Staff Application | Inflowcare

Demographics 0 / 8

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Personal Information
Physical Information
Address Information
Background History
Other Information
Emergency Contacts
Health Assessment
Tuberculosis Assessment

Personal Information

Status : Completed

First Name*

Middle Name

Last Name*

Email 2

Email 3

SSN*

Gender*

Male Female

Home Phone*

Mobile Phone

Date of Birth*

Age

Country of Birth*

Maiden Name

Mother's Maiden Name

Language*

Other Languages

Ethnicity*

Personal Information

Physical Information

Height Feet*

Height Inch*

Weight In Pound*

Eye Color*

Hair Color

Race

Physical Information

Address Information

Background History

Have you ever been excluded or terminated in any federal health care program or new york medicaid?

Yes No

Have you been convicted of a crime in New York State or any other jurisdiction?

Yes No

Have you had a final finding of patient or resident abuse?

Yes No

Please provide an explanation.*

Background History

Other Information

Have you used an Alias?

Yes No

Alias*

Are you a citizen of the United States?

Yes No

If no, are you legally authorized to work in the US?

Yes No

How did you hear about us?

Please specify other information (Hear about us)

Position applied for

Please specify other information (Position applied for)

Available Start Date

Driving License Information

Do you have a valid driver license?

Other Information

Emergency Contacts

Health Assessment

Tuberculosis Assessment

Have you had a history of a temporary or permanent residence (for >=1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in Western or Northern Europe)?

Yes No

Do you have a current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a tumor necrosis factor (TNF) -alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone >=15 mg/day for >=1 month), or other immunosuppressive medication?

Yes No

Have you had close contact with someone who has had infectious TB disease since your last TB test?

Yes No

When?

Did you have adequate personal protection when exposed?

Yes No

Have you had a prior bacille Calmette-Guerin (BCG) Vaccination?

Yes No

When?

Have you ever been diagnosed with Latent TB infection (LTBI)?

Yes No

When?

Have you ever been treated for Latent TB infection (LTBI)?

Yes No

When?

Have you ever been diagnosed with TB infection (TB)?

Yes No

When?

Have you ever been treated for TB infection (TB)?

Yes No

When?

Have you had any prior diagnostic testing for TB disease?

Yes No

When?

Have you ever had a tuberculin skin test (TST)?

Yes No

When

Result

Have you ever had a chest x-ray done for tuberculosis?

Yes No

Date

Result

Do you currently have any of the following symptoms? Weakness

Yes No

Fatigue

Yes No

Lack of Appetite

Yes No

Weight Loss

Yes No

Low Grade Fever

Yes No

Night Sweats

Yes No

Flu like Symptoms

Yes No

Chest Pain

Yes No

Shortness of Breath

Yes No

Persistent Cough

Yes No

Blood Streaked Sputum

Yes No

Clear, Yellow/Dark Sputum

Yes No

Tuberculosis Assessment

Work History 0 / 3

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Work Information
Personal References
Employment History

Work Information

Have you worked with Sincere Care Agency

Have you worked with us before?*

Reason for Leaving

Work Start Date

Work End Date

Have you worked with Sincere Care Agency

Personal References

Reference #1

Name

Telephone

Relationship

Personal References

Employment History

Work #1

Most Recent Employer #1*

Job Title*

Type of work you performed

Reason for leaving

Contact Name*

Phone Number*

Fax Number

Country

Address

APT / SUITE

City

State / Province

Zip Code / Postal Code

Start Date

End Date

May we contact this employer?

Yes No

Work #2

Most Recent Employer #2*

Job Title*

Type of work you performed

Reason for leaving

Contact Name*

Phone Number*

Fax Number

Country

Address

APT / SUITE

City

State / Province

Zip Code / Postal Code

Start Date

End Date

May we contact this employer?

Yes No

Employment History

Education 0 / 4

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High School
Technical School
College
Certification

High School

Did you graduate?*

High School Name*

High School Address

High School

Technical School

Did you graduate?*

Technical School Name*

Technical School Address*

Technical Degree

Technical Period*

Technical School

College

Did you graduate?*

College Name*

College Address*

College Honors

College Major*

College Degree

College Period*

College

Certification

Certification*

Name of Institute ( )

Experience ( )

List all other professional licenses or certificates you have

Certification

Government Forms 0 / 5

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New York Taxes
Federal Taxes
I-9
Dept. of Labor Statistics
Direct Deposit

New York Taxes

How will you File New York Taxes?

Are you a resident of New York City?

Are you a resident of Yonkers?

Please use the NYS worksheet HERE to find out your allowances

Total number of allowances you are claiming for New York State and Yonkers, if applicable

Total number of allowances for New York City

Use the fields below to have additional withholding per pay period under special agreement with your employer.

New York State amount

New York City amount

Yonkers amount

New York Taxes

Federal Taxes

How will you file your Federal Taxes?

How many Children under 17 years old will you be claiming?

Child Dependent amount

How many Other dependents will you be claiming?

Other Dependent amount

Total

Federal Taxes

I-9

I attest, under penalty of perjury, that I am (check one of the following boxes):

A citizen of the United States

A noncitizen national of the United States (An individual born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.)

A lawful permanent resident

An alien authorized to work until expiration date (if applicable, mm/dd/yyyy):

Aliens authorized to work must provide one of the following document numbers to complete Form I-9:

Alien Registration Number

USCIS Number

Form I-94 Admission Number

Foreign Passport Number

Country of Issuance

I-9

Dept. of Labor Statistics

Form 8850

If you are under age 40, enter your date of birth

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.

Check here if any of the following statements apply to you:

I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
I am at least age 18 but not age 40 or older and I am a member of a family that:
a. Received SNAP benefits (food stamps) for the past 6 months; or
b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
During the past year, I was convicted of a felony or released from prison for a felony.
I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.

Check here if any of the following statements apply to you:

I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
I am at least age 18 but not age 40 or older and I am a member of a family that:
a. Received SNAP benefits (food stamps) for the past 6 months; or
b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
During the past year, I was convicted of a felony or released from prison for a felony.
I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.

Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.

Check here if you are a member of a family that:

Received TANF payments for at least the past 18 months; or
Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

Check here if you are a member of a family that:

Received TANF payments for at least the past 18 months; or
Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.

Dept. of Labor Statistics

Direct Deposit

Form of Payment

First Name

Last Name

Bank Name

Type of Account

Checking Routing Number

Confirm Checking Routing Number

Checking Account Number

Confirm Checking Account Number

Saving Routing Number

Confirm Saving Routing Number

Saving Account Number

Confirm Saving Account Number

Direct Deposit

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Personal Information

Personal Information

Physical Information

Physical Information

Address Information

Address Information

Background History

Background History

Other Information

Driving License Information

Other Information

Emergency Contacts

Emergency Contacts

Health Assessment

Health Assessment

Tuberculosis Assessment

Tuberculosis Assessment

Work Information

Personal References

Personal References

Employment History

Employment History

High School

High School

Technical School

Technical School

College

College

Certification

Certification

New York Taxes

Use the fields below to have additional withholding per pay period under special agreement with your employer.

New York Taxes

Federal Taxes

Federal Taxes

I-9

I-9

Dept. of Labor Statistics

Dept. of Labor Statistics

Direct Deposit

Direct Deposit

To begin e-sign, please submit the following sections for approval.

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