Roads To Freedom Home Care

Attendant Handbook

22 East Third Street Williamsport, PA 17701

Voice 570-601-1663 On-Call 570-560-4906

Fax 570-601-1456

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Roads To Freedom Home Care

Employment Application

Applicant Information

Full Name: Date: Last First M.I.

Address: Street Address Apartment/Unit #

City State ZIP Code

Phone: Email

Date Available: Social Security No.: Desired Salary: $

Position Applied for:

Are you a citizen of the United States? YES NO

If no, are you authorized to work in the U.S.? YES

NO

Have you ever worked for this company? YES NO

If yes, when?

Have you ever been convicted of a felony? YES NO

If yes, explain:

Education

High School: Address:

From: To: Did you graduate? YES NO

Diploma:

College: Address:

From: To: Did you graduate? YES NO

Degree:

Other: Address: _______________________________________________

From: _________ To: _________ Did you graduate? YES NO

Degree: _________________________

Date of Application:_________ Received by:______________

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References Please list three professional references.

Full Name: Relationship:

Company: Phone:

Address:

Full Name: Relationship:

Company: Phone:

Address:

Full Name: Relationship:

Company: Phone:

Address:

Previous Employment

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES NO

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES NO

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

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Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES NO

Drivers License

Valid License: From: To:

Insurance Carrier:

Daily Mode of Transportation:

Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release from Roads To Freedom Home Care.

I expressly authorize without reservation, RTFHC, it’s representatives, employees or agents to contact and obtain information from all references, employers, public agencies, licensing authorities and educational institutes and to otherwise verify the accuracy of all information provides to RTFHC in the application, resume or interview. I hereby waive any and all rights and claims I may have regarding RTFHC in obtaining, seeking and gathering and using such information in the employment process and other persons, corporations or organizations for furnishing information about me.

I understand that RTFHC is an equal opportunity employer and does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

I understand this application does not constitute agreement or contract for employment under RTFHC and is good for 30 days. After 30 days I must reapply if I wish to be considered for employment with RTFHC.

If I am hired, I will be required under federal immigration laws to complete an I-9 Form and provide proof of identity and legal authority to work in the United States of America.

Signature: Date:

Roads To Freedom Home Care’s Mission:

To empower people with all disabilities by providing: Resources, Options, And Disability related Services needed

To obtain individual Freedom in their lives.

Job Description Title: Personal Care Attendant Reports to: PAS Supervisor

Essential Functions: 1. Provide essential personal assistant services such as bathing, dressing,

bowl/bladder management, transfer assistance, meal preparation, light housekeeping and other tasks as outlined on consumer’s Person-Centered Service Plan.

2. Ability to lift, bend and perform other physical tasks as directed by the consumer or supervisor.

3. Ability to travel when needed.4. Ability to work a varied schedule including weekends and evenings.5. Ability to be punctual and dependable.6. Ability to be respectful of all individuals for whom you work, both in the

community and in the office setting. Qualifications:

1. Must be 18 years of age or older.2. Must possess basic math, reading and writing skills.3. Must possess a valid social security number.4. Must be willing to submit to a criminal record check, child abuse

clearance and FBI fingerprinting. Must PASS Criminal, Child Abuse andFBI fingerprinting clearances according to DPW regulations.

5. Must demonstrate the capability to perform health maintenance activitiesrequired by consumer’s Person-Centered Service Plan or be willing toreceive training in performance of health maintenance activities.

6. Must have the required skills to perform personal assistance servicesspecified in consumer’s Person-Centered Service Plan.

7. Must support the Independent Living Philosophy.8. Must submit and pass TB test.

This is a non-exempt position. Roads To Freedom Home Care is an equal opportunity employer.

Employee_______________________________________________ Date____/____/_____

Job Description

Title: Personal Care Attendant Reports to: PAS Supervisor I acknowledge that I have received and reviewed a copy of my job description and the qualifications for employment. I also confirm that by my signature and date I completed a face to face interview. In addition, I acknowledge that in order to begin working, I must complete a full 2-day training session, a 2 step TB test and provide RTFHC with a current, valid State ID and social security card and submit to all clearances as outlined by Roads To Freedom Home Care. I must also provide a minimum of two references which have been validated by RTFHC staff. I have provided RTFHC with a current CNA/MA/LPN/RN or other certification or degree. In order to receive a higher payrate, I must provide RTFHC with my annual renewal documentation.

Employee (Print) _____________________________________________________________ Employee (Signature) _____________________________________Date ____/____/_____

Attendant Safety

Bed Bugs: In the event that bed bugs, head lice, rodents, insects or other infestations are found in the home; it is RTFHC’s policy that Attendants and Consumers must notify the agency immediately. RTFHC Attendants will continue to provide services with safe guards in place such as protective gear. Attendants will continue with safe guards in place until completion of treatment and proper documentation stating that the infestation has been eradicated is received by RTFHC Director.

Gifts: Attendants are not permitted to receive or accept gifts from consumers of any kind. Gift giving and receiving creates a whole new dimension of the caregiver / consumer relationship and is better avoided. If attendants are found to have accepted gifts from consumer’s or family members of the consumer, they are subject to review by the Director of RTFHC.

Dress Code: Attendants are not required to wear scrubs but are encouraged to if they feel comfortable doing so. Sneakers or nurse’s shoes are preferred. Attendants should be a representation of RTFHC and look presentable upon entering a consumer’s home. A consumer reserves the right to inform RTFHC staff of an attendant’s dress that is distracting, uncomfortable or otherwise interferes with the way that the consumer is cared for. Heavy scents including perfume, nicotine, lotions or oils are also discouraged due to sensitivities.

Employee Disclosure Statement

Roads To Freedom Home Care will mail requests for clearances to the Pennsylvania State Police, Childline and the Federal Bureau of Investigation for all employees as appropriate. Having a criminal history does not automatically disqualify an individual from being employed by RTFHC.

I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse as defined by the Child Protective Services Law.

Employment eligibility and retention will be determined on an individual basis for applicants with one or more of the convictions listed below, regardless of the age of the applicant when the offense occurred. Additionally, RTFHC reserves the right to not hire an applicant if other offenses appear on an applicant’s rap sheet that after review, are determined to be prohibited to hire.

Offense Code Prohibitive Offense Type of Conviction CC 2500 Criminal Homicide Any CC 2502A Murder I Any CC 2502B Murder II Any CC 2502C Murder III Any CC 2503 Voluntary Manslaughter Any CC 2504 Involuntary Manslaughter Any CC 2505 Causing or Aiding in Suicide Any CC 2506 Drug Delivery Resulting In Death Any CC 2702 Aggravated Assault Any CC 2901 Kidnapping Any CC 2902 Unlawful Restraint Any CC 3121 Rape Any CC 3122.2 Statutory Sexual Assault Any CC 3123 Involuntary Deviate Sexual Intercourse Any CC 3124.1 Sexual Assault Any CC 3125 Aggravated Indecent Assault Any CC 3126 Indecent Assault Any CC 3127 Indecent Exposure Any CC 3301 Arson and Related Offenses Any CC 3502 Burglary Any CC 3701 Robbery Any

CC 4101 Forgery Any CC 4114 Securing Execution of Documents by

Deception Any

CC 4302 Incest Any CC 4303 Concealing the Death of a Child Any CC 4304 Endangering the Welfare of a Child Any CC 4305 Endangering the Welfare of a Child –

Dealing in Infant Children Any

CC 4911 Tampering with Public Records or Information

Any

CC 4952 Intimidation of Witnesses or Victims Any CC 4953 Retaliation Against Witnesses or Victims Any CC 5903C Obscene or Sexual Materials to Minors Any CC 5903D Obscene or Other Sexual Materials Any CC 6301 Corruption of Minors Any CC 6312 Sexual Abuse of Children Any CC 5902B Promoting Prostitution Felony CC 13A14 Delivery by Practitioner Felony CC 13A30 Possession with Intent to Deliver Felony CC 13A35 Illegal Sale of Non-Controlled Substance Felony (i) (ii) (iii) Substance Felony CC 13A36 Designer Drugs Felony CS1Axx* Any Other Felony Drug Conviction

Appearing on a PA Rap Sheet Felony

Conviction within the 3900 series, including but not limited to the offenses listed below will be considered as well.

