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Education

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Previous Experience

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References

Please list three professional references

(Not Family and Friends)


Authorization

Please read the following carefully, initial each paragraph, sign adn print your name, date once completed.

CONFIRMATION OF HONEST AND ACCURATE COMPLETION

By my signature and initial below, I promise that I have personally completed this application. I declare under penalty of perjury that information provided in thsi employment application (and accompanying resume, applicable) is true and complete, and I understand that any false information or significant omission I make disqualify me from further consideration for employment if discovered at a later date. I understand that any job offer is conditional based o nthe satisfactory review of my qualifications including any background or drug which may be requried.

DRUG AND ALCOHOL SCREENING

I give permission for a pre-employment drug and alcohol screening examination and if the company make conditional job offer, I give permission for a complete physical and mental examination. I also consent the appropriate release of any and all medical information, as may deem necessary.

OTHER EMPLOYMENT AND/OR ACTIVITIES

I understand that, if hired I may not hold other employment or engage in other activities that created a conflict of interest with my position with the company, unless I have been given permission in writin by the company.

AUTHORIZATION TO OBTAIN INFORMATION

I, voluntarily and knowingly authorize any present or past employer or supervisor, educational institution administrator, law enforcement agency, state, local, or federal agency, credit bureau, collection agency, private business, military branch or the national personnel records center, personal reference and/or other persons that give records or information they may have concerning my criminal history, motor vehicle, educational history license history, employment history (including character, earnings, and reasons for termination), or any other information requested by company deemed pertinent to my employment.

Criminal History

Please respond to the following questions in the most complete and accurate manner possible. Do not identify convictions for which the criminal record has been expinged or sealed by the court; or, misdemeanor convictions for whichc any probation has been completed and the case dismissed by the court. Furthermore, please note that no applicant will be denied employment solely on the grounds that they have been charged, or convicted of (or pleaded guilty to) a criminal offese; or solely on an affirmative answer. The nature, date surrounding circumstances, and relevance of the offense to the positions(s) applied for will be considered.

Confidentiality, Non-Competition and Non-Solicitation Agreement

I understand and acknowledge that I will commence and/or continue my employment with Assured Health Care Services ("ASSURED").

During the course of my employment, I will be engaged in a position of trust and confidence in which I may be exposed to, or otherwise have disclosed to me, certain trade secrets, confidential information, and other technical and busness information and material of ASSURED and of customers and other third parties as to which ASSURED may owe a duty of cofidentiality ("Confidential Information"), including but not limited to the following: methods, processes, formulae, compositions, employee lists, inventions, machines, computer programs and procedures, research projects, customer lists, pricing data, supply data, needs data, suppliers and sources of supply and materials, marketing, production, sales and service strategies, systems, and/or plans, financial and accounting information or data, personnel information or any other non-public information of a similar nature not known to the public thath, if musised or disclosed, could adversely affect the vusiness of ASSURED, Confidential Information includes any such information that has been or may be created or prepared by others. Condfidential Information, however, shall not include any information that has been voluntarily disclosed to the public by duly authorized representative of ASSURED, independently developed and disclosed by others, or otherwise enters the public domain thourgh lawful means. Ifurhter understand that it is in the mutual benefit of ASSURED and its employees that ASSURED protects the Condifential Information from unauthorized use or disclosure and that ASSURED be protected against certain other actions described herein.

Therefore, in consideration of my employtment (or continued employment) with ASSURED and as a condition of, and in consideration for, among other things, my employment with ASSURED and my receipt of any compensation now and/or hereafter paid to Employee by ADINAI, I am requried to and agree to execute and deliver this Agreement. Accordingly, I, the undersigned, hereby acknowledge and agree in whole to this Agreement as follows.

1. I will faithfully devote my full-time servuces and vest efforts to perform the duties that may be required of and from me by ASSURED. I further agree that, during my employment with ASSURED, I will not accept employment with a competitor of ASSURED, provide competing services for or on behalf of a competitor of ASSURED, engage in self-employment which involves ASSURED's business, divert any business opportunity from ASSURED, make any preparations to compete against ASSURED, or otherwise compete in any manner with ASSURED. I also agree that, during the period of my employment with ASSURED, I will not perform any paid or unpaid work for any third party or on my own account that might, in the judgement of ASSURED, negatively impact my duties to ASSURED or that may directly or indirectly damage the interests of ASSURED.

