1 st Day Forms. Welcome to Senior Rehab Solutions! The following forms need to be completed prior to your first day of employ. Personnel Status Form

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1 1 st Day Forms Welcome to Senior Rehab Solutions! The following forms need to be completed prior to your first day of employ. Personnel Status Form W-4 Form I-9 Form Request for Criminal History Check Invitation to Self Identify EEO-1 Self Identification Form Direct Deposit Form EMPLOYEE TO PROVIDE Copies of 2 Forms of ID from I-9 List and Therapy Licensure TB Test Results

2 Personnel Status Change Form Facility Name: Hire Date: Social Security Number: - - New Hire FMLA/LOA Rehire Termination Full Time: Part Time: PRN Discipline: First Name: M.I. Last Name: Street Address: Apt. City: State: Zip: Home Phone #: Cell Phone #: Gender: Race: Date of Birth: Emergency Contact: Phone #: Employee Signature Date. Office Use Only Below: Effective Date: LOA PRN Family Medical Leave Act? Yes No LOA Reason: STATUS CHANGE RATE CHANGE Rate Change: From: To: Effective Date: Reason for Change (circle one): Merit Promotion Demotion Transfer Status Change Benefits Info: Any Details: TERMINATION CHANGE Date Notice Given: Term Date: Rehireable Not Rehireable Reason (circle one): AJ - Abandoned Job CV-Company Policy Violation D Deceased LC-Lost Prof. Cert. or License I Insubordination JP-Job Performance NCNS-No Call No Show OE-Other Employment R Relocating RE-Resigned REN-Resigned w/out Notice S-Return to School TG-Terminated-Good Standing Type (circle one): Voluntary (Quit) Involuntary (Discharged) Reduction in Force- Layoff Termination Details: Badge # Input/Update in Casamba Rate of Pay: Input/Update HPL SRS Representative Signature: Date: HR001-5/09

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14 REQUEST FOR CRIMINAL HISTORY CHECK Based on Chapter 250 of the Health and Safety Code, this facility is required to conduct a criminal history check on all potential employees who are employed in direct contact with a resident in our facility. This check must be initiated within 24 hours of employment and identifying information will be submitted electronically to the Texas Department of Public Safety to obtain the potential employee s criminal conviction record. In addition, if we have reason to believe, based on your application or documents presented, you have lived/worked out of the state of Texas we will run a national/international criminal history check. The facility may repeat this procedure at any time in the future, as they deem appropriate. It is understood that this is privileged information and is for exclusive use of this facility The facility may not employ a person if the facility determines, as a result of the criminal history check, that a person has been convicted of an offense listed in Chapter 250 that bars employment or that a conviction is a contraindication to employment with the residents the facility serves. If you do become employed at this facility and are convicted of an offense that would preclude employment in a nursing facility and/or are excluded from participation in any Federal/State health care program after your hire date, you must report this immediately to the Administrator of this facility. In order to conduct this check, the applicant must provide at least the following identifying information : (1) Complete name: (First) (Middle) (Last) (2) Maiden name and/or other names you go by: (3) Date of birth: (4) Social security number: I have read the above statement and understand these requirements. Employee Signature Date Employee Printed Name HR CENTERS 102 3/10

15 DPS Computerized Criminal History (CCH) Verification (AGENCY COPY) I,, acknowledge that a Computerized Criminal History APPLICANT or EMPLOYEE NAME (Please print) (CCH) check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply. (This is not a consent form.) Authority for this agency to access an individual s criminal history data may be found in Texas Government Code 411; Subchapter F. Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, therefore the organization conducting the criminal history check is not allowed to discuss with me any criminal history record information obtained using this method. The agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search. Once this process is completed the information on my fingerprint criminal history record may be discussed with me. In order to complete the process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at Records/Review of Personal Criminal History or by calling the DPS Program Vendor at , submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company. (This copy must remain on file by your agency. Required for future DPS Audits) Signature of Applicant or Employee Date Agency Name (Please print) Please: Check and Initial each Applicable Space CCH Report Printed: YES NO initial Purpose of CCH: Agency Representative Name (Please print) Signature of Agency Representative Date Empl Vol/Contract initial Date Printed: initial Destroyed Date: / initial Retain in your files Rev. 09/2013

16 TAC Chapter 93-EMPLOYEE MISCONDUCT REGISTRY (EMR) REQUIREMENTS Before a facility may hire a person, the facility must check the Employee Misconduct Registry (EMR) and the Nurse Aide Registry (maintained under the Omnibus Budget Reconciliation Act of 1987) to see if the person is listed as unemployable. Facilities are prohibited from employing a person who is listed in either agency as having abused, neglected, or exploited a resident or consumer of a facility or individual receiving services from an agency. Each facility is required to provide information about the EMR to all employees. The information must: (a) be in writing; and (b) state that persons listed on the EMR are not employable. If the Department of Aging and Disability Services (DADS) receives a report that an employee of a facility committed reportable conduct, DADS will investigate the report to determine whether the employee has committed the reportable conduct. The standards for abuse, neglect, exploitation, and misappropriation that apply to these investigations are the standards that apply to the type of facility where the investigation takes place. DADS will give written notice to an employee alleged to have committed an act of reportable conduct that will include the following items and must state: (1) a brief summary of the findings and facts on which the findings are based; (2) the employee s rights to an informal review (IR) to dispute the findings; (3) a notification that the request for an IR must be made no later than 10 days after the day the employee receives the written notice. This written notice to the employee provides the address and contact information for the local DADS regional office; and a statement of the right of the employee to judicial review of the order; and (4) that persons listed on the EMR are not employable. If the employee does not request an informal appeal contesting the finding of an act of reportable conduct, DADS will record the incident of reportable conduct in the EMR. If an employee commits reportable conduct, the Texas Department of Aging and Disability Services (DADS) will record the following information: (a) the employee s name; (b) the employee s address; (c) the employee social security number; (d) the name of the facility (e) the address of the facility (f) the date of the act of misconduct; and (g) a description of the act of misconduct. Employee Signature Date Employee Printed Name HR CENTERS 103-5/09