Offense Code Prohibitive Offense CC 3901 Theft CC 3921 Theft by Unlawful Taking CC 3922 Theft by Deception CC 3923 Theft by Extortion CC 3924 Theft by Property Lost CC 3925 Receiving Stolen Property CC 3926 Theft of Services CC 3927 Theft by Failure to Deposit CC 3928 Unauthorized use of a Motor Vehicle CC 3929 Retail Theft CC 3929.1 Library Theft CC 3929.2 Unlawful Possession of Retail or Library Theft Instruments CC 3929.3 Organized Retail Theft CC 3930 Theft of Trade Secrets

CC 3931 Theft of Unpublished Dramas or Musicals CC 3932 Theft of Leased Properties CC 3933 Unlawful Use of a Computer CC 3934 Theft From a Motor Vehicle

Finally, being named as a perpetrator of a founded or indicated report of child abuse disqualifies an individual from consideration for employment. The applicant swears/affirms that he/she has not been named as a perpetrator of a founded or indicated report of child abuse, as defined by the Child Protective Services Law.

I HEREBY SWEAR/AFFIRM THAT THE INFORMATION AS SET FORTH ABOVE IS TRUE AND CORRECT. I UNDERSTAND THAT THE PENALTY FOR FALSE SWEARING IS A MISDEMEANOR OF THE THIRD DEGREE PURSUANT TO SECTION 4904(b) OF THE CRIMES CODE.

Employee (Print) _____________________________________________________________

Employee (Signature) ______________________________________ Date____/____/____

Employer (Signature) ______________________________________ Date____/____/____

SP 4-164 (7-2015) PENNSYLVANIA STATE POLICE REQUEST FOR CRIMINAL RECORD CHECK

1-888-QUERYPA (1-888-783-7972)

This form is to be completed in ink by the requester – (information will be mailed to the requester only). If this form is not legible or not properly completed, it will be returned unprocessed to the requester. A response may take four weeks or longer.

TRY OUR WEBSITE FOR A QUICKER RESPONSE https://epatch.state.pa.us

REQUESTER NAME

ADDRESS

CITY/STATE/ ZIP CODE

TELEPHONE NO. (AREA CODE)

SUBJECT OF RECORD CHECK

(FIRST) (MIDDLE) (LAST)

MAIDEN NAME AND/OR ALIASES SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YYYY)

SEX RACE

The Pennsylvania State Police response will be based on the comparison of the data provided by the requester against the information contained in the files of the Pennsylvania State Police Central Repository only.

FEES FOR REQUESTS - $8.00. NOTARIZED FEE REQUESTS - $13.00. ***MAKE ALL MONEY ORDERS PAYABLE TO: COMMONWEALTH OF PENNSYLVANIA ***

REASON FOR REQUEST ◄◄◄◄◄◄CHECK THE BOX THAT MOST APPLIES TO THE PURPOSE OF THIS REQUEST►►►►►►

INTERNATIONAL ADOPTION - INTERNATIONAL ADOPTION MUST BE NOTARIZED AND MAILED IN. ($13.00 FOR REQUEST)

ADOPTION (DOMESTIC) EMPLOYMENT VISA OTHER

WARNING: 18 Pa.C.S. 4904(b) UNDER PENALTY OF LAW - MISIDENTIFICATION OR FALSE STATEMENTS OF IDENTITY TO OBTAIN CRIMINAL HISTORY INFORMATION OF ANOTHER IS PUNISHABLE AS AUTHORIZED BY LAW.

Homeland Security is Everyone’s Responsibility - Pennsylvania Terrorism Tip Line 1-888-292-1919

FOR CENTRAL REPOSITORY USE ONLY CONTROL NUMBER

AFTER COMPLETION MAIL TO:

PENNSYLVANIA STATE POLICE CENTRAL REPOSITORY – 164

1800 ELMERTON AVENUE HARRISBURG, PA 17110-9758

DO NOT SEND CASH OR PERSONAL CHECK

CHECK ONE BLOCK INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE

A CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF $8.00, PAYABLE TO:

“COMMONWEALTH OF PENNSYLVANIA” THE FEE IS NONREFUNDABLE

NOTARIZED INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE A CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF $13.00, PAYABLE TO:

“COMMONWEALTH OF PENNSYLVANIA” THE FEE IS NONREFUNDABLE

FEE EXEMPT-NONCRIMINAL JUSTICE AGENCY – NO FEE

Roads To Freedom

22 E. 3rd Street

Williamsport, PA 17701

570-560-4906

FBI Fingerprinting Information Form Please complete the information below so that we may register you for electronic fingerprinting

with IndentoGO Systems. The fingerprinting will be done at no charge to you. **ALL FIELDS ARE REQUIRED**

First Name Middle Name Last Name Date of Birth Phone #

Country of Birth City/State of Birth Country of Citizenship

Height (inches) Weight (lbs) Eye Color Hair Color Preferred Language Sex Race Ethnicity

Address City/State/Zip

Identification Driver’s License # State ID #

Alias/Maiden Name

Fingerprinting Location

Susquehanna Computer Innovations Inc. 280 Kane Street Suite 1 South Williamsport, PA 17702 Phone: 570-323-0089 Hours: Monday – Friday 8:00-5:00pm Saturday: By Appointment Only

Office Use Only https://uenroll.identogo.com/ Department of Human Services (1KG738) ____ Proof of Residency____

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PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

Type or print clearly in ink. If obtaining this certification for non-volunteer purposes or if, as a volunteer having direct volunteer contact with children, you have obtained a certification free of charge within the previous 57 months, enclose an $13.00 money order or check payable to the PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES or a payment authorization code provided by your organization. DO NOT send cash. Certifications for the purpose of “volunteer having direct volunteer contact with children” may be obtained free of charge once every 57 months. Send to CHILDLINE AND ABUSE REGISTRY, PA DEPARTMENT OF HUMAN SERVICES, P.O. BOX 8170 HARRISBURG, PA 17105-8170. APPLICATIONS THAT ARE INCOMPLETE, ILLEGIBLE OR RECEIVED WITHOUT THE CORRECT FEE WILL BE RETURNED UNPROCESSED. IF YOU HAVE QUESTIONS CALL 717-783-6211, OR (TOLL FREE) 1-877-371-5422.

PURPOSE OF CERTIFICATION (Check one box only) Foster parent Prospective adoptive parent Employee of child care services School employee governed by the Public School Code School employee not governed by the Public School Code Self-employed provider of child-care services in a family child-care home An individual 14 years of age or older applying for or holding a paid position as an employee with a program, activity, or service An individual seeking to provide child-care services under contract with a child care facility or program An individual 18 years or older who resides in the home of a foster parent for children for at least 30 days in a calendar year An individual 18 years or older who resides in the home of a certified or licensed child-care provider for at least 30 days in a calendar year

Volunteer having direct volunteer contact with children If purpose is volunteer having direct volunteer contact with chil-dren, choose SUB PURPOSE:

Big Brother/Big Sister and/or affiliate Domestic violence shelter and/or affiliate Rape crisis center and/or affiliate Other:

PA Department of Human Services Employment & Training Program participant (signature required below)

SIGNATURE OF OIM/CAO REPRESENTATIVE OIM/CAO PHONE NUMBER

An individual 18 years or older, excluding individuals receiving services, who resides in a family living home, community home for individuals with an intellectual disability, or host home for children for at least 30 days in a calendar year An individual 18 years or older who resides in the home of a prospective adoptive parent for at least 30 days in a calendar year

AGENCY/ORGANIZATION NAME: PAYMENT AUTHORIZATION CODE, IF APPLICABLE:

Consent/Release of Information Authorization form is attached. Applicant must fill in the “Other Address” sections. By completing the other address sections, you are agreeing that the organization will have access to the status and outcome of your certification application.

