Career Application

I have been formally instructed regarding Agency policy and procedures for maintaining the confidentiality of all information contained in client/personnel files and records, as well as any other proprietary information regarding the agency that is obtained verbally.

I understand that, except as needed to conduct business, client and/or personnel information/proprietary information may not be discussed with anyone, either inside or outside the Agency.

I understand that medical records will not be removed from the Agency office unless the client has signed a Release of Information Form, and the removal of such information is approved by Agency Administrator and/or designee.

I understand that any breach of confidentiality may be grounds for immediate termination of employment.

The following questions are designed to assist Governing Body members, Professional Advisory members and staff in determining the nature and extent of any outside interest that might possibly involve conflict of interest with the affairs of the organization. Please read each question carefully and then answer briefly and concisely in the space that follows. In the event that you have any doubts as to what the question means, answer it to the best of your ability and identify the reason for doubt.

Glossary

• Competitor: A person offering for sale or selling products and/or services in competition with this organization.
• Family: Spouse, parents, children, brothers, sisters.
• Purchaser: Any person who buys, rents, or otherwise procures, has bought, rented or procured, or in any way has received from this organization any goods, materials, wares, merchandise, supplies, machinery, equipment, or professional and/or other service.
• Person: An individual, firm, partnership, trust, corporation, or other business entity.
• Vendor: Any person who sells, rents, agrees to furnish, has offered to sell, rent, or agree to furnish, or has sold supplies, machinery, equipment, real estate, credit, insurance, or service, profession or otherwise, to or on behalf of the organization.

Authority: This form may be used by all employees to comply with the attestation requirements of section 435.05(2), Florida Statutes, which state that every 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 408.809(2), Florida Statutes which requires proof of compliance with level 2 screening standards.

This form must be maintained in the employee's personnel file. If this form is used as proof of screening for an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application.

I hereby attest to meeting the requirements for employment and that I have not been arrested for, and/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.

Criminal offenses found in section 435.04, F.S.

• Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.
• Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.
• Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.
• Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
• Section 782.04, relating to murder.
• Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.
• Section 782.071, relating to vehicular homicide.
• Section 782.09, relating to killing of an unborn quick child by injury to the mother.
• Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.
• Section 784.011, relating to assault, if the victim of the offense was a minor.
• Section 784.03, relating to battery, if the victim of the offense was a minor.
• Section 787.01, relating to kidnapping.
• Section 787.02, relating to false imprisonment.
• Section 787.025, relating to luring or enticing a child.
• Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.
• Section 787.04(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.
• Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.
• Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.
• Section 794.011, relating to sexual battery.
• Former section 794.041, relating to prohibited acts of persons in familial or custodial authority.
• Section 794.05, relating to unlawful sexual activity with certain minors.
• Chapter 796, relating to prostitution.
• Section 798.02, relating to lewd and lascivious behavior.
• Chapter 800, relating to lewdness and indecent exposure.
• Section 806.01, relating to arson.
• Section 810.02, relating to burglary.
• Section 810.14, relating to voyeurism, if the offense is a felony.
• Section 810.145, relating to video voyeurism, if the offense is a felony.
• Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.
• Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.
• Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.
• Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.
• Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.
• Section 826.04, relating to incest.
• Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.
• Section 827.04, relating to contributing to the delinquency or dependency of a child.
• Former section 827.05, relating to negligent treatment of children.
• Section 827.071, relating to sexual performance by a child.
• Section 843.01, relating to resisting arrest with violence.
• Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.
• Section 843.12, relating to aiding in an escape.
• Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.
• Chapter 847, relating to obscene literature.
• Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang.
• 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.
• Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.
• Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.
• Section 944.40, relating to escape.
• Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.
• Section 944.47, relating to introduction of contraband into a correctional facility.
• Section 985.701, relating to sexual misconduct in juvenile justice programs.