17 EMPLOYEE MISCONDUCT POLICY Before a facility may hire a person, the facility must check the Employee Misconduct Registry (EMR) and the Nurse Aide Registry (maintained under the Omnibus Budget Reconciliation Act of 1987) to see if the person is listed as unemployable. Facilities are prohibited from employing a person who is listed in either agency as having abused, neglected, or exploited a resident or consumer of a facility or individual receiving services from an agency. Each facility is required to provide information about the EMR to all employees. The information must: (1) be in writing; and (2) state that persons listed on the EMR are not employable. EMPLOYEE MISCONDUCT PROCEDURE 1. Before hiring an employee, form HR104A will be signed by the potential employee acknowledging notification of an Employee Misconduct Registry check and requirements. 2. Verification that the Nurse Aide Registry and Employee Misconduct Registry has been searched prior to employment will be documented on this form with the findings attached. 3. Verification will become part of the pre-employment process. FOR OFFICE USE ONLY VERIFICATION OF SEARCH Nurse Aide Registry Date Facility Employee Signature Employee Misconduct Registry Date Facility Employee Signature Comments HR CENTERS 104-5/09

18 FOR OFFICE USE ONLY OIG/Medicaid Participation/Exclusion Program Name/Contractor: Date Verified: Excluded: YES NO The above person has applied for employment at this facility or has been contracted to perform services at this facility or is a vendor who serves this facility. This individual or entity has been checked through the OIG s and Medicaid s List of Excluded Individuals/Entities and has not been excluded from participation in any Federal or State health care program. Note: If the above entity or individual appears on the exclusion list, the administrator is to be notified immediately. Facility Representative Date HR CENTERS 105-5/09

19 INVITATION TO SELF-IDENTIFY INDIVIDUALS WITH DISABILITIES AND VETERANS In accordance with Federal regulations relating to Equal Employment Opportunity (EEO) and affirmative action, our firm is prohibited from discrimination in employment practices because of veteran or disability status and is required to take affirmative action to employ and advance in employment qualified individuals with disabilities and covered veterans. If you are an individual with a disability or covered veteran and would like to be considered under our Affirmative Action Program (AAP), we invite you to self-identify. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. This information will be kept confidential and will be kept separate from your resume and/or employment application in compliance with EEO Federal regulations. Date of Application/Resume: Position Applied: Location of Position for which Application/Resume was made: Name (last, first, middle, maiden, if any): Address (Street & No. or P. O. Box, City, State, Zip): Check Applicable box(es): I am an individual with a disability An individual with a disability is defined under Section 3 of the Americans with Disabilities Act of 1990 (42 USC 2102) that amended Section 503 of the Rehabilitation Act of 1973 means, with respect to an individual, (A) a physical or mental impairment that substantially limits one or more major life activities of such individual; (B) a record of such an impairment, or (C) being regarded as having such an impairment. I am an other protected veteran veterans who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the U.S. Department of Defense. For those with Internet access, the information required to make this determination is available at A copy of this list may also be obtained by calling (301) and requesting a copy of the list be mailed to you. I am a recently separated veteran any veteran during the three-year period beginning on the date of such veteran s discharge or release from active duty in the U.S. military, ground, naval or air service. I am a disabled veteran (1) a veteran of the U.S. military ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability. I am a Armed Forces Service Medal Veteran - any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order (61 FR 1209)

20 I am a special disabled veteran A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability: (1) rated at 30% or more; or (2) rated at 10% or 20% in the case of a veteran who has been determined under 38 USC 3106 to have a serious employment handicap; or (3) a person who was discharged or released from active duty because of service-connected disability. I am a Vietnam era veteran a person who (1) served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred: (a) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (b) between August 5, 1964 and May 7, 1975, in all other cases; or (2) was discharged or released from active duty for a service-connected disability if any part of such active duty was performed (a) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (b) between August 5, 1964 and May 7, 1975 in all other cases. None of the above mentioned references apply to me Please provide the following information regarding your disability: My disability is: Special methods, skills and procedures that could qualify for positions that I might not otherwise be able to do because of a disability: Suggested accommodations that could be made for the disability: Signature Date Print Name

21 EEO-1 Self-Identification Form Senior Rehab Solutions is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, Senior Rehab Solutions invites applicants to voluntarily self-identify their gender, race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment. (PLEASE PRINT) Date: Position(s) Applied For: Location of Position: Referral Source(s): State Employment Agency Friend Relative Walk-In Company Website Other Name: LAST FIRST MIDDLE Phone - - Address: NUMBER STREET CITY STATE ZIP CODE 1. Gender Male Female 2. Ethnicity Are you Hispanic or Latino? A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race. Yes, I am Hispanic or Latino. No, I am not Hispanic or Latino. 3. Race IMPORTANT If you checked No, I am not Hispanic or Latino on #2, then check one or more of the following, as they apply: White A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. Black or African American A person having origins in any of the Black racial groups of Africa. American Indian/Alaskan Native A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. I choose not to disclose at this time

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