Medical Staffing Application & New Hire Packet · Resume establishing a minimum of one (1) year...

Medical Staffing Application & New Hire Packet

Employee/Applicant Name:_________________________________ Title: _________________ Started By: _____________________________________________ Date:___________

ProStat, Inc. 2208 Quarry Dr. (Suite 206) Reading, PA 19609 Tel. (610) 736-9000 Fax (610) 736-9006

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Interview & Employment Offer Guide and Checklist Candidate Name:_____________________________ Position: ____________ Location:___________________ Interview:

❏ Review ALL application paperwork and RSS documents for completeness (Completed) ❏ Reference Request Forms {exact match from application} (Completed & Reviewed) ❏ Skills Checklist (Completed & Reviewed) ❏ Review Job Description AND Proceed with Interview:

❏ Face-to-face Interview Questionnaire (Completed & Reviewed) ❏ Abuse & Neglect Training (Completed) and Acknowledgment Form (Signed) ❏ Drug Screen Consent and Drug Result Form (Completed & Reviewed) ❏ WOTC Form 8850, 9061, & 9175. (Completed & Reviewed) ❏ Offer of Employment:

❏ Present Offer of Employment to Applicant (Completed & Reviewed) ❏ Applicant signs and a copy is made for them (Completed)

-------------------------- STOP! Below to be completed post-offer of employment only --------------------------

Post Offer Paperwork All Employees:

❏ Have Applicant complete the Medical Questionnaire (Completed & Reviewed) ❏ If employee answers “Yes” to any of the questions, either a Physician’s Statement or Physical that

states, “Able to work without any restrictions” will be required. ❏ Collect PPD or Chest x-ray results (Completed & Reviewed) ❏ W-4 (Completed & Reviewed) ❏ I-9 with authorized supporting documentation (Completed & Reviewed) ❏ Proof of Residency (Complete & Collect Documentation) ❏ Mandatory Reporter Form (Completed & Reviewed) ❏ Re-Payment Authorization Form (Completed & Reviewed) ❏ Criminal Background Consent Form (Completed & Reviewed) ❏ Notice of ACA to Employees (Provided to Employee) ❏ Direct Deposit Form (Completed & Reviewed) ❏ Child Abuse Training (Assigned) ❏ Take Picture for I.D. Badge (Completed and emailed to Corporate) ❏ Only if DCW Applicant: ❏ Transportation Consent & Waiver Flowsheet ❏ Childline Application Form and Childline Waiver Cert. 3/16 (Completed & Reviewed) ❏ Family Caregiver Case Acknowledgement (Completed & Reviewed) ❏ Only if Certified/Licensed Applicant: ❏ Resume establishing a minimum of one (1) year related experience.(Requested) ❏ Current CNA Certification or LPN/RN Licenses (Requested) ❏ Physician’s Statement and Flu Shot (Assigned) ❏ CPR for LPN & RN Employees Only (Requested)

Comments: Person completing this form: _____________________________________________ Title: ________________ Signature: ______________________________________________ Date: ________________


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Face-to-Face Interview (NOTE: Use standardized interview questions for all applicants)

Name of Applicant: ____________________________________________ Title: __________________ Phone: _________________________________ Email, if applicable: ___________________________ Date of interview: ____________________ Location: _______________________________________ Interview Conducted by: _________________________________________Title: __________________

1. What brought you to us? How did you find out about us?

2. What do you think you can offer us/this position?

3. Do you have PROFESSIONAL or RELEVANT experience in this line of work? Please explain:

4. Give an example of a problem that you faced and how you handled it?

5. Describe how you handled a time when you were asked to do something you weren’t trained to do?

6. What do you think would be the hardest part of this job for you?

7. If a client would ask you to do something you knew you weren’t allowed to do, either it’s against company policy/procedure or not in your scope of training, what would you do?

