Staff Application | Inflowcare

Demographics 0 / 9

Submit for approval

Personal Information
Physical Information
Address Information
Background History
Other Information
Emergency Contacts
Hepatitis B Vaccine
Tuberculosis Assessment
Influenza Vaccination

Personal Information

Status : Completed

First Name*

Middle Name

Last Name*

Email 2

Email 3

SSN*

Gender*

Female Male

Phone 1*

Phone 2

Phone 3

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

Hepatitis B Vaccine

Hepatitis B Vaccine Consent/Declination

I acknowledge that I am at risk of exposure or have been unknowingly exposed to the Hepatitis B virus as a result of my employment and acknowledge that the agency will arrange for me to receive the Hepatitis B vaccine. I have read the information sheet concerning the disease

Request that I receive the Hepatitis B vaccine

Refuse the Hepatitis B vaccine and hold harmless the agency. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining the vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Provide written proof of immunity

Provide written proof of previous vaccination

Provide written proof of medical contraindication

HEPATITIS B VACCINATION CONSENT

I have been provided with information on the Hepatitis B vaccine and have been evaluated by an agency health professional.

I have had the opportunity to ask questions about the benefits and risks of the Hepatitis B Vaccination.

I understand that there is no guarantee that I will become immune and that there is a possibility I may experience adverse side effects from the vaccine.

I am NOT allergic to yeast or yeast products.

I am NOT currently immune-suppressed, either by disease or medication.

For women: I have been advised that the effects of the vaccine on a developing fetus are unknown, as studies have not been conducted.

Hepatitis B Vaccine

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

Unexplained 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

Influenza Vaccination Consent

Please read the below influenza information and fill out ONE of the boxes below As a healthcare professional, I am aware that I may have exposure to the influenza virus. I am also aware that I can either consent or decline the vaccination.

I understand that if I choose to decline the influenza vaccine, and my job duties may cause me to infect patients or to become infected, I may be required to wear a surgical mask for the duration of my shift. Failure to wear a surgical mask during duty will result in disciplinary action, up to and including termination.
I understand that I may change my mind at any time and accept the influenza vaccination if the vaccine is available.
I understand that if I decline the vaccine AND refuse to wear a surgical mask, I am voluntarily resigning my position at Harbor Care LLC

CONSENT: I have been informed about and offered the opportunity to receive the influenza vaccine. I understand that it is my responsibility to schedule to have the vaccination with either my healthcare provider or with Harbor Care LLC. As with any medical treatment, there is no guarantee that I will become immune to influenza or that I will not experience any adverse side effects from the vaccine. The vaccine takes about two weeks to reach maximum protection. Therefore, I will not consider myself to be fully protected from contracting the flu until that time.

I will receive the influenza vaccine from:

Harbor Care LLC

My personal doctor

Elsewhere

Harbor Care LLC

My personal doctor

Elsewhere

DECLINE: in declining the influenza vaccination for non-medical reasons, I am aware that I cannot get the influenza disease from the influenza vaccination. I can be infected by the influenza virus but not feel ill for 24-48 hours before symptoms appear, and I can pass the virus to vulnerable patients who are at risk of complications or death from influenza. I can also pass the virus to my family, friends, and co-workers. Influenza strains change every year and an immunization received in prior years does not usually provide immunity to this year's strain of influenza. I acknowledge receipt of a flu mask and understand that once influenza is declared prevalent, I MUST wear it while providing any patient care. Despite these facts, I am choosing to decline the influenza vaccine right now because of (check all the apply):