2. The Employee hereby represents that his or her employment by ASSURED is not prohibited by or in violation of any other restrictive covenant or provision of any other agreement with anohter prior employer and Employee hereby agrees to indemnify, defend, and hold harmless ASSURED from any and all liabilities arising out of Employee's breach of any other such covenant or provision.

3. Unless required by law, I shall not, directly or indirectly, use, divulge, publish or disclose to any person or organization any of the Confidential Information for any reason or purpose whatsoever without the written consent of ASSURED, or provide any such person or organization access to the Confidential Information, or any list, document or other material (including work papers) containing Confidential Information.

4. Upon the cessation of my employment for whatever reason. I shall immediately return to ASSURED any and all documents and materials then in my possession or under my control relating to ASSURED or its business, inculidng but not limited to: tablets, laptops, notebooks, cell phones, PDAs, ipads, thumb/ jump/ usb drives, drawings, slides, photographs, tapes, papers, bluprints, reports, manuals, correspondence, customer lists, pricing lists, instructional manuals, training manuals, computer files, forms, customer agreements, computer programs and disks, ASSURED-provided mobile electronic devices, and all other data or materials, and copies or abstracts thereof, relating in any way to ASSURED's business, or in anyt way obtained during the course of employment with ASSURED, whether or not they contain Confidential Information.

5. Throughout any period during which I am an employee of ASSURED, and for a period of (2) years from and after the date upon which I shall cease for any reason whatsoever to be an employee of ASSURED, I covenant and agree that I will not, directly or indirectly, on my own behalf of for the benefit of another:

i. Solicit any Customer to withdraw, curtail or cancel its business with ASSURED;

ii. Perform, provide or sell to any Customer any products or services of any type that ASSURED can render to any Customer; or

iii. Solicit for employment or hire, or assis in the solicitation or hiring of any person who is an employee, agent, independent contractor, partner, officer or director of ASSURED.

For purposes of this Section 5, Customer shall mean any person or entity who, during the twelve month period immediately preceding the date upon which my employment with ASSURED ceased for any reason, paid or engaged ASSURED for products or servuces of any type or from whom ASSURED solicited, sought potential business or developed specofic plans to target and seek such perspective customer's business. Customer shall also include any person or entity who, during the two year period immediately preceding the date upon which my employment with ASSURED ceased for any reason, I directly or indirectly obtained business from for ASSURED, sought potential business from for ASSURED or developed specific plans for ASSURED or me to target and seek such potential business from such person or entity.

6. Throughout any period during which I am an employee of ASSURED, and for a period of two (2) years from and after the date upon which I shall cease for any reason whatsoever to be an employee of ASSURED, I covenant and agree that I will not for myself or for the benefit fo another engage, directly or indirectly, either as proprietor, stockholder, partner, officer, employee or otherwise, in a Prohibited Capacity in any business which provides products or services substrantially similar to those probided by ASSURED during the twelve month period prior to my cessation of employment. For purposes of this SEction. "Prohibited Capacity" shall mean any capacity which involves the performance of tasks substantially similar to those performed by me for ASSURED at any time within the twelve months immediately prior to the cesssation of my employment wioth ASSURED.

7. The covenants under Section 5(ii) & 6 shall only applly within: (a) the territory within a fifty (50) mile radius of any ASSURED office in which I performed services during any employment in the twelve (12) month period prior to my cessation of emplyoment; and (b) any county, city, township, or similar state political subdivision in which I, on behalf of ASSURED, sold or provided products or services in the twelve (12) month period prior to my cessation of employment. The covenants contained in this Agreement shall be construed as a series of separate covenants, one for each radius, county, city, state, or any similar subdivision. Except for geographic coverage, each such separate covenant shall be deemed identical in terms.