8. Would you have a problem giving a man a bath? Giving a woman a bath?

9. We will perform a drug test today. Is that OK?

10. Can you work days or nights? Weekends?

11. Do you have reliable transportation and vehicle insurance?


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Reference Request Applicant Profile Applicant Name_____________________________SSN:_________________Position ____________ Employer Name___________________________________ Employed from _________ to _________ Reference Name_____________________________________________ Tel. (____) _____-________ By my signature on this application, I hereby authorize ProStat to request and receive from all former employers, any and all pertinent information concerning my prior employment and its termination including the reasons for such termination. I forever release such prior employers and those references named herein from any and all liability which may arise out of any information provided hereunder. Applicant Signature _____________________________________________ Date ______________

--------------------------------------------------------------------------------------------------------------------------------- Employer The individual named above has applied for employment with ProStat. To ensure a thorough screening process, we ask that you provide the information requested below. Evaluation Skill Levels (please circle) 1=poor; 2=average, 3=above average Technical proficiency 1 2 3 Quality of work 1 2 3 Established priorities 1 2 3 Accepts direction/cooperation 1 2 3 Accurate documentation 1 2 3 Adheres to safety procedures /protocols 1 2 3 Adaptability 1 2 3 Communicates effectively 1 2 3 Attendance/reliability 1 2 3 Is this applicant eligible for rehire? (_)YES / (_)NO If no, please explain:______________________ Employment dates: From: ____________ To: ___________ Position: ____________________ Reference provided by: ______________________________________ Title: ________________ Signature: ___________________________________________ Date: _______________________ Verbal reference obtained by ProStat, Inc.: Signature: ___________________________________________ Date: _______________________


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--------------------------------------------------------------------------------------------------------------------------------- Employer The individual named above has applied for employment with ProStat. To ensure a thorough screening process, we ask that you provide the information requested below. Evaluation Skill Levels (please circle) 1=poor; 2=average, 3=above average Technical proficiency 1 2 3 Quality of work 1 2 3 Established priorities 1 2 3 Accepts direction/cooperation 1 2 3 Accurate documentation 1 2 3 Adheres to safety procedures /protocols 1 2 3 Adaptability 1 2 3 Communicates effectively 1 2 3 Attendance/reliability 1 2 3 Is this applicant eligible for rehire? (_)YES / (_)NO If no, please explain:______________________ Employment dates: From: ____________ To: ___________ Position: __________________ Reference provided by: ______________________________________ Title: ________________ Signature: ___________________________________________ Date: _______________________ Verbal reference obtained by ProStat, Inc.: Signature: ___________________________________________ Date: _______________________


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--------------------------------------------------------------------------------------------------------------------------------- Employer The individual named above has applied for employment with ProStat. To ensure a thorough screening process, we ask that you provide the information requested below. Evaluation Skill Levels (please circle) 1=poor; 2=average, 3=above average Technical proficiency 1 2 3 Quality of work 1 2 3 Established priorities 1 2 3 Accepts direction/cooperation 1 2 3 Accurate documentation 1 2 3 Adheres to safety procedures /protocols 1 2 3 Adaptability 1 2 3 Communicates effectively 1 2 3 Attendance/reliability 1 2 3 Is this applicant eligible for rehire? (_)YES / (_)NO If no, please explain:______________________ Employment dates: From: ____________ To: ___________ Position: __________________ Reference provided by: ______________________________________ Title: ________________ Signature: ___________________________________________ Date: _______________________ Verbal reference obtained by ProStat, Inc.: Signature: ___________________________________________ Date: _______________________


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Abuse & Neglect Training Acknowledgement Form

I, __________________________________, hereby certify that I have been provided with the Abuse & Neglect Training per the requirements of the Office of Long-term Living Guidelines as provided in the Protective Services “Direct Service provider” Webinar; dated September 2013.

________________________________________ Signature

________________________________________ Date ________________________________________ Witness


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Consent to Pre-Employment Drug Testing I hereby agree, to submit to a drug or alcohol test and to furnish a sample of my saliva, urine, breath, hair and or blood for analysis. I understand and agree that if refuse to submit to a drug or alcohol test, or if I otherwise fail to cooperate with the testing procedures, I will not be considered for employment with ProStat, Inc. I further authorize and give permission to have ProStat, Inc. to send the specimen or specimens collected, to a company-approved laboratory or testing facility for a further screening to test for the presence of any prohibited substances at my own expense, and for the laboratory or other testing facility to release any and all documentation relating to such test to ProStat, Inc. ______________________________________________ ________________ Applicant Signature Date ______________________________________________ Applicant Name Printed ______________________________________________ ________________ ProStat Inc. Signature Date


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RE-PAYMENT AUTHORIZATION FORM

Employee Name: ________________________ Social Security Number: _____-_____-______

I, ___________________________, (“Borrower”) understand that I may choose to provide ProStat, Inc. with current and acceptable copies of the below required testing that I have previously