Medical reasons

Religious reasons

Personal reasons

Medical reasons

Religious reasons

Personal reasons

Influenza Vaccination Consent

Work History 0 / 4

Submit for approval

Work Information
Armed Forces
Personal References
Employment History

Work Information

Have you worked with Harbor Care LLC

Have you worked with us before?*

Reason for Leaving

Work Start Date

Work End Date

Have you worked with Harbor Care LLC

Armed Forces

Have you served in the armed Forces?*

Rank

Service Period

Armed Forces

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*

Address 2*

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*

Address 2*

City*

State / Province*

Zip Code / Postal Code*

Start Date*

End Date*

May we contact this employer?*

Yes No

Employment History

Education 0 / 4

Submit for approval

High School
Technical School
College
Certification

High School

Did you graduate?*

Yes No

High School Name*

High School Address

High School

Technical School

Did you graduate?*

Yes No

Technical School Name*

Technical School Address*

Technical Degree

Technical Period*

Technical School

College

Did you graduate?*

Yes No

College Name*

College Address*

College Honors

College Major*

College Degree

College Period*

College

Certification

Certification*

HHA None PCA

Name of Institute ( )

Experience ( )

Yes No

List all other professional licenses or certificates you have*

Certification

Government Forms 0 / 5

Submit for approval

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

New York Taxes

How will you File New York Taxes?

Married

Married but withhold at higher single rate

Single or Head of household

Are you a resident of New York City?

Yes No

Are you a resident of Yonkers?

Yes No

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

Step 1: Personal Information

How will you file your Federal Taxes?

Single or Married filing separately

Married filing jointly or Qualifying surviving spouse

Head of household

Step 2: Multiple Jobs or Spouse Works

If you (and your spouse) have a total of only two jobs held at the same time, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate for jobs with similar pay.

Step 3: Claim Dependent and Other Credits

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

Step 4: Other Adjustments (optional)

Other income (not from jobs).

If you want tax withheld for other income (not from jobs) you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income.*

Deductions.

{If you expect to claim deductions other than the standard decution and want to reduce your withholding, use the Deductions Worksheet on page 3 (Form W-4 Instructions) and enter the result here}*

Extra withholding.

Enter any additional tax you want withheld each pay period*

Federal Taxes

I-9

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1. A citizen of the United States

2. 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.)

3. A lawful permanent resident (Enter USCIS or A-Number.)

4. A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

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.

WOTC

Have you worked for this Employer before? Are you a Re-hire?

Yes No

Enter last day of employment

Are you under age 40?

Yes No

Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance for part or all of that time period?

Yes No

When did the period of unemployment begin?

What state did you receive unemployment compensation in?

Have you or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?

Yes No

Or received SNAP Benefits for at least a 3 month period

Yes No

Enter name of primary recipient

and City, State where benefits were received

Are you a member of a family that received Temporary Assistance for Needy Families (TANF) assistance for at least 18 months before you were hired?

Yes No

Or, did your family stop being eligible for Temporary Assistance for Needy Families (TANF) assistance within 2 years before being hired, because you reached the maximum time those benefits can be received?

Yes No

Enter name of primary recipient

and City, State where benefits were received

Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days, before you were hired?

Yes No

Were you convicted of a Felony during the year before you were hired?

Yes No

Date of Conviction

Date of release

Was this federal or state?

Are you a Veteran of the US Armed Forces?

Yes No

Are you a member of a family that received SNAP (Food Stamps Benefits)?

Yes No

Are you entitled to compensation for a service-connected disability?

Yes No

Were you discharged from active duty within the last year?

Yes No

Were you unemployed for a combined total of 6 months before you were hired?

Yes No

Were you employed for 35 or more hours during any week in the 180-day period immediately prior to the date on which you began employment with the employer?

Yes No

Were you referred to an employer by:

A Vocational Rehab Agency approved by the state?

Yes No

An Employment Network under the Ticket to Work Program?

Yes No

The Dept. of Veteran Affairs?

Yes No

New York Urban Youth Jobs Program

I am currently unemployed, I was unemployed prior to completing this application or I do not have enough paid work or work that is adequate with respect to my skills and training.

Yes No

Please give start date of most recent employment:

I am currently working.

Yes No

Please give start date:

I am enrolled in High School:

Yes No

I am 16 or 17 years old and have the permission of my parent of guardian to submit this application.