8. All rights, including without limitation any writing, discoveries, inventions, innovations, and computer programs and related documentation and all intellectual property rights therein, including without limitation copyright and ptent rights, (collectively, the "Intellectual PRoperty") crated, designed or constructed by me during my term of employment with ASSURED shall be the sole and exclusive property of ASSURED. I agree to deliver and assign to ASSURED all such Intellectual Property and all rights which I may have therein and agree to execute all documents, including without limitation patent applications, and make all arrangements necessary to furher document such ownership and/or assignment and to take whatever other steps may be needed to five ASSURED the full benefit thereof. Without limitation to the foregoing, I specifically agree that all copyrightable materials generated during programs, training documents, proposals, estimates, sales material amd amy related documentation, shall be considered works made for gire under the copyright laws the United States and shall upon createion be owned excliusovely by ASSURED. To the extend that any such materials, under applicable law, may not be considered works made for hire, I hereby assign to ASSURED the ownership of all copyrights in such materials, withour the necessity of any further consideration, and ASSURED shall be entitled to register and gold in its own name all copyrights in respect of such materials.

9. I agree that, upon cessation of my employment with ASSURED for any reason. ASSURED may notify any future or prospective employer of the existence of this Agreement.

10. I agree that the provisions of this Agreement are reasonable as to scope, duration and geographic territory, as applicable, and are necessary to protect the reasonable and legitimate business interests of ASSURED because, among other things, (i) ASSURED is engaged in a highly competitive industry, (ii) I will have access to trade secrets and know-how of ASSURED, (iii) I will be able ti become gainfully employed in a suitable and satisfactory manner without violation of this Agreement, and (iv) these limitations are necessary to protect the trade secrets, Confidential Information and goodwill of ASSURED.

11. Because ASSURED's damages resulting form any breach of the covenants set forth in this Agreement may be difficult to measure and calculate or may be inadequate, I agree that the failure to comply with the terms of this Agreement will cause ASSURED irreparable injury for which no adequate remedy at law may exist, In the event of a breach, or threatened breach, by me of any of the provisions of this Agreement, ASSURED shall be entitle, without the requirement to psot any bond, to an immediate injunction restraining Employee from commiting any action violation of this Agreement. EMployee agrees that it shall not, in any equity proceeding relating to the enforcement of the terms of this Agreement, (a) raise the defense that ASSURED has an adequate remedy at law or (b) assert any claim against Employer. Nothing herein shall be construed as prohibitng ASSURED from pursuing any other remedies available to it for such breach or threatened breach, including, wihtout limitation, the recovery of damages.

12. In additon to any other remedies available to ASSURED, ASSURED shall also be entitled to recover its costs and expeses (including reasonable attornys' fees) incurred in enforcing its rights under this Agreement or in any dispute over the terms of this Agreement.

13. No right or remedy herein conferred upon the parties in intended to be exclusive of any ohter right or remedy contained in this Agreement or in any instrument or document delivered in connection with or pursuant to this Agreement, and every such right or remedy shall be cumulative and shall be in addition to every other such right or remedy contained herein and therein or now or hereafter existing at law or in equity or by statute, or otherwise.

14. Each of the covenants of this Agreement are severable and if any of them is held to be invalid or unenforceable by an court for any reason, ASSURED and I agree that such covenant shall be adjusted or modified by the court to the extent necessary to cure the invalidity or unenforceablity, and the modified covenant shall thereafter be enforceable as if originally made in this Agreement, If any covenant is held invalid (whether or not it is reformed), the remaining covenants shall continue in full force and effect.

15. No unilateral change in my compensation or other terms of employment with ASSURED will affect the terms of this Agreement.

16. This Agreement may not be changed, modified, released, discharged, abandoned, or otherwise terminated, in whole or in part, except by an instrument in writing signed by a duly authorized officer or director of ASSURED and by the undersigned. No supervisor, manager, or other employee of ASSURED has the authority to change the terms of this Agreement.

17. This Agreement may be assigned by ASSURED to and enforced by a successor entity in the event of a merger or consolidation of ASSURED or in connection with the sale of allo or substantially all of ASSURED's business or assets.

18. This Agreement shall be governed by Maryland law, without reference to its conflicts of law provisions.

19. This Agreement supersedes and nulifies any similar agreement which previously may have been executed by me.

20. Nothing contained in this Agreement shall be construced to:

i. ALter my or ASSURED's right to terminate my employment with ASSURED at any time, with or without notice or casue; or

ii. Create any employment relationship between me and ASSURED other than employment-at-will.

21. Employee's breach of the obligation under Section 5 of this Agreement shall automatically toll and supend the period so stated in Section 5 for so long as the violation continues.

22. This Agreement may be executed in counterparts, each of which shall be deemed tio be an original, but such counterparts, when taken together, shall constitute one agreement.