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

• Any authorizing statutes, if the offense was a felony.
• This chapter, if the offense was a felony.
• Section 409.920, relating to Medicaid provider fraud.
• Section 409.9201, relating to Medicaid fraud.
• Section 741.28, relating to domestic violence.
• Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.
• Section 817.234, relating to false and fraudulent insurance claims.
• Section 817.481, relating to obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony.
• Section 817.50, relating to fraudulently obtaining goods or services from a health care provider.
• Section 817.505, relating to patient brokering.
• Section 817.568, relating to criminal use of personal identification information.
• Section 817.60, relating to obtaining a credit card through fraudulent means.
• Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
• Section 831.01, relating to forgery.
• Section 831.02, relating to uttering forged instruments.
• Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
• Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.
• Section 831.30, relating to fraud in obtaining medicinal drugs.
• Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony.
• Section 895.03, relating to racketeering and collection of unlawful debts.
• Section 896.101, relating to the Florida Money Laundering Act.

I understand that agency staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as authentication on patient record documents and other agency documents generated in the electronic system.

For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge the combined use of my Electronic Signature Passcode and Log In authentication password will serve as my legal signature. I understand that I will be required to update my password regularly for security purposes. I understand that prior to exporting documentation to the agency server, I am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. I understand that I am responsible for the security and accuracy of information entered into my organization's WellSky application, and as such, I will:

• Not share or otherwise compromise my electronic signature credentials, including Log In authentication password or Electronic Signature Passcode.
• Exit the online application at the end of each working day or whenever the computer is not in my immediate possession.
• Not save my Log In password and Electronic Signature Passcode on the computer, but will enter them upon each access of the application.
• Review all of my documentation online prior to submitting to the agency server.

I hereby certify that I have read and fully understand the contents of the Employee Handbook. Furthermore, I have been given the opportunity to discuss any information contained therein or any concerns that I may have. I certify that my employment and continued employment is based in part upon my willingness to abide by and follow the Agency's policies, rules, regulations and procedures. My signature below certifies my knowledge, acceptance and adherence to the Agency's policies, rules, regulations and procedures and that the Agency's offer of employment was based on my promise to abide by and follow said policies, rules, regulations and procedures.

I further certify that my application and subsequent acceptance of employment is true and bona fide, and I am honestly interested in working in the position(s) for which I have been employed. Furthermore, I certify that I have sought and obtained employment with this Agency solely to provide me with the benefits of a job and for no other purpose.

I acknowledge that the Agency reserves the right to modify or amend its policies at any time, without prior notice. These policies do not create any promises or contractual obligations between this Agency and its employees. At this Agency, my employment is at will. This means I am free to terminate my employment at any time, for any reason, with or without cause, and this Agency retains the same rights. I further understand and agree that the Owner/President of this Agency is the only person who may make an exception to this, including the at-will status of my employment, and it must be in writing and duly executed by the Owner/President of this Agency.

If applicable to my employment, I have read and understood the notice regarding polygraph tests and my rights under this state's law.

Authorization to Release Information: I authorize the references and/or employers listed on my employment application, or any other documents I have provided to this Agency, to give the Agency any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing such information to this Agency. I agree and understand that this Agency and its agents may investigate or seek information concerning my background and/or previous employment, whether of record or not. I further agree and understand that if employed, the Agency may at any time seek any information from whatever source, which in its discretion, it deems relevant to my employment.

No Drug Use Policy: This Agency does not hire persons who use illegal drugs. All persons seeking employment or employed with this Agency may be required to take and pass a screen for illegal drugs, and may be subject to periodic tests for illegal drugs.

THIS AGREEMENT is effective as of the date entered below and is by and between the Company and Contractor.

Recitals: Whereas, the Company is primarily involved in the business of providing Home Health Services to persons requiring these services; and whereas, the Company wishes to engage the Contractor and the Contractor wishes to be so engaged, to provide Home Health Services to persons designated by the Company, as an independent contractor, upon the terms and conditions contained below.

