Dear Applicant; Original documents needed at the time of drop-off:

Transcription

1 Dear Applicant; Thank you for applying with us! 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 43 rd Street, Suite 11, Gainesville, FL 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) $ 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 business days. 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#

2 AAA Marinelli Home Care Agency, Inc. DBA: An independently owned and operated Home Instead Senior Care Franchise Gainesville Office: 4061 NW 43 rd St., Suite 11,Gainesville, Fl Phone: EMPLOYMENT APPLICATION INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person 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, an independently owned and operated Home Instead Senior Care franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your 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: ( ) Cell Phone: ( ) Work Phone: ( ) Alternate Phone: ( ) Other Names Previously Used: Last Name First Name Middle Name Last Name First Name Middle Name Emergency Contact(s): Name ( ) Phone Name ( ) Phone 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# CAREGiver_Employment_Application_ docx Page 1 of 5

3 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 essential functions 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 the amount 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) Mornings Afternoon Evenings Overnights Live-In Weekdays Weekends Hours/Week Desired: 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 From: To: PREFERENCES Please indicate all areas in which you are willing to work: Bradford Area: Starke Duval Area: Downtown Keystone Heights Melrose Lawtey Baldwin Macclenny 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 and current 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 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# CAREGiver_Employment_Application_ docx Page 2 of 5

4 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: High School: College: School Type School Name City, State Major/Subject # Yrs Attended Graduate High School Vocational/Technical College/University Y / N Y / N Y / N WORK HISTORY Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous 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 $ per Salary (Hour, Week, Month) Reason for Leaving 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# CAREGiver_Employment_Application_ docx Page 3 of 5

5 THIRD MOST RECENT EMPLOYER ( ) Company Name City State Phone Number Dates Employed: From to Job Title Supervisor's Name Duties $ per Salary (Hour, Week, Month) Reason for Leaving 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 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 references are provided. Since we will contact these references, please notify them in advance. 1) 2) 3) 4) 5) 6) Full Name Phone Number H ( ) W ( ) H ( ) W ( ) H ( ) W ( ) H ( ) W ( ) H ( ) W ( ) H ( ) W ( ) Best Time of Day to Call Relationship Number of Years Known CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including 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# CAREGiver_Employment_Application_ docx Page 4 of 5

6 consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to 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 AND AAA Marinelli Home Care Agency, Inc. IS TERMINABLE AT-WILL, SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST 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 serving Alachua, Bradford, Columbia, Levy, Putnum & Union Counties. Lic# CAREGiver_Employment_Application_ docx Page 5 of 5

7 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 or listen 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 you like 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? 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#

8 7. What attracts you to this job in our company? Why? 8. How would you describe yourself as an employee? What are your strengths? What things 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 at work 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 with patients and their families? 12. Describe a situation in which you saw someone go the extra mile for a customer or a patient? 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#

9 AAA Marinelli Home Care Agency, Inc NW 43rd Street, Suite 11 Gainesville, FL Phone: CAREGiver Descriptions & Pay Rates Detailed job descriptions can be located in the Home Instead Senior Care CAREGiver Handbook. Name of Service Description Rate of Pay Assist with walking and light exercise. Companionship 4 hour shift meal preparation (client only) and related clean up, reading & writing letters, mending, encouraging client by participating in mind stimulating activities. $7.70 per hour Home Helper 4 hour shift 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. $7.70 to start $8.00 per hour After training completed/90 day eval. Special Service* 4 hour shift Rise n' Shine or Tuck-In Service 1.5 to 2 hours Sleep-Over Service 8 hour shift Long Night Service Deeper, more detailed housekeeping. *Please note: Must obtain prior approval from the office for Special Services pay rate. Includes Companionship and Home Helper services listed above. 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. $7.70 to start $8.50 per hour After training completed/90 day eval. $20.00 to start $24.00 Flat Rate After training completed/90 day eval. $7.70 per hour 8 Hour Shift $12.00 addt'l added to flat rate 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 NW 43rd Street, Suite 11, Gainesville, FL Phone: Fax: 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#

10 DRUG AND ALCOHOL POLICY POLICY Drug and alcohol abuse adversely affects the health and safety of employees and compromises their ability to provide services to our clients. Therefore, AAA Marinelli Home Care Agency, Inc., d.b.a. an independently owned and operated Home Instead Senior Care franchise ( the Company ) is committed to 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 controlled substances (as defined under state and federal law), and the possession of implements and paraphernalia 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 while performing 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 directly before or during the workday, including lunch and breaks. The use of alcohol during the work day under Company-related and approved circumstances (whether on or off the Company s property) such as the Company s representative luncheons or dinners; specific celebrations; while conducting other Company-related business or socializing; or while otherwise representing the Company, is permitted only to the extent that it does not lead to impaired performance, inappropriate behavior, endanger the safety of any individual, or violate applicable law. C. Unless otherwise authorized by this policy, reporting to work, returning to work, being or remaining at work, while under the influence of alcohol, illegal drugs, or any other controlled substance (not specifically prescribed by the employee s medical provider), or having any of the substances in your system while on duty, while on the Company s premises, while operating a vehicle leased or owned by the Company, or while performing services for or on behalf of the Company, is prohibited. D. Off duty abuse of alcohol which results in excessive absenteeism or tardiness or is the cause of accidents or poor performance will result in corrective action, up to and including termination, in accordance with the Company s policies regarding absenteeism, tardiness, poor performance and unsafe work practices. E. Off-the-job illegal drug use or activities, or convictions relating to such illegal drug use or activities, is also a violation of this policy. Off-the-job illegal drug use or activities or conviction 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 performance or attendance, jeopardizing the safety or welfare of the employee, fellow employees, and/or the organization s clients, risking damage to company business or property. Prescribed and Over-the-Counter Drugs: 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# Drug_Alcohol_Policy_ docx Rev

