Pediatric Home Healthcare, LLC
  Employment Application
* Indicates Mandatory Fields

*First Name
Middle Name
*Last Name
*D.O.B. *Gender
*Address 1
Address 2
*Zip *City *State *S.S.N.
*Cell Phone
Home Phone
*Email Address
*Position Applying For:
*How Were You Referred: Referred Person:
*Are you legally Eligible to be Employed in United States?
*Will you now or anytime in the future need to be sponsored for Employment Visa Status?
( Office Positions can skip this section )
Willing to provide service to a client with a pet? Cat  Dog
Willing to provide service to a client who smokes?
Own reliable transportation?
Do you have a valid driver’s license?
DL. No.:  
DL. Expiry Date:
Preferred Day and Time
Day From To
( Office Positions can skip this section )
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Monday  Apply Time to All
Certificate Name Expiry Date
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Name Zip City State Major / Subject # Yrs Attended Graduate
High School
Previous Employment
Previous Employment 1
Employer: Yes No
Address: Zip:
City: State:
Job Title: From: To:
Supervisor: Phone:
Previous Employment 2
Employer: Yes No
Address: Zip:
City: State:
Job Title: From: To:
Supervisor: Phone:
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Clinical Reference
Clinical Reference #1
Company Name: Company Phone:
By initialing this box, I hereby release from all liability the company or person completing this form and authorize them to release all information regarding my employment with them. I understand that his information may be released to clients of the requesting company and other requesting third parties on a need to know basis. I also release the requesting company from all liability for any damages from the disclosure of this information.
Name/Title: Date:
Clinical Reference #2
Company Name: Company Phone:
By initialing this box, I hereby release from all liability the company or person completing this form and authorize them to release all information regarding my employment with them. I understand that his information may be released to clients of the requesting company and other requesting third parties on a need to know basis. I also release the requesting company from all liability for any damages from the disclosure of this information.
Name/Title: Date:
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Reference 1
Address: Zip:
City: State:
Home Phone: Work Phone:
Relation: Years known:
Reference 2
Address: Zip:
City: State:
Home Phone: Work Phone:
Relation: Years known:
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Statement of Employability
1. * Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other?
Yes  No
2. If yes, please explain.   
3. By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253.
4. Criminal History Check: I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and that I may not have face to face patient contact until results are returned. I will be notified of results.
5. I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.
Employee Acknowledgment
1. Confidentiality: Agency maintains confidentiality of operations, activities, and business affairs of the Agency and the clients according to 1996, Health Information Portability and Accountability Act (HIP AA). Due to the nature of our work, each employee will gain~ directly or indirectly, sensitive and confidential information on clients/patients and staff members. The health care professional safeguards the client's right to privacy by judiciously protecting information of a confidential nature including medical treatment information, diagnosis, medical records, personal patient information, etc. This information should be shared only with those persons who, due to their position, have a need to know. Sensitive or confidential information must never be used as the basis for social conversation or gossip. If an employee is in doubt as to whether or not certain information may be shared, s/he should consult with his/her supervisor.
2. Drug Testing Policy: Agency conducts "on hire and random/for cause" drug testing on its employees. Agency maintains a drug free workplace policy with regard to the possession, use, distribution and sale of drugs or alcohol. All employees are prohibited from the unlawful or unauthorized manufacture, distribution, dispensing, possession or use of a controlled substance or any alcoholic beverages while in the workplace or on Company paid time Violation of this policy can result in disciplinary action, up to and including termination of employment. I acknowledge I have received a copy of the agency's policy on drug testing.
3. Harassment Policy: This agency is committed to providing a work environment that is free from all forms of discrimination and unlawful harassment including sexual harassment. This policy applies to all employees including management personnel. Sexual harassment is any unwelcome sexual advances either explicit or implicit as a term or condition of employment. Improper behavior may be verbal, visual, or physical in nature and/or the creation of a hostile environment. Management will investigate complaints of sexual harassment promptly, impartially and without fear of retaliation to the employee. An employee should report the alleged incident immediately and confidentially to the appropriate manager or Human Resources.
4. Non Solicitation/Illegal Remuneration: Agency does not reimburse or provide incentives to physicians, durable equipment providers, family or other referral entities for patient referrals for home health services. Employees may not solicit patients for the agency. Employees found in violation of this nonsolicitation policy will be subject to discipline up to and including termination of employment.
5. NonDiscrimination: Agency does not discriminate against clients or volunteers based on age, race, color, religion, military status, gender preference, sex, marital status, national origin, disability, or source of payment.
6. Abuse, Neglect, and Exploitation: Agency employees will report suspected abuse, neglect and/or exploitation to the state departments of both the Texas Department of Family and Protective Services, the Department of Aging and Disability Services, and Agency management. Agency employees suspected of abuse, neglect or exploitation will be suspended immediately, an investigation will be conducted, and if the investigation validates the claim, the employee will be terminated.
7. Workers' Compensation: Agency is a subscriber to workers' compensation insurance. An employee who incurs an injury on the job that requires emergency medical treatment or is life threatening should proceed to the nearest emergency room. Emergency medical treatment (nonlife threatening) or nonemergency treatment should be referred to the agency's designated clinic. Notify the agency of an injury within 24 hours to complete paperwork. Medical expenses for injuries are covered with the exception of the following: employee's willful intent to hurt self or others, intoxication or drug use, horseplay, acts of God, and/or acts of a third party.