23. Employee acknowledges that Employee has been given sufficient time and opportunity to review, consider, and obtain independent legal and other advice in conenction with the execution of this Agreement, and that Employee has not been forced to sign this Agreement, or any part thereof under duress.

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Reference Form

The person below has applied to Assured Home Care Services for employment. This applicant submitted your name as a for employer for reference purposes. We would appreciate your cooperation in replying to the questions listed below. Please be assured that your response will be treated with strict confidence. Thank you for your consideration.

APPLICANT DO NOT WRITE BELOW


EMPLOYMENT DATE

PERSONAL EVALUATION ABOVE AVERAGE SATISFACTORY NEEDS IMPROVEMENT POOR
Quality of Work
Interest and Enthusiasm
Ability to relate to patient
Ability to Change
Willingness/Ability to float
Attendance
Punctuality

AGREEMENT

This agreement between Assured Homecare Services: (Hereinafter referred to as the "Agency"), and the person whose signature appears below {Hereinafter referred to as the "Applicant"), witnessed, that for and in consideration of the efforts and services of the Agency, the Applicant agree as follows.

I agree that this Agreement shall continue in force for any position accepted or employment obtained directly or indirectly from referral by the Agency for a period of one (1) year from the date any referral of me is made to a prospective employer, whether or not such employment obtained, or position accepted is for the particular position for which I was referred by the Agency.

I agree to abide by the rules and regulations of the Agency and understand I am entitled to participate in some employee benefit plans offered by the agency.

I further understand and agree that in assisting me to obtain employment, the agency may make or cause to be made an investigation pertaining to my employment record, general character, and mode of living, and that I have the right, under the provision of the Fair Credit Reporting Act, to request, in writing a complete disclosure of the nature and scope of any investigation. I agree to indemnify and hold harmless the Agency, it's principals and employees from liability resulting from services performed by the Agency in obtaining a placement for me or arising from my services in any such placement for me.

I HAVE READ AND UNDERSTAND THE ABOVE CONTRACT AND HAVE RECEIVED A DUPLICATE OF THE CONTRACT.


Signed and Dated by Caregiver: 


Assured Homecare Services: 

Date Licensed by the State of Maryland, Department of Health and Mental Hygiene 

Agreement made this day ofby and between Assured Homecare Services: a corporation organized and existing by the laws of the State of Maryland (hereafter referred to as • AHS") and the party (Hereinafter referred to as “caregiver").

Whereas Caregiver has contacted AHS and is eligible to be referred from time to time to clients of AHS (•clients) as a provider of home health care service:

Whereas AHS and caregiver wish to clarify and document the legal relationship among AHS, Caregivers and clients:

Now, therefore, the premises considered the parties hereto, intending to be legally bound, do hereby agree as follows:

  • Caregivers represent and warrants to AHS
    • a) Caregiver has the perquisite education, training, certification and/or licensing to provide the services for which he/she has been referred by AHS.
    • b) Caregiver owns and will provide basic equipment (such as stethoscopes, blood pressure cuffs, etc. which are ordinarily and customarily used in the provision of such services.
    • c) Caregiver will provide his or her own uniforms.
    • d) Caregiver will provide his or her own transportation to and from the location where services are provided to clients.
    • e) Caregiver is responsible for performing his or her services to established professional standards, and that AHS does not supervise or control the way services are rendered.
    • f) Caregiver is free to accept or reject any referrals which AHS may offer from time to time.
  • Caregiver has been informed by AHS that he/she may; at Caregivers, sole expense, elect to purchase policies of insurance which will provide coverage against personal injury or other loss or damage which may arise out of the performance of services to clients.
  • Caregiver covenants and agrees to hold harmless and indemnity AHS and AHS clients against any claims, demands, and the like that may be made against AHS or Its clients by Caregiver or any third party arising out of the performance by Caregiver of services.
  • Nothing in this Agreement shall be constructed as altering or amending the separate contract between AHS and Caregiver.
  • This is the entire agreement between AHS and Caregiver. This Agreement cannot be modified or amended except by written agreement signed by both parties here to:

Assured Homecare Services: 

Licensed by the State of Maryland, Department of Health and Mental Hygiene 

Job Description 

Title: Certified Medical Technician, Certified Nursing Assistant, Home Health Aide

Report to the Director of Nursing

Mission: To administer care to client under the ongoing direct and/or indirect

supervision of a registered nurse.