11 This policy does not prohibit the use of a therapeutic drug unless such therapeutic drug affects the employee s capacity to properly perform job duties or creates a danger to him/her or to others in the work place. Therapeutic Drugs include legally obtained prescription drugs, controlled substances and 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 perform job duties or may create a danger to himself/herself or to others in the work place is required to report the therapeutic drug use to the human resources manager. An employee may be allowed to continue to work, even though under the influence of a therapeutic drug, if the Company has determined, after consultation, that the employee does not pose a threat to his/her own safety or health or the safety or health of other employees, and the employee s job performance is not significantly, detrimentally affected by the therapeutic drug. Otherwise, the employee may be required to take a leave of absence or comply with other appropriate action determined by the Company. Administration of Policy: Reporting Employees are required to notify their supervisor if they have any evidence or reason to believe that the policy and rules set forth above have been, or are being violated. If an employee feels their supervisor is involved, they should notify the CEO or the Human Resources Manager. Failure to appropriately notify or report such conduct may also be grounds for appropriate corrective action. An employee found to be in violation of this policy may be subject to corrective action up to and including discharge. Drug and Alcohol Testing To ensure compliance with this policy, The Company reserves the right to require employees to undergo blood tests, urinalysis or other procedures designed to detect the presence of alcohol or the illegal use of drugs under the circumstances described below. 1. Post-Offer/ Pre-Employment Testing: After a conditional offer of employment is extended, all job applicants will be subject to pre-placement drug and alcohol testing. When the applicant has 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 applicant will not be employed by the Company. 2. Work-Related Accidents: Employees involved in work-related accidents resulting in any bodily injury (either to themselves or to others) or property damage will be subject to drug and alcohol testing. 3. Reasonable Suspicion: The Company reserves the right to test those employees management reasonably suspects may be violating any portion of this policy. 4. Post-Treatment/ Post-Rehabilitation Testing: Employees who successfully complete an approved counseling or rehabilitation program pursuant to this policy may be subject to unannounced testing. 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# Drug_Alcohol_Policy_ docx Rev

12 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 or test 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 know test 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 job performance to seek assistance from qualified professionals. It is the responsibility of the employee to seek assistance from qualified professionals before alcohol and/or drug problems are discovered by the Company. Any attempt by an employee to seek such assistance after a violation of this policy has been detected may have no effect on the corrective action, up to and including discharge, which the Company may determine, in its sole management discretion, is appropriate. The Company may require an employee who has violated any portion of this policy, and whom the Company, in its sole management discretion determines will be allowed the opportunity to continue employment, to seek assistance from qualified professionals or participate in a rehabilitation program, at the employee s expense, 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 Company reserves the right to conduct searches of employee possessions, including purses, briefcases, or motor vehicles, while the employee is on company property or on duty. The Company also reserves the right to take custody of and submit for testing any item, article, or substance it discovers during a search that appears to the company may be evidence of a violation of this policy. Searches may be conducted at any time without advance notice. Any employee who refuses to cooperate with such searches will be subject 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 understand I am responsible for reviewing the information contained herein and will seek clarification or verification where necessary. Employee Signature Supervisor Signature Date Date 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# Drug_Alcohol_Policy_ docx Rev

13 AFFIDAVIT OF COMPLIANCE WITH Background Screening Requirements Authority: This form may be used by all employees to comply with: the attestation requirements of section (2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately 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 (2), Florida Statutes which requires proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the Agency, the Department of Health, the Agency for Persons with Disabilities, the Department of Children and Family Services, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement 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 an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, 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 been found 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 Florida Statutes or under any similar statute of another jurisdiction: (f) Section , relating to vehicular homicide. Criminal offenses found in section , F.S a) Section , relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct. (b) Section , relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct. (c) Section , relating to adult abuse, neglect, or exploitation of aged persons or disabled adults. (d) Section , relating to murder. (e) Section , relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child. (g) Section , relating to killing of an unborn quick child by injury to the mother. (h) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony. (i) Section , relating to assault, if the victim of the offense was a minor. (j) Section , relating to battery, if the victim of the offense was a minor. (k) Section , relating to kidnapping. (l) Section , relating to false imprisonment. (m) Section , relating to luring or enticing a child. AHCA Form # , August 2010 Page 1 of 3 Section 59A (3)(b)2, Florida Administrative Code Form available at:

14 (n) Section (2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings. (o) Section (3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person. (p) Section (1), relating to exhibiting firearms or weapons within 1,000 feet of a school. (q) Section (2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property. (r) Section , relating to sexual battery. (s) Former s , relating to prohibited acts of persons in familial or custodial authority. (t) Section , relating to unlawful sexual activity with certain minors. (u) Chapter 796, relating to prostitution. (v) Section , relating to lewd and lascivious behavior. (w) Chapter 800, relating to lewdness and indecent exposure. (x) Section , relating to arson. (y) Section , relating to burglary. (z) Section , relating to voyeurism, if the offense is a felony. (aa) Section , relating to video voyeurism, if the offense is a felony. (bb) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony. (cc) Section , relating to fraudulent sale of controlled substances, only if the offense was a felony. (dd) Section , relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult. (ee) Section , relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult. (ff) Section , relating to exploitation of an elderly person or disabled adult, if the offense was a felony. (gg) Section , relating to incest. (hh) Section , relating to child abuse, aggravated child abuse, or neglect of a child. (ii) Section , relating to contributing to the delinquency or dependency of a child. (jj) Former s , relating to negligent treatment of children. (kk) Section , relating to sexual performance by a child. (ll) Section , relating to resisting arrest with violence. (mm) Section , relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication. (nn) Section , relating to aiding in an escape. (oo) Section , relating to aiding in the escape of juvenile inmates in correctional institutions. (pp) Chapter 847, relating to obscene literature. (qq) Section (1), relating to encouraging or recruiting another to join a criminal gang. (rr) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor. (ss) Section , relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct. (tt) Section (3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm. (uu) Section , relating to escape. (vv) Section , relating to harboring, concealing, or aiding an escaped prisoner. (ww) Section , relating to introduction of contraband into a correctional facility. (xx) Section , relating to sexual misconduct in juvenile justice programs. (yy) Section , relating to contraband introduced into detention facilities. (3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s , whether such act was committed in this state or in another jurisdiction. Criminal offenses found in section (4), F.S (a) Any authorizing statutes, if the offense was a felony. AHCA Form # , August 2010 Page 2 of 3 Section 59A (3)(b)2, Florida Administrative Code Form available at:

15 (b) This chapter, if the offense was a felony. (c) Section , relating to Medicaid provider fraud. (d) Section , relating to Medicaid fraud. (e) Section , relating to domestic violence. (f) Section , relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems. (g) Section , relating to false and fraudulent insurance claims. (h) Section , relating to patient brokering. (i) Section , relating to criminal use of personal identification information. (k) Section , relating to fraudulent use of credit cards, if the offense was a felony. (l) Section , relating to forgery. (m) Section , relating to uttering forged instruments. (n) Section , relating to forging bank bills, checks, drafts, or promissory notes. (o) Section , relating to uttering forged bank bills, checks, drafts, or promissory notes. (p) Section , relating to fraud in obtaining medicinal drugs. (q) Section , relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony. (j) Section , relating to obtaining a credit card through fraudulent means. If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached. Purpose of Prior Screening: Screened conducted by: Agency for Health Care Administration Department of Health Agency for Persons with Disabilities Department of Children and Family Services Department of Financial Services Date of Prior Screening: 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 , 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 AHCA Form # , August 2010 Page 3 of 3 Section 59A (3)(b)2, Florida Administrative Code Form available at:

16 Release authorization and Request for Criminal History, SSN verification, National Sex Offender 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: 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 for considering you for employment. These reports may include public record information such as your driving records, criminal history and personal reputation, mode of living, character and workers compensation claims. Private information such as your credit history may also be obtained. The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. I hereby authorize AAA Marinelli Home Care Agency, Inc., dba Home Instead Senior Care to obtain consumer reports about me as described above for the purpose of qualifying me for employment. I release AAA Marinelli Home Care Agency, Inc.,., dba Home Instead Senior Care as well as Florida MVR Services, Inc., IntelliCorp and all other search entities from which the consumer reports are obtained from any claim or liability related to obtaining, compiling or releasing such reports. I also agree that this authorization and release will remain on file for the term of my employment and will serve as an ongoing authorization to obtain consumer reports related to my employment. I understand and agree to a yearly Authorization and Request for Criminal History and MVR, which I fully understand to be paid by me. I agree to pay all related fees. The SSN Verification, Criminal Super Search, Nationwide Sex Offender Registry, Employment Verification and MVR processing fee is based on the number of states and counties you lived in the past 7 years. MVR checks as dictated by your driving record. Each county and state lived must 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 for your 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#

17 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 43 rd St., Suite 11, Gainesville, FL 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: 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#