FIRST NAME APPLICANT DEMOGRAPHIC INFO

MIDDLE NAME RMATION (DO NOT USE INITIALS) LAST NAME SUFFIX

SOCIAL SECURITY NUMBER

___ ___

GENDER Male Female Not reported

DATE OF BIRTH (MM/DD/YYYY) AGE

Disclosure of your Social Security number is voluntary. It is sought under 23 Pa.C.S. §§ 6336(a)(1) (relating to information in statewide database), 6344 (relat-ing to employees having contact with children; adoptive and foster parents), 6344.1 (relating to information relating to certified or licensed child-care home residents), and 6344.2 (relating to volunteers having contact with children). The department will use your Social Security number to search the statewide database to determine whether you are listed as the perpetrator in an indicated or founded report of child abuse.

HOME ADDRESS MAILING ADDRESS (if different from home address)

OTHER ADDRESS (if Consent/Release of Information Authorization form is attached)

ADDRESS LINE 1 ADDRESS LINE 1 ADDRESS LINE 1

ADDRESS LINE 2 ADDRESS LINE 2 ADDRESS LINE 2

CITY CITY CITY

COUNTY COUNTY COUNTY

STATE/REGION/PROVINCE STATE/REGION/PROVINCE STATE/REGION/PROVINCE

ZIP/POSTAL CODE ZIP/POSTAL CODE ZIP/POSTAL CODE

COUNTRY COUNTRY COUNTRY

Different mailing address ATTENTION ATTENTION

CONTACT INFORMATION HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER MOBILE TELEPHONE NUMBER

EMAIL (By submitting an email contact, you are agreeing to ChildLine contacting you at this address.)

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PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

PREVIOUS NAMES USED SINCE 1975 (Include maiden name, nickname and aliases.) First Middle Last Suffix

1.

2.

3.

4.

5.

PREVIOUS ADDRESSES SINCE 1975 (Please list all addresses since 1975, partial address acceptable; attach additional pages if necessary.)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

HOUSEHOLD MEMBERS (Please list everyone who lived with you at any time since 1975 to present.

Please include parent, guardian or the person(s) who raised you; attach additional pages as necessary.)

Name (First, Middle, Last) Relationship Present Age Gender

1. Parent Guardian person(s) who raised you

2. Parent Guardian person(s) who raised you

3.

4.

5.

6.

7.

8.

9.

10.

I affirm that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code). If I selected volunteer, I understand that I can only use the certificate for volunteer purposes.

APPLICANT’S SIGNATURE DATE

CHILDLINE USE ONLY DATE RECEIVED BY CHILDLINE SUFFICIENT PAYMENT INFORMATION RECEIVED

YES NO

VALID PAYMENT AUTHORIZATION CODE

WAIVED (supervisor initials) ___________

CERTIFICATION ID #

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INSTRUCTIONS TO COMPLETE THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION APPLICATION:

General: • Type or print clearly and neatly in ink only.• Ifobtainingthiscertificationfornon-volunteerpurposesorif,asavolunteerhavingdirectvolunteercontactwithchildren,youhave obtainedacertificationfreeofchargewithintheprevious57months,enclosean$13.00moneyorderorcheckforeachapplication.No cashwillbeaccepted.Personal,agency,orbusinesschecksareacceptable.Certificationsforthepurposeof“volunteerhavingdirect volunteer contact with children” may be obtained free of charge once every 57 months. If no payment is enclosed for a non-volunteer purpose, you must provide a payment authorization code, otherwise your application will be rejected and returned to you.

• DO NOT SEND POSTAGE PAID RETURN ENVELOPES for us to return your results. Results are issued through an automated system generated mailing process.

• Certificationresultswillbemailedtoyouwithin14daysfromthedatethecertificationapplicationisreceivedattheChildLineandAbuse Registry.

• Failure to comply with the instructions will cause considerable delay in processing the results of an applicant’s child abuse history certificationapplication.

Purpose of Certification - Do not check more than one box: • Check the foster parent box if applying for purposes of providing foster care.• Check the prospective adoptive parent box if applying for the purpose of adoption.• Check the employee of child care services box if applying for the purpose of child care services in the following:

- Child day care centers; group day care homes; family day care homes; boarding homes for children; juvenile detention center services orprograms for delinquent or dependent children; mental health services for children; services for children with intellectual disabilities; earlyintervention services for children; drug and alcohol services for children; and day care services or other programs that are offered by a school.

• Check the school employee governed by the Public School Code box if you are a school employee who is required to obtainbackground checks pursuant to Section 111 of the Public School Code and will continue to be required to obtain background checks priorto employment in accordance with that section and on the periodic basis required by Act 153.

• Check the school employee not governed by the Public School Code box if you are a school employee not governed by Section 111of the Public School Code, but covered by Act 153 (pertaining to school employees in institutions of higher education).Definition of school employee: A school employee is defined as an individual who is employed by a school or who provides a program, activity or service sponsored by a school. The term does not apply to administrative or other support personnel unless they have direct contact with children. Definition of school: A facility providing elementary, secondary or postsecondary educational services. The term includes the following:

(1) Any school of a school district.(2) An area vocational-technical school.(3) A joint school.(4) An intermediate unit.(5) A charter school or regional charter school.(6) A cyber charter school.(7) A private school licensed under the act of January 28, 1988 (P.L.24, No. 11), known as the Private Academic Schools Act.(8) A private school accredited by an accrediting association approved by the state Board of Education.(9) A non-public school.

(10) An institution of higher education.(11) A private school licensed under the act of December 15, 1986 (P.L. 1585, No. 174), known as the Private Licensed Schools Act.(12) The Hiram G. Andrews Center.(13) A private residential rehabilitative institution as defined in section 914.1-A(c) of the Public School Code of 1949.

• Check the self-employed provider of child-care services in a family child-care home if providing child care services in one’s home(other than the child’s own home) at any one time to four, five, or six children who are not relatives of the caregiver.

• Check the individual 14 years of age or older who is applying for or holding a paid position as an employee box if the employmentis with a program, activity, or service, as a person responsible for the child’s welfare or having direct contact with children:Applying as an employee who is responsible for the child’s welfare or having direct contact (providing care, supervision, guidance, orcontrol to children or having routine interaction with children) in any of the following in which children participate and which is sponsoredby a school or public or private organization:- A youth camp or program;- A recreational camp or program;- A sports or athletic program;- A community or social outreach program;- An enrichment or educational program; and- A troop, club, or similar organization

• Check the individual seeking to provide child care services under contract with a child care facility or program box if you areproviding child care services as part of a contract or grant funded program.

• Check the box for individual 18 years or older who resides in the home of a foster parent for at least 30 days in a calendar year ifyou are an adult household member in this setting and require certification.

• Check the box for individual 18 years or older who resides in the home of a certified or licensed child-care provider for at least 30days in a calendar year if you are an adult household member in this setting and require certification.

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• Check the box for individual 18 years or older, excluding individuals receiving services, who resides in a family living home,community home for individuals with an intellectual disability, or host home for children for at least 30 days in a calendar year ifyou are an adult household member in this setting and require certification.

• Check the box for individual 18 years or older who resides in the home of a prospective adoptive parent for at least 30 days in acalendar year if you are an adult household member in this setting and require certification.

• Check the volunteer having direct volunteer contact with children box if applying for the purpose of volunteering as an adult for anunpaid position as a volunteer with a child-care service, a school, or a program, activity or service as a person responsible for the child’swelfare or having direct volunteer contact with children. In addition, check the box of one of the organizations listed, i.e. Big Brother/BigSister, domestic violence shelter, rape crisis center. If you are NOT applying for a volunteer in one of the organizations listed, please checkthe other box and write the name of the organization in the space provided.

• Check the PA Department of Human Services employment & training program participant box if you are applying for the purposeof participating in a PA Department of Human Services employment and training program through a county assistance office (CAO) orthe Office of Income Maintenance (OIM). The signature AND phone number of the CAO or OIM representative is required. If there is nosignature and no phone number, your application will be rejected and returned to you.

• If you were provided a “PAYMENT AUTHORIZATION CODE” by an organization, please provide the agency/organization name in thespace provided and the payment authorization code in the space provided.

• Please check the CONSENT/RELEASE OF INFORMATION box if you included a payment code in the space above and attached thecompleted Consent/Release of Information Authorization form to your Pennsylvania Child Abuse History Certification application whenyou mail it to our office. The Consent/Release of Information Authorization form allows the department to send your results to a third party.If the Consent/Release of Information Authorization form is NOT attached to the certification application, the results WILL be mailed to theapplicant’s home address and not to the third party.