Yes No

Parent or Guardian Name:

Parent or Guardian Phone Number:

I am currently attending high school, enrolled in a High School Equivalency (HSE) program, or have obtained a high school diploma.

Yes No

I am 18 to 24 years old.

Yes No

I have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or I am enrolled in a TASC program.

Yes No

I confirm that I currently meet one or more of the youth categories listed below.

I am pregnant or a parent of a child.
I am over 18 and do not have a high school diploma of GED/HSE diploma.
I am a member of a family that is receiving assistance from Temporary Assistance for Needy Families (TANF).
I am a member of a family that is receiving SNAP benefits (food stamps).
I am a member of a family that is receiving SSI benefits.
I am receiving a free of reduced-cost school lunch.
I have served in jail or prison, or am on probation or parole.
I am currently or was in foster care of the custody of the Office of Children and Family Services.
I am a veteran.
I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years.
I am the daughter or son of a parent who is collecting unemployment insurance.
I live in public housing or receive housing assistance such as a Section 8 voucher, or is homeless.

I confirm that I currently meet one or more of the youth categories listed below.

I am pregnant or a parent of a child.
I am over 18 and do not have a high school diploma of GED/HSE diploma.
I am a member of a family that is receiving assistance from Temporary Assistance for Needy Families (TANF).
I am a member of a family that is receiving SNAP benefits (food stamps).
I am a member of a family that is receiving SSI benefits.
I am receiving a free of reduced-cost school lunch.
I have served in jail or prison, or am on probation or parole.
I am currently or was in foster care of the custody of the Office of Children and Family Services.
I am a veteran.
I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years.
I am the daughter or son of a parent who is collecting unemployment insurance.
I live in public housing or receive housing assistance such as a Section 8 voucher, or is homeless.

I consider myself to have a different risk factor not identified in the above list.

Yes No

Dept. of Labor Statistics

Direct Deposit

Form of Payment

Paycard Direct Deposit

Enter your account information to get paid with direct deposit.

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 File Upload Accepted Formats : (pdf, png, jpg, jpeg)

Direct Deposit

Skill/Availability 0 / 3

Submit for approval

Days
Available Work Locations
Patient Gender

Days

From Time

To Time

Live In

Sunday

Live In: --

From Time

To Time

Live In

Monday

Live In: --

From Time

To Time

Live In

Tuesday

Live In: --

From Time

To Time

Live In

Wednesday

Live In: --

From Time

To Time

Live In

Thursday

Live In: --

From Time

To Time

Live In

Friday

Live In: --

From Time

To Time

Live In

Saturday

Live In: --

From Time

To Time

Live In

Days

From Time

To Time

Live In

Sunday

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Live In:

From Time

To Time

Live In

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Monday

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Live In:

From Time

To Time

Live In

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Tuesday

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Live In:

From Time

To Time

Live In

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Wednesday

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Live In:

From Time

To Time

Live In

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Thursday

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Live In:

From Time

To Time

Live In

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Friday

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Live In:

From Time

To Time

Live In

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Saturday

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Live In:

From Time

To Time

Live In

Copy times to
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Days

Available Work Locations

Which location are you available to work in?

Available Work Locations

Patient Gender

I can work with

Patient Gender

E-Sign 0 / 0

Submit for approval

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

Pending

Completed

#	Form	Status

Documents 0 / 0

Submit for approval

	#	Name	Notes	Status	Action

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

Hepatitis B Vaccine

Hepatitis B Vaccine Consent/Declination

HEPATITIS B VACCINATION CONSENT

Hepatitis B Vaccine

Tuberculosis Assessment

Tuberculosis Assessment

Influenza Vaccination Consent

Influenza Vaccination Consent

Work Information

Armed Forces

Armed Forces

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

Days

Days

Available Work Locations

Available Work Locations

Patient Gender

Patient Gender

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

Thank You