8. Progressive Discipline Policy: Agency utilizes a progressive discipline process in cases of misconduct or unacceptable performance. This includes verbal warning, written warning and final warning. Disciplinary action may begin at an advanced stage of the process or may result in immediate termination based upon the nature and severity of the offense, employee's past record and other circumstances.
Probationary Period Policy
1. As an employee of Pediatric Home Healthcare, LLC , I understand that I am on a probation period forthe first 30 days of my employment.
2. Probationary Period will begin on the first day of my scheduled shift under the Texas "Unemployment Compensation Law".
3. As stated in the Texas" Unemployment Compensation Law", if Pediatric Home Healthcare, LLC terminates me for inadequate work performance, the agency will not be held accountable forany unemployment benefits I might qualify for at a later date.
Attendance and Tardiness
1. If you must leave your shift, for any reason, prior to your scheduled time, you must first contact your office/recruiter, inform them of why you must leave your shift and remain in the home until an alternative caregiver is able to receive report and continue care for your patient. If the parent or guardian of your client is requesting you leave prior to your scheduled endofshift, you must contact the office/recruiter and report the parent’s request.
2. We at  Pediatric Home Healthcare, LLC  hold each and every employee to a high standard. If an employee agrees to work a shift with a patient,  Pediatric Home Healthcare, LLC  expects you to show up to the residence 15 minutes prior to start of shift to receive report and fulfill your obligation to the patient. If an emergency occurs and you cannot work, it is your responsibility to notify the office at least 6 hours prior to the start of your shift. If you are ill and cannot work, please notify a recruiter immediately and you may be asked to present a note from the Physician that treated you. If you have a transportation problem that arises, notify a recruiter immediately and we may be able to provide transportation for you. Continued/numerous absenteeism or tardiness could result in disciplinary action up to and including termination. A no call/no show for a shift that you have agreed to work will result in immediate termination of employment with  Pediatric Home Healthcare, LLC  .
Hepatitis B Vaccination
1. Due to your occupational exposure to blood or other potentially infectious materials, you may be at risk for acquiring hepatitis B viral (HBV) infection. The vaccination series is available, at no cost, to you. Please indicate below your declination or acceptance to receive the vaccine.
2. The virus can be transmitted through contact with infectious fluids of a patient who has hepatitis B virus. You have been taught the concepts of Universal Precautions concerning safe patient care and the use of equipment to avoid unnecessary exposure. Synthetic hepatitis B vaccine is derived from yeast cells. It is not composed of human blood or plasma. It is given as a series of three injections into the arm muscle at prescribed intervals (initial shot, one month later, and six months later). It has proven to be over 8090% effective in protecting against the disease. There may be hypersensitivity to the vaccine, and there may be soreness and swelling of the injection arm. Other side effects may occur at an incidence of under 3% of injections.
3. The vaccine will not be given to persons with known sensitivity to aluminum hydroxide, thimerosal, yeast or hepatitis antigen and will only be given with your personal physician's recommendations in the cases of pregnancy or presence of other infection of immunosuppressive state. The vaccine does not grant 100% assurance of immunity.
4. * Please select the choice that accurately refects your Hepatitis B Vaccine status:
I have had the Hepatitis B Vaccine before at an earlier date.
I do not wish to have the Hepatitis B Vaccine.
I wish to recieve the Hepatitis B Vaccine.
TB Fact Sheet
1. * Mycobacterium Tuberculosis is transmitted by air, carried in droplets that are created when a person with respiratory TB coughs, sneezes or shouts. TB Infection occurs when someone inhales the droplet particles containing the Mycobacterium. A person may have no symptoms, but still have latent TB infection (LTBI) and may develop TB disease at some point in their lives. TB skin tests may become positive in 2 to 12 weeks after the exposure. The following criteria is utilized to identify if an employee has potential TB. This criteria is also utilized to determine if an employee needs another chest xray. This information is also presented in training. Do you have any of the following Potential active symptoms of TB which include but limited to: Persistent cough greater than 2 weeks duration, Bloody sputum, Hoarseness, Fatigue, Chest pain, Night sweats, Weight loss, Anorexia, or Fever?
Yes   No
2. * Do you consider yourself part of any of the following groups that have a higher prevalence of TB infection? 1. Medically underserved populations 2. Homeless individuals 3. Current or past prison inmates 4. Alcoholics 5. Injecting drug users 6. Elderly 7. Foreignborn persons from Asia, Africa, the Caribbean and Latin America 8. Contacts to individuals with TB 9. Groups with a greater risk to progress from latent TB infection to active disease 10. Individuals with HIV infection, silicosis, SIP gastrectomy or jejunoileal bypass surgery, greater than 10 lb. Below normal body weight, chronic renal failure, diabetes mellitus, immunosuppressed due to medication, and those with some malignancies. 11. Individuals who have been infected within the past 2 years and individuals with fibrotic lung disease on chest xray.
Yes  No
3. * By initialing this box, I have reviewed the signs and symptoms of TB. I am not experiencing symptoms of TB. I understand if I experience any of the above symptoms I am to report to management immediately.
Agreement to comply
1. * By checking this box, I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.