Applicant Demographic Information: • Name - Include the applicant’s full legal name. Initials are not acceptable for a first name. If your full legal name is an initial, pleaseprovide supporting documentation along with your certification application.

• Social Security number - Include the applicant’s social security number. A social security number is voluntary; HOWEVER, PLEASENOTE THAT APPLICATIONS THAT DO NOT INCLUDE SOCIAL SECURITY NUMBERS MAY TAKE LONGER TO BE PROCESSED.

• Gender - Please check one box.• Date of birth - Fill in the applicant’s date of birth (Example: 01/22/1990).• Age - Fill in the applicant’s current age.

Address: • The address listed must be the applicant’s current home address. This is also where the results of the certification will be mailed, unless

otherwise noted. If the different mailing address box is checked and a mailing address is provided in the “different” mailing addresscolumn, the results will be mailed to the “mailing” address and not the “home” address. Note: If the consent/release of information box ischecked and an “other” address is provided, the results will be mailed to the “other” address.

Contact Information: • Please provide your home, work or mobile telephone number. Fill in the number where the applicant can be reached in the event that

there are questions about the information on the application.• Please provide an email address. By providing an email address, you are consenting to ChildLine contacting you by email in the event

that you cannot be reached by phone. NO CONFIDENTIAL INFORMATION WILL EVER BE SHARED OR PROVIDED IN AN EMAILFROM OUR OFFICE.

Previous Names Used Since 1975: • The applicant must list any and all full legal names that they have ever had since 1975. This includes maiden names, nicknames, aliases

and also known as (aka) names.

Previous Addresses Since 1975: • List all addresses where the applicant has resided since 1975. The applicant can attach an additional sheet of paper with all of theaddresses listed if necessary. If the applicant cannot remember the exact mailing addresses since 1975, filling in as much information aspossible about the location is acceptable.

Household Members: • Include anyone that the applicant lived with since 1975 (parents, guardians, siblings, children, spouse (ex), paramour, friends, etc.). In

addition, include the household member’s relationship to the applicant, their age (to the best of your knowledge) and their gender. If theapplicant was under the age of 18 in 1975, this section MUST include the applicant’s PARENT(S) or GUARDIAN(S). If this section is leftblank, the application will be rejected and returned to the applicant.

Signature: • Applications MUST be signed and dated. Applications that are not signed and dated will be rejected and returned to the applicant.

CHILDLINE USE ONLY: • Please DO NOT WRITE in this section. This is for CHILDINE staff only.

Additional Information: Applicants can visit https://www.compass.state.pa.us/CWIS for more information about submitting the child abuse certification online or to register for a business/organization account.

CHILDLINE AND ABUSE REGISTRY P.O. BOX 8170

HARRISBURG, PENNSYLVANIA 17105-8170

CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

I, ( _______________________________ ), hereby authorize the PA Department of Human Sevices, ChildLine to Applicant’s Name

release my Pennsylvania Child Abuse History Clearance information directly to ( _______________________________ ). Name of Requesting Agency

I understand that this information is confidential in nature pursuant to §6339 (relating to information in confidential reports)

of the Child Protective Services Law (CPSL) (23 Pa.C.S Chapter 63) and is not otherwise to be released by

( _______________________________ ) without my expressed authorization or pursuant to Section 3490.126 of Name of Requesting Agency

Title 55 of the Pennsylvania Code which states this information is confidential and the requesting agency can be held

criminally liable for a breach of confidentiality related to release of this information. I also understand that the

aforementioned information will not be released directly to me ( _______________________________ ) as stated Applicant’s Name

on the Pennsylvania Child Abuse History Certification application. I understand that I will not receive a copy

of my Pennsylvania Child Abuse History Certification directly from ChildLine; however, I may request a copy of

my Pennsylvania Child Abuse History Certification from ( _______________________________ ) upon written request. Name of Requesting Agency

I have read this Consent/Release of Information Authorization form and fully understand and agree to its content. I further

understand and agree to all information and ramifications of the Pennsylvania Child Abuse History Certification application

as it otherwise relates to this consent. Further I understand that if I am listed in the statewide database for child abuse

that my consent allows the result stating such information to be shared with the agency/organization noted on next page.

Page 1 of 2

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Please send my certification result(s) to:

Agency Name:

Agency Street Address:

Agency City, State, Zip Code:

Date Applicant’s Signature

As the agency/organization representative, I understand that, except for the subject of a report, persons who receive this information are subject to the confidentiality provisions of the CPSL and 55 Pa. Code, Chapter 3490 and are required to ensure the confidentiality and security of the information and are liable for civil and criminal penalties for releasing information to persons who are not permitted access to this information. I agree to receive and maintain this information in accordance with these requirements.

Date Agency’s Representative Signature

NOTE: IF THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION FORM/APPLICATION (CY 113) IS NOT COMPLETED ACCURATELY OR IF IT IS INCOMPLETE, THE CY 113 WILL BE RETURNED TO THE APPLICANT AND NOT BACK TO A THIRD PARTY.

Revised 12-29-15

Page 2 of 2

CY 999 3/16

Employment Eligibility Verifications and Notifications

Eligibility Verifications The services you provide as an employee or contractor of Roads To Freedom Home Care will be paid for with money from Medical Assistance. Therefore, RTFHC must verify that you are eligible to be paid with those funds be doing multiple checks. We must check three different databases:

• System for Award Management • List of Excluded Individuals with Entities • Medicheck

If you are on any of those lists, you will NOT be eligible to work. Also if you become ineligible while you are working for Roads to Freedom Home Care you must inform RTFHC immediately. RTFHC must also verify that you are eligible for employment by verifying your social security number.

Notification In addition, RTFHC must provide the following information to the Department of Human Services (DHS) quarterly concerning all newly hired employees and employees who employment has ended:

• Name • Social Security Number • Date of Hire • Starting Wage • Position • End Date (as applicable)

The Department of Human Services uses this information to determine if RTFHC is meeting the requirement to employ individuals who receive public assistance. This does not impact your ability to be employed. Employee_______________________ Maiden Name/Alias__________________________ Date of Birth____________________ Social Security #_____________________________ Employee Signature________________________________________ Date ___/____/____ For office use only: SS# Verified by______________________________________ Date ____/____/______

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►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) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address 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

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

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:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

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.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

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)

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)

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)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

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. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

RESIDENCY CERTIFICATION FORMLocal Earned Income Tax Withholding

EMPLOYEE INFORMATION - RESIDENCE LOCATION

TO EMPLOYERS/TAXPAYERS:

This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes.

This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.

NAME (Last Name, First Name, Middle Initial) SOCIAL SECURITY NUMBER

STREET ADDRESS (No PO Box, RD or RR)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE DAYTIME PHONE NUMBER

CERTIFICATION

SIGNATURE OF EMPLOYEE DATE (MM/DD/YYYY)

PHONE NUMBER EMAIL ADDRESS

MUNICIPALITY (City, Borough or Township)

COUNTY RESIDENT PSD CODE TOTAL RESIDENT EIT RATE

EMPLOYER INFORMATION - EMPLOYMENT LOCATION

EMPLOYER BUSINESS NAME (Use Federal ID Name) EMPLOYER FEIN

STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE PHONE NUMBER

MUNICIPALITY (City, Borough or Township)

COUNTY WORK LOCATION PSD CODE WORK LOCATION NON-RESIDENT EIT RATE

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES,

please refer to the Pennsylvania Department of Community & Economic Development website:

www.newPA.com

CLGS-32-6 (8-11)

Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying schedules and statements and to the best of my (our) belief, they are true, correct and complete.

Instructions:1. For checking accounts, please attach a voided check.