Services. Contractor shall provide, directly to Home Health Services persons designated by the Company, services at such times and at such places as shall be agreed to between the Company and Contractor. Contractor agrees that all patients are accepted for services only by the Company.

Compensation. The contractor shall be entitled to receive from the Company a payment with respect to each service provided by the Contractor to persons designated by the Company, as set forth by the parties. Contractor shall not be entitled to any other compensation or reimbursement for costs or expenses unless approved by the Company.

Contractor's Representations. Contractor represents that Contractor is, and will continue to be during the term of this Agreement, duly licensed as necessary in the State of Florida to provide the services hereunder and will perform without negligence and in compliance with applicable laws and professional regulations.

Insurance. Contractor shall be responsible for obtaining and maintaining appropriate levels of professional liability insurance, automobile liability insurance, and personal injury protection insurance, and shall provide certificates of insurance upon request.

Term. This Agreement shall commence as of the date first written and shall continue for successive one-year terms unless terminated according to the terms of the agreement.

Independent Operation and Indemnity. The parties acknowledge that neither the Contractor nor the Company shall be deemed principal, employee, agent or executive officer of the other. Contractor shall conduct duties as an independent contractor and shall indemnify and hold the Company harmless from claims arising out of Contractor's performance.

Restrictive Covenant and Confidentiality. Contractor agrees not to compete with the Company for patients and legal entities Contractor has serviced under this Agreement, and agrees that information concerning patients, suppliers, office files, procedures, policies and other company business is confidential and may not be used or disclosed except as permitted by the Company.

Disclosure and Access. Contractor agrees to promptly notify Company of inquiries, investigations, complaints or disciplinary actions and authorizes regulating entities to release information relating to such actions. Contractor shall provide Company access to books, documents and records when requested.

Company Responsibilities. The Company will admit clients, maintain records, schedule visits, specify documentation requirements, provide review and policies, perform evaluations, and make payments according to contract and agency procedures.

Contractor Responsibilities. Contractor will provide documentation of services, follow schedules, comply with agency policies, maintain qualifications and background requirements, participate in required activities, provide required personnel files, complete orientation, maintain Medicare/Medicaid eligibility as applicable, and comply with all agency requirements.

Miscellaneous. This Agreement shall be governed by Florida law. No amendment or assignment is valid unless signed in writing by the parties. This Agreement is the entire agreement between the parties and may be executed in counterparts.

I have read the information concerning Hepatitis B vaccination. I understand the benefits and risks of the Hepatitis B vaccination and have had the opportunity to ask questions.

1. The vaccine will be administered in a series of three doses: the initial dose, the second dose a month later, and the third dose six months after the first. I understand I must complete the series for full immunization.
2. If I receive the vaccine, I have a 90-95% chance of developing antibodies to the Hepatitis B surface antigen and therefore immunity to the infection of the Hepatitis B virus.
3. The vaccine may not be effective if I am already incubating the Hepatitis B virus.
4. The duration of immunity is unknown at this time and I may require a booster in five years.
5. The vaccine only protects against Hepatitis B virus and does not confer immunity against Hepatitis A or non-A/non-B agents.
6. After receiving the vaccination, minor side effects such as injection site soreness and redness, low-grade fever, malaise and nausea have been reported.

By declining this vaccine, I understand that due to my occupation's exposure to blood and other infectious materials, I may be at risk of acquiring Hepatitis B infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to myself. However, I decline the vaccine at this time. I understand that if in the future I choose to be vaccinated, I can receive the vaccine series at no charge at that time.

The early signs and symptoms of tuberculosis are as follows:

• Cough
• Night Sweats
• Fever
• Loss of Weight
• Loss of Appetite
• Coughing Blood

I have read the above information and do not now have these symptoms. If these symptoms develop, I will contact my supervisor immediately for follow-up.