAA Marinelli Home Care Agency, Inc., d.b.a. is an independently owned and operated Home Instead Senior Care franchise serving Alachua,Bradford, Columbia, Levy, Putnum & Union Counties. Lic# 232373

WORK HISTORY RELEASE FORM

I, ____________________________________________________________________, do hereby give

my consent for _______________________________________________________________________(Past Employer’s Name)

to release information regarding my work history to Home Instead Senior Care, located at 4061 NW 43rd

St., Suite 11, Gainesville, FL 32606.

_________________________________________________________ _________Applicant Signature Date

(Below is Office Use Only)

Name of Company: ____________________________________________________________________

Contact Person: _______________________________________________________________________

Position: ____________________________________________________________________________

Dates of Employment: From: _____________________ To: ___________________________

Attendance Record: ____________________________________________________________________

Reasons for Leaving:

___________________________________________________________________

Strong Points:

_________________________________________________________________________

Weak Points: _________________________________________________________________________

Eligible for Rehire? Yes: _______ or No: _______

_____________________________________________________________________________________

Checked by: _______________________________________________________ Date: ____________

564 CAREGiver Application Letter 031412...CAREGiver_Employment_Application_03142012.docx Page 5 of 5...

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