Duties and Responsibilities 

Safety: 

  • Assist with activities of daily living and personal care including

Hygiene: 

  • Perform mouthcare, bathing, perineal care, hair combing, fingernail care, shaving, dressing and undressing. Provide or assist with AOL'S (activities of daily living}.

Emergency Care: 

  • Must be competent to perform CPR (cardiopulmonary resuscitation) and Abdominal Thrust (Heimlich Maneuver) when required. Able to give First Aid care when needed.

Body Alignment and Mobility Needs: 

  • Must be able to perform positioning skills, range of motion, assist with transfer, assist with ambulation, assist with use of durable medical equipment, i.e., wheelchair, walker, cane, hospital bed with side rails, Hoyer Lift. Must know proper body mechanics, and know how and when to bend, pull and push. Must change client's position every 2 hours.

Important Information: 

  • • The aide should know how to take a blood pressure and know when a BP reading is high or low enough to report to family or agency.
  • • The aide will keep family and agency aware of any significant changes with client.
  • • The aide may be asked to accompany client to Doctor's appointment. etc., and may be asked to drive. Verify with office that a liability wavier has been signed before driving.
  • • Light housekeeping as it pertains to the client only. It does not mean whole house or heavy-duty cleaning.
  • • If you are asked to do anything that is out of your scope of practice, i.e., change a bandage or give medication, you should not do it, politely tell your client that you are not trained to do that, and if necessary, call the Director of Nursing.

Additional CMT Responsibilities: 

If you accept an assignment that requires you to administer medication from an MAR:

  • • Initial for every medication that you administer
  • • Ensure that your printed name and signature is on the bottom of each page
  • • Identify the 5 RIGHTS for medication administration
  • Right client
  • Right medication
  • Right time
  • Right route
  • Right dose

JOB DESCRIPTION ACKNOWLEDGEMENT FORM

By signing below, I attest that I have read the job description entirely and agree it is within my scope of practice. I understand my duties and will perform my obligation as stated in the job description according to the company policies as well as adhering to the rules and regulations of Maryland Board of Nursing.

Hippa Compliance Policy

Policy 

It is the policy of AHS to maintain security, privacy and confidentiality for clients in accordance with HIPPAA (The Health Insurance Portability Accountability Act of 1961)

Procedure 

AHS Employees and independent contractors will discuss and use client information only within the organization and with relevant care providers.

AHS employees and independent contractors will utilize security measures during handling of client medical demographic information.

AHS employees and independent contractors will have confidential security codes to access computers containing client medical and demographic information.

Computer screens will be pointed away from the public

Client's medical and demographic information will not be transmitted via e-mail

Computer equipment disks or software containing client information will be archived in the office.

Faxes with printed client medical and demographic information will be filled in the medical record and disposed of immediately

Contact will be made with a person at the receiving end of faxes

AHS employees will not share their passwords with others

Communication with or about clients involving health information will be private and limited to those who need the information for treatment, payment educational purposes as indicated and health care operations Only AHS employees and independent contractors with an authorized "need to know" will have access to the clients protected information.

UNIVERSAL PRECAUTION

TO BE USED IN THE CASE OF PATIENTS CARE: 

Gloves 

  • For touching any patient's blood or body fluids
  • For handling any soiled items
  • For performing any vein puncture
  • Change alters contact

Gowns  

  • Worn during any procedure likely to generate splashes of blood or body fluids

MASK AND PROTECTIVE EYE WEAR  

  • Worn during any procedure likely to generate droplets of body fluids

HANDS 

  • Wash immediately if contaminated with blood or body fluids
  • Wash immediately after gloves are removed
  • To prevent needle stick injuries, needles should not be recapped, purposefully bent, broken or removed from disposable-resistant containers located as close practical to the areas in which they were used.
  • To minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags or other ventilation devices should be available for use in area where the need for resuscitation is predictable.

Hepatitis 8 Vaccination Decision  

Please indicate either your agreement or declination  


Agreement: 

  • My signature indicates I understand it is my responsibility to confirm scheduling of appointments and to complete the vaccination series.

Declination: 

  • My signature indicates that I am declining the opportunity to be vaccinated for Hepatitis B. if in the future I want to receive this vaccination, I understand that I Can complete an agreement form and receive the vaccination series at no charge To me.

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