2. For savings accounts, please attach a savings-book deposit slip.

3. Direct deposits typically take effect within two pay cycles.

Note:If your financial institution is a credit union, ensure you have the right Routing and Account numbers. Some credit unions use different sets of numbers for direct deposit. If you are uncertain, please contact your credit union for more information.

eccapayroll.com | [800] 864-2843 | 1600 Peninsula Dr. Erie PA 16505

Employee Voluntary Direct Deposit Election Form

Company Name ____________________________________________________________________________________________________________________

Company Payroll ID ________________________________________________________________________________________________________________

Account Holder Name ______________________________________________________________________________________________________________

Account Holder Employee # ________________________________________________________________________________________________________

Bank or Credit Union Name ________________________________________________________________________________________________________

ABA / Routing Number _____ _____ _____ _____ _____ _____ _____ _____ _____

Account Number ___________________________________________________________________________________________________________________

Type of Account Checking Savings

Direct Deposit Options Net Check Direct Deposit

Fixed Check, Remaining Direct Deposit

Fixed Check Amount $____________________

Partial Check Direct Deposit

Partial Amount $____________________ Partial Percent ____________________%

Employee Signature ________________________________________________________________________________________________________________

©2018, ECCA Payroll+ All Rights ReservedForm Revised: 12/18

1/1

eccapayroll.com | [800] 864-2843 | 1600 Peninsula Dr. Erie PA 16505

Employee Maintenance Form

New Hire Re-hire Changes Only

Company Name ____________________________________________________________________________________________________________________

Company Payroll ID _________________________________________ Employee# ______________________________ (Leave blank for new hires)

SSN ____________________ - ____________________ - ____________________

Last Name __________________________________________________ First Name ________________________ M.I. ______________________________

Address 1 __________________________________________________________________________________________________________________________

Address 2 __________________________________________________________________________________________________________________________

City __________________________________________________________ State ______________________________ Zip _______________________________

Gender Male Female Birth Date ________ / _______ / __________ Hire Date ________ / _______ / __________

Branch ________________________________Department ________________________________________________________________________________

Compensation Hourly Rate $ __________/ hour Average or Default Hours __________ Shift or Shift Rate $ __________

Salary (per pay period) $ __________ AutoPAY Salary or Hours?

Pay Frequency Weekly Bi-Weekly Semi-Monthly Monthly

Federal Filing Status

Single

Married

Exempt

Exemptions ___________________________

Additional Amount ___________________

Additional Percent ____________________

State Tax Status

Single

Married

Exempt

Exemptions ___________________________

Additional Amount ___________________

Additional Percent ____________________

Local Tax Status (if applicable)

(PA Only)

Work PSD _____________________________

Res PSD ______________________________

LST ____________________________________

(NA or X for Exempt)

(Non PA)

Locality _______________________________

County ________________________________

Code Calc ($ / %) Amt

Ded

uctio

ns

Special Instructions

1/1

©2018, ECCA Payroll+ All Rights ReservedForm Revised: 12/18

Attendant Training

• Date of Hire is the first day of training. • All attendants will receive notification when trainings will be held. • If required trainings are not completed within time frame given, Roads To

Freedom Home Care reserves the right to remove attendants from their schedules until required trainings are completed.

• Attendants may return to their regular schedules when trainings are completed and or TB tests, Clearances are updated and current.

• All attendants under both models of care (Consumer Employer and Agency Model) are required to complete initial 2-day training and required trainings throughout the year.

• Licensures such as CNA/LPN or RN certification may be considered as meeting the training requirements.

• Initial training consists of 2 full days (8 hours each day). • Per the Department of Health Regulations for Attendant training hours, a

minimum of 12 hours per year will be completed. 8 out of 12 hours must be hands on training under the direction of a registered nurse.

• Attendants may not start working with consumer’s until initial training and other requirements have been met.

• Attendants will receive regular time pay for their training hours as approved by RTFHC.

• If outside training is taken, RTFHC must receive certification of completion to consider it part of attendants required hours.

Employee Signature___________________________________ Date ____/____/____

Tuberculosis (TB) Testing for All Personal Care Attendants

Due to Pennsylvania state requirements all Personal Care Attendants must receive a 2-step (TB) test. The initial TB will be placed the first day of training for new hires. You are responsible to return to Roads To Freedom 48-72 hours after the initial TB test has been placed. Failure to do so will result in the attendant paying out of pocket to have the test completed. Current attendants are responsible to complete an annual 1-step TB test. Along with RTFHC you may also receive the TB at the following Williamsport location:

• MedExpress Urgent Care1953 E 3rd StreetLoyal PlazaWilliamsport, PA 17701570-323-4072

The results of your TB test will need to be read or received by RTFHC before you may start work. If you fail to follow through with the two-step process, RTFHC will not cover the cost, the cost is your sole responsibility. Per state requirements, we need this information as soon as possible so that the results can be kept on file. If you fail to complete the TB testing either initially or annually you will not be permitted to work until the testing is completed.

If you can produce documentation of a TB test completed prior to hire that is less than 365 days old, RTFHC will accept this and documentation will be placed in your file. Please note that you will still be put on rotation to complete this yearly test requirement.

Thank you for your cooperation and dedication to serving our consumers.

Employee Signature___________________________________ Date ____/____/____

Consent Form for Protection Against Viral Hepatitis I have been informed of the symptoms and modes of transmission of blood borne pathogens including Hepatitis B Virus (HBV). I know about the infection control program and understand the procedure to follow is an exposure or incident occurs. It has been explained to me by Roads To Freedom Home Care that I may receive HBV vaccine for protecting against Hepatitis B at UPMC Susquehanna Occupational Health Services Clinic.

• UPMC Susquehanna Health System Occupational Health Services 700 High Street Williamsport, PA 17701 570-321-1000

I am aware that the HBV vaccine consists of 3 injections over the course of 6 months and I understand the possible side effects and adverse reactions. I have been informed of the appropriate first aid procedure to follow up in the event of possible exposure to blood or body fluids. I understand I must report the exposure immediately to my employer who will then instruct me regarding follow-up counseling and possible blood testing by the nearest hospital or clinic in the area. I understand that due to my occupation I am at risk of exposure to blood or potentially infectious materials and that I may be at risk of acquiring Hepatitis B. I accept the risks associated with my position and can chose at anytime to be vaccinated against HBV. Please check one of the following: ______ I decline the HBV vaccine at this time ______ I would like to receive the HBV vaccine ______ I have been immunized with the HBV vaccine Employee Name:_____________________________________________________________ Employee Signature:_________________________________________________________ Employer Signature:_______________________________________ Date:____/____/____

I understand that if I choose to receive the vaccine and begin the process but do not follow through with the process as dictated by the provider,

I will be responsible for the cost of the entire vaccine series.

CONFIDENTIALITY AND HIPPA POLICY

A. CONSUMERS:

RTFHC assures all personal information about individuals served by RTFHC, including names, addresses, photographs, information relating to disability, sexual orientation, and records of evaluation are held confidential

and limited only to purposes directly connected with the project, including project evaluation activities. This

information may not be disclosed, directly or indirectly, unless the consumer has signed a Release of Information

authorizing disclosure of specific information. The notice of Privacy Practices under RTFHC along with HIPAA regulations WILL apply.

The Release of Information must specify the parties to whom the information is to be released and the purposes for

which it is to be used. A Release of Information must be updated annually.

It is also the policy of the agency not to disclose any information relating to any consumer or activities relating to

consumers during meetings involving staff and/or service providers, government officials, etc, unless the consumer

has given prior written consent. The notice of Privacy Practices under the RTFHC HIPAA regulations apply.

In addition, a signed confidentiality agreement is kept on file at RTFHC for every staff and/or volunteer who actively participates in the operations of RTFHC.

B. EMPLOYEES:

It is the policy of RTFHC that a confidential personnel record on each employee be maintained in a secure file under control of the Executive Director. It is the right of the employee to have access to their individual record

according to scheduled file review periods. This record is obtained through the Executive Director and may not

leave the premises. A signed statement must be obtained before access of personnel records can be granted to any

other persons.

C. COMMUNICATION:

This notice shall be posted publicly at all times and shall be communicated to all consumers of service, RTFHC employees and volunteers. The policy expressed becomes permanent immediately.

**FOR CONSUMER/EMPLOYEE/VOLUNTEER INTAKE OR ANNUAL REVIEW**

By signing, I certify that I received a copy of this statement and the statement was adequately explained to me.

Consumer /Employee /Volunteer Date

Signature of RTFHC Representative Date

22 E 3rd Street Williamsport, PA 17701Voice: (570) 601-1663Toll Free Voice: (800) 984-7492

Video Relay Systems: (866) 842-5426

Fax: (570) 601-1456

Universal Precautions

Hand washing and wearing gloves are the most important part in stopping the spread of infection.

1. Washing your hands regularly and properly is the key. 2. Wash your hands using soap and friction, keeping fingers pointed down to

the sink. 3. Wash your hands approximately 20-30 seconds to remove many micro-

organisms as possible. Longer if your hands are very dirty. 4. When caring for an individual who has stage III or stage IV wounds or any

other leaking body fluids, change gloves often and wash your hands. 5. If you have a large spill of body fluids use gloves and clean up the spill

with disposable products like paper towels or Clorox wipes. Dispose of the contaminated items in a plastic bag and then dispose of it in the garbage.

6. Clean surfaces contaminated by spills with an antibacterial agent such as Lysol or bleach water.

7. For contaminated items that are not disposable, launder or clean them separately as soon as possible in warm-hot water with Lysol or bleach if possible.

Employee Name:_____________________________________________________________ Employee Signature:______________________________________ Date:____/____/____

Reference Check #1

Applicant Name:_____________________________________________________________ I authorize Roads To Freedom Home Care to verify my past employment history and release from all liability all persons requesting and supplying information. Applicant Signature:_______________________________________ Date:____/____/____ Reference Name:_____________________________________________________________ How long have you known this person?:_______________________________________ Position Held:_________________________ From:_______________ To:______________ Brief Job Description:________________________________________________________ Please Rate 1-5 1 = Lowest 2 = Highest Attendance 1 2 3 4 5 Punctuality 1 2 3 4 5 Follows Direction 1 2 3 4 5 Confidentiality 1 2 3 4 5 Would you re-hire this person Yes or No and explain Yes:_________________________________________________________________________ No:__________________________________________________________________________ If your relationship to this person was not work related, please describe why you believe this person would do well assisting people with disabilities with personal care and household management. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Employer Signature:______________________________________ Date:____/____/____

Reference Check #2

Applicant Name:_____________________________________________________________ I authorize Roads To Freedom Home Care to verify my past employment history and release from all liability all persons requesting and supplying information. Applicant Signature:_______________________________________ Date:____/____/____ Reference Name:_____________________________________________________________ How long have you known this person?:_______________________________________ Position Held:_________________________ From:_______________ To:______________ Brief Job Description:________________________________________________________ Please Rate 1-5 1 = Lowest 2 = Highest Attendance 1 2 3 4 5 Punctuality 1 2 3 4 5 Follows Direction 1 2 3 4 5 Confidentiality 1 2 3 4 5 Would you re-hire this person Yes or No and explain Yes:_________________________________________________________________________ No:__________________________________________________________________________ If your relationship to this person was not work related, please describe why you believe this person would do well assisting people with disabilities with personal care and household management. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Employer Signature:______________________________________ Date:____/____/____

Workplace Injury

What to do in case of work-related injury? If you suffer a work-related injury, your health and well-being are out first concern. If your injury is of a serious nature and requires the assistance of ambulance or rescue personnel; the appropriate emergency service provides should be contacted immediately. If the injury is of a less serious nature, the following procedures must be followed:

1. Report your injury to your supervisor as soon as possible. Your supervisor, scheduler or on call person will complete a Report of Injury form and provide you with the information identifying providers that have been selected on the panel specifically developed for your company. Jon Bausinger is the contact person for Worker’s Compensation claims and he can be reached at (570) 327-9070 x 204. He will file a claim and submit it the UPMC Work Partners, our Worker’s Compensation carrier. A claim number will be generated and you will receive treatment at one of the panel providers on the attached list.If an injury occurs after hours, you should inform the on-call person who will complete a Report of Injury form and go to the Emergency Room at the nearest hospital and inform them that your injury is work related. Contact Jon Bausinger the following morning to receive your claim number. If there is follow up care needed you will need to follow up with one of the providers.

2. Seek initial medical attention from the providers on the attached list. As per the Worker’s Compensation Act of Pennsylvania, if you are injured at work, your employer’s insurance is responsible to pay reasonable and medically necessary treatments for the reported work-related injury. The is only if you select a provider for your initial care from the attached list.

Worker’s Compensation Information 1. The worker’s compensation law provides wage loss and medical benefits

employees who cannot work or who need medical care because of a workrelated injury.

2. Benefits are required to be paid by your employer when self-insured orthrough insurance provided by your employer. Your employer is requiredto post the name of the company responsible for paying worker’scompensation benefits at its’ primary place of business and at its sites ofemployment in a prominent and easily accessible place including withoutlimitation areas used for treatment of injured employees or for theadministration of first aid.

3. You should report immediately any injury or work-related illness to youremployer.

4. Your benefits could be delayed or denied if you do not notify youremployer immediately.

5. If you claim is denied by your employer, you have the right to request ahearing before a worker’s compensation judge.

6. The Bureau of Worker’s Compensation cannot provide legal advice.However, you may contact the Bureau of Worker’s Compensation foradditional general information at:

• Bureau of Worker’s Compensation1171 South Cameron StreetRoom 103Harrisburg, PA 17104-2501(800) 482-2383TTY (717) 772-4447www.state.pa.us

Worker’s Compensation Employee Notification

• The Pennsylvania Worker’s Compensation Act is designed to provide reimbursement for reasonable medical care for someone who suffers an injury arising in the course of his/her employment and causally related thereto. Pursuant to the Act, your employer will provide payment for reasonable surgical or medical services, services rendered by physicians or other health care providers, medicines and supplies as and when needed.

• If you require emergency medical treatment, you may seek it from any provider; however, any subsequent non-emergency treatment shall be obtained from one of the designated health care providers whose names appear on the list posted on your employer’s premises. If you are faced with a medical emergency, you may secure assistance from a hospital or physician/ health care provider of your choice. However, once the emergency no longer exists, the injured employee must treat with a listed provider for the remainder of the ninety (90) day period.

• During the initial ninety (90) days from the date of your first visit, you have

the right to switch from one health care provider one the list to another, and your employer will pay for treatment.

• If a designated health care provider refers you for treatment to another health care provider whose name is not on the list, your employer will pay for the treatment rendered by the provider to whom you were referred.

• Naturally, you have the right to seek treatment or medical consultation

from a non-designated health care provider during the initial ninety (90) day period following your first visit but you are personally responsible for payment of those services.

• You have the right to seek treatment from any health care provider at the

expiration of the (90) day period from the date of your first visit. Your employer will pay for this treatment unless the treatment is found to be unreasonable or unnecessary be a utilization review organization

pursuant to the utilization review process contained in the Worker’s Compensation Act.

• Your employer will be responsible for the cost of that treatment after the

initial ninety (90) day period has ended but only if you notify the employer that you are receiving treatment from a non-designated health care provider and only if that notice is provided to your employer within five (5) days of the first visit to that provider. If you provide notice to your employer of treatment by a non-designated provider more than five (5) days after the first visit to the provider, the employer will not be responsible to pay for treatment rendered by that non-designated provider until it receives notification from you that you are receiving such treatment.

• Should a designated health care provider prescribe invasive surgery, your

employer will pay for an additional opinion from a health care provider of your choice. If the additional opinion differs from the opinion of the designated health care provider and if the additional opinion provides a specific and detailed course of treatment, you will then determine which course of treatment to follow. If you choose to follow the procedures recommended in the additional opinion, your employer will pay to have such procedures performed by one of it’s designated health care providers and will not be responsible for payment for treatment by a non-designated provider for a period of ninety (90) day from the date of your visit to the health care provider from whom you obtained the additional opinion.

I hereby acknowledge that I have been informed of and understand my rights and duties under the Pennsylvania Worker’s Compensation Act as set for herein. _____________________________ ____________________________ Date: ____/____/____ Employee Name (Printed) Employee Name (Signature)

Employee RE-NOTIFICATION at or near the time of the claimed work injury. I hereby acknowledge that I have been informed again and that I understand my rights and duties under the Pennsylvania Worker’s Compensation Act. I have received a copy of this worker’s compensation employee notice form. ____________________________ _____________________________ Date: ____/____/____ Employee Name (Printed) Employee Name (Signature)

March 20, 2019

Roads to FreedomWilliamsport, PA 17701

Dear Valued WorkPartners Policy Holder,

Thank you for choosing WorkPartners for your workers’ compensation program. As part of our services, we have enclosed your workers’ compensation provider panels developed for your workplace locations to be utilized for work-related injuries sustained from your policy effective date and going forward. In the event of a panel update, that updated listing will be effective as of the date of notice and is to be used for any work-related losses reported from that day forward.

Posting of an up-to-date workers’ compensation panel is a requirement under the Pennsylvania Workers’ Compensation Act. You are also required to have your employees to sign the Employee Rights and Duties Form, which confirms they are aware of your designated Workers’ Compensation Provider Panel. This signature is required at time of hire/establishment of new panel and after an injury is reported. For your convenience, we have attached a copy of the Employees Rights and Duties and Employee Acknowledgement forms.

Please confirm your receipt and agreement to post the attached workers’ compensation panels atyour designated workplace location(s). In order that a panel is available for your employees as quickly as possible, we look forward to hearing your feedback within five (5) calendar days. After that time period we will accept the panel as approved by you, in the absence of a response.

If you have any questions or requests regarding your panel creation, please contactWCPanels@upmc.edu. We appreciate the opportunity to partner with you.

Sincerely,

WorkPartners Panel Management Team

Panel updated: 3/20/19

*In accordance with Section 306(f.1)(1)(i) of the Worker's Compensation Act AND 34 Pa. Code Section 127.753 Disclosure Requirements, this health care provider is employed, owned or controlled by UPMC

Roads to Freedom - Williamsport (17701)YOUR WORKERS COMPENSATION CLAIMS ARE MANAGED BY WORKPARTNERS

Send Bills To: PO Box 2971, Pittsburgh, PA 15230Fax: (412) 454-8717

To Report a Claim Call: 1-800-633-1197WC Policy:WC100-2028438-2019A Policy Effective Date:03/19/2019

NOTICE TO EMPLOYEES IN CASE OF WORK-RELATED INJURIES1. If you suffer a work-related injury, your employer or its insurance company must pay for reasonable surgical and medical services and supplies,

orthopedic appliances and prosthesis, including training in their use.2. In order to insure that your medical treatment will be paid for by your employer or the insurance company, you must select from one of the following

health care providers.3. You must continue to visit one of the physicians listed below, if you need treatment, for ninety (90) days from the date of your first visit.4. If one of the persons below refers you to another licensed specialist, your employer or their insurer will pay the bill for these services.5. After this ninety- (90) day period, if you still need treatment and your employer has provided a list as set forth below, you may choose to go to another

health care provider for treatment. You should notify your employer of this action within five days of your visit to said provider.6. If a physician on the list prescribes invasive surgery, you may obtain a second opinion from any physician of your choice. If the second opinion is

different than the listed physicians opinion, you may determine which course of treatment to follow; however, the second opinion must contain a specific and detailed treatment plan. If you choose the second opinion, the procedures in that opinion must be performed by one of the physicians on the list for the first ninety- (90) days. Therefore, in this situation, the employee may be required to treat with an employer-designated provider for up to 180 days.

7. If you are faced with a medical emergency, you may secure assistance from a hospital, physician, or health care provider of your choice for your work-related injury. However, when the emergency is resolved, you must seek treatment from a provider listed below.

Name Address Scheduling Area of Specialty

*UPMC Susquehanna WorkCenter at Divine Providence Hospital

1100 Grampian BlvdWilliamsport, PA 17701

570-320-7444 Occupational Medicine

Mid-State Occupational Health Services - Williamsport 2605 Reach RdWilliamsport, PA 17701

570-327-8790 Occupational Medicine

MedExpress Urgent Care - Williamsport 1953 E 3rd StWilliamsport, PA 17701

570-323-4072 Urgent Care

*UPMC Susquehanna General Surgery at Williamsport 740 High St, Ste 1003Williamsport, PA 17701

570-321-3160 General Surgery

*UPMC Susquehanna Neurosurgery 740 High St, Ste 3002The Neuroscience CenterWilliamsport, PA 17701

570-321-2820 Neurosurgery

*UPMC Susquehanna Health Orthopedics at Williamsport

1705 Warren AveWilliamsport, PA 17701

570-321-2020 Orthopedics

*UPMC Susquehanna Health Sports Medicine 1201 Grampian Blvd, Ste 2FWilliamsport, PA 17701

570-321-2020 Orthopedics

*UPMC Susquehanna Health Ophthalmology 1201 Grampian Blvd, Ste 2AWilliamsport, PA 17701

570-326-8800 Ophthalmology

One Call Physical Therapy Call Toll-Free for Closest Location 1-844-284-2525 Physical TherapyOne Call Chiropractic Call Toll-Free for Closest Location 1-844-284-2525 ChiropracticOne Call Imaging Services Call Toll-Free for Closest Location 1-844-284-2525 Diagnostic ImagingOne Call Durable Medical Equipment Call Toll-Free for Supplier 1-844-284-2525 DMEmyMatrixx (an Express Scripts company) Call Toll-Free for Closest Location

BIN# 003858, Group# KYHA1-800-945-5951 Pharmacy

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WorkPartners Claims Management Services PO Box 2971 Pittsburgh PA 15230

WORKERS' COMPENSATION INFORMATION

To All Employees:

The workers' compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury.

Benefits are required to be paid by your employer if self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers' compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place. It is also required to be posted in any areas used for treatment of injured employees or for the administration of first aid.

You should report immediately any injury or work-related illness to your employer. Your benefits could be delayed or denied if you do not notify your employer immediately.

If your claim is denied by your employer, you have the right to request a hearing before a Workers' Compensation Judge.

The Bureau of Workers' Compensation cannot provide legal advice. However, you may contact theBureau of Workers' Compensation for additional general information:

Bureau of Workers' Compensation1171 South Cameron Street, Room 103Harrisburg, Pennsylvania 17104-2501Telephone No. within Pennsylvania: 1-800-482-2383Telephone No. outside of this Commonwealth: 717-772-4447TTY: 1-800-362-4228 (for hearing and speech impaired only)www. state. pa. us, PA keyword: workers' comp

For a complete list of panel physicians, please contact your employer. Please call 1-800-633-1197 with any additional questions.

I, , employee of , (employer)

certify that I have been provided with, read, and understood the information set forth above consistent with the requirements of the Pennsylvania Workers' Compensation Act.

Date:

Fax this form to WorkPartners (412-454-8717) if it is being completed as a result of a work injury; then place the original in the employee file. If this form is being completed for any reason other than in conjunction with an injury please do not fax to WorkPartners, only place in the employee file.

Page 2 of 2

WorkPartners Claims Management Services PO Box 2971 Pittsburgh PA 15230

EMPLOYEE'S ACKNOWLEDGEMENT FORM UNDERSECTION 306(f)(1)(i) OF THE PENNSYLVANIA WORKER'S COMPENSATION ACT

I recognize and agree that my employer has provided a list of at least six (6) designated health care providers, no more than two (2) of whom are coordinated care organizations and no fewer than three (3) of whom are physicians. Therefore, I acknowledge that I must treat with one of these health care providers for ninety (90) days from the date of my first visit. If I fail to treat with one of these designated health care providers, I understand that my employer will not be liable for the payment for services rendered during this ninety (90) day period. Subsequent treatment may be provided by any health care provider of my choice. However, I must advise my employer within five (5) days of my first visit to each and every non-designated health care provider. Failure to do so may affect whether my employer is liable for payment for services rendered prior to appropriate notice.

My employer has informed me of my rights and duties, and my signature acknowledges that I have been so informed and that I understand my rights and duties.

Employee' s Signature Date

Employee' s Name (Print) Employee Number

Employer Department

Witness' Signature Date

Fax this form to WorkPartners (412-454-8717) if it is being completed as a result of a work injury; then place the original in the employee file. If this form is being completed for any reason other than in conjunction with an injury please do not fax to WorkPartners, only place in the employee file.

HHA eXchange Mobile App Acknowledgment

HHA eXchange is the electronic visit verification (EVV) tool which attends utilize to clock in and clock out from shifts. For your convenience, HHA eXchange has a mobile app on both Apple’s App Store and Good Play Store for Android Devices. Attendants may be contacted via the HHA eXchange mobile app when available shifts are open to inform them of staffing opportunities. In addition, RTFHC may also contact attendants via the add to address compliance requirements and other communication needs. The 21st Century Cures Act requires electronic visit verification (EVV) systems for Medicaid-funded personal care services (PCS) and home health care services to be implemented by 1/1/2020. Therefore, we encourage all attendants to download and install the HHA eXchange app and create a new profile which allows you to sign in and take advantage of prioritized communication from Roads To Freedom Home Care’s scheduling office. Step 1: Search for HHA eXchange on either the iPhone App Store or Android’s Google Play Store depending on your device. Step 2: Locate the following icon for the HHA eXchange app and download and install. Step 3: Tap the “3 dots” icon in the upper right corner of the app to create a profile. You will be given a “Mobile ID Number” which you will give to RTFHH so your account can be linked with our system.

“Mobile ID Number”_______________________________________________________

Employee Signature___________________________________ Date ____/____/____

Authorization Tuberculosis/Hepatitis Vaccine

Employee_________________________________________________________ First Middle Initial Last

Has been hired as an employee for Roads To Freedom Home Care and is authorized to receive a Tuberculosis screening and or Hepatitis B vaccine series. 2 Step TB Series Needed Y or N Date Given Step 1 TB Y or N ____/____/_____ Step 2 TB Y or N ____/____/_____ Chest X-Ray Needed Y or N ____/____/_____ HEP B Vaccine Needed Y or N ____/____/_____ ________________________________________________________ ____/____/_____ Authorized Signature Attention Medical Facility: This is the authorization to place and read the tests as specified. This form does not take the place of formal documentation needed. The results of these tests must be placed on your letterhead and returned to our office. Thank you in advance for your cooperation. If you have any questions or concerns, please contact us immediately.

Roads To Freedom Home Care 22 E 3rd Street

Williamsport, PA 17701 Phone 570-601-1663

Fax 570-601-1456

Employee Contact Information

Employee_________________________________________________________ Primary Number________________________________ Alt Phone____________________ Email________________________________________________________________________ Mailing Address______________________________________________________________ ______________________________________________________________________________ Preferred Method of Contact__________________________________________________

Emergency Contact Information

1. Emergency Contact Name:_____________________________________________

Emergency Contact Relationship________________________________________

Emergency Contact Phone__________________ Alt Phone__________________

2. Emergency Contact Name:_____________________________________________

Emergency Contact Relationship________________________________________

Emergency Contact Phone__________________ Alt Phone__________________

3. Emergency Contact Name:_____________________________________________

Emergency Contact Relationship________________________________________

Emergency Contact Phone__________________ Alt Phone__________________

Employee Signature___________________________________ Date ____/____/____

Attendant Employment Checklist

Employee______________________________ Date of Hire____/____/_____

Checklist

Identification: PA Drivers License PA State ID ______

Social Security Number: ______

Training Day #1 ____/____/____ ______

Training Day #2 ____/____/____ ______

TB Test #1 ____/____/____ ______

TB Test #2 ____/____/____ ______

Reference #1 ______

Reference #2 ______

Face to Face Interview ____/____/____ ______

Clearances

PA Criminal Background Clearance ______

Child Abuse Clearance ______

Exclusion List ______

FBI Fingerprint Clearance ______

Proof of Residency ______

Certification

CNA or MA Certificate ______

LPN ______

RN ______

Roads To Freedom Home Care22 East 3rd St., Williamsport, PA 17701

Voice: (570) 601-1663 Toll Free Voice: (800) 984-7492

Video Relay Systems: (866) 842-5426

Fax: (570) 601-1456

Roads To Freedom Home Care

Personal Assistance Services Training Receipt

I have completed the Roads To Freedom Home

Care Personal Assistance Services trainings under the direction of RTFHC's registered nurse. I acknowledge that I am permitted to provide care to consumer's of RTFHC using my training skills and knowledge gained.

During my training, I was informed of my attendant care rights and responsibilities under RTFHC Program, as well as the rights and the responsibilities that are mandated by the Pennsylvania Department of Health.

I further understand that I can contact RTFHC at any time with questions or concerns regarding the skills I gained during my training. I also understand I am not permitted to perform additional skills without specialized training, even at the request of a consumer.

Employee Date

RTFHC Representative Date

CWIA-25 06-12 (Page 2)

New Hire Reporting: Lending a Hand to Pennsylvania’s Children

Pennsylvania New Hire Reporting ProgramCenter for Workforce Information & Analysis

COMMONWEALTH OF PENNSYLVANIADepartment of Labor & Industry

New Hire Reporting Form

REQUIRED EMPLOYER INFORMATION: (Please type or print LEGIBLY in blue or black ink ONLY)

Employer FEIN:

Employer Name:

Employer Address (Street, City, State, Zip):PO Box’s are not acceptable

Employer Contact Name:

Employer Contact Phone Number:

Employer Contact Fax Number:

Employer Contact Email:

Please fax this form to:866-PAHIRES (866-748-4473) (TOLL FREE)Or 717-657-HIRE (717-657-4473) (Local)

Or mail this form to: Commonwealth of Pennsylvania New Hire Reporting Program P.O. Box 69400 Harrisburg, PA 17106-9400

Questions?Contact New Hire Customer Service at 888-PAHIRES (888-724-4737) Or by email at: RA-LI-CWDS-NewHire@pa.gov

This form may be duplicated as needed

Save time and postage costs.Online reporting is fast, free and paperless.

For more information about how to get started, please visit

www.pacareerlink.state.pa.usOr contact our customer service at 888-PAHIRES (888-724-4737)

REQUIRED EMPLOYEE INFORMATION: (Please type or print LEGIBLY in blue or black ink ONLY)

ONE EMPLOYEE PER BOX

Employee Social Security Number

Legal Name (First) (Middle) (Last)

Street Address (Post Office Box is not acceptable) Apartment Number (if available)

Zip Code City State

Date of Hire (MM/DD/YYYY) Date of Birth (MM/DD/YYYY)(Must be within 3 years of current date)

ONE EMPLOYEE PER BOX

Employee Social Security Number

Legal Name (First) (Middle) (Last)

Street Address (Post Office Box is not acceptable) Apartment Number (if available)

Zip Code City State

Date of Hire (MM/DD/YYYY) Date of Birth (MM/DD/YYYY)(Must be within 3 years of current date)

ONE EMPLOYEE PER BOX

Employee Social Security Number

Legal Name (First) (Middle) (Last)

Street Address (Post Office Box is not acceptable) Apartment Number (if available)

Zip Code City State

Date of Hire (MM/DD/YYYY) Date of Birth (MM/DD/YYYY)(Must be within 3 years of current date)

Attendant Handbook

1. Attendant Application2. Job Description3. Job Description Acknowledgment4. Attendant Safety5. Employee Disclosure Statement6. Criminal History Clearance Form7. FBI Fingerprinting Form8. PA Child Abuse History Form9. Consent Release Child Abuse History Certification10. Employment Eligibility Verification11. Employment Eligibility Verification and Notifications12. W-4 201913. Local Earned Income Tax-Residency Certification14. ECCA Employee Direct Deposit15. ECCA Employee Finances16. Attendant Training17. TB Testing18. Consent Form for Protection Against Viral Hepatitis19. Confidentiality Policy20. Universal Precautions21. Reference Check #122. Reference Check #223. Workplace Injury24. Workers Compensation Employee Notification25. Workers Compensation Docs 201926. HHA eXchange Mobile App Acknowledgment27. Authorization TB and HBV28. Employee Contact Information29. Attendant Checklist30. Training Receipt31. New Hire Reporting Form32. Attendant Handbook Contents Page

My signature verifies I have reviewed Roads To Freedom Home Care’s Attendant Handbook and received a copy for my records.

Employee Signature___________________________________ Date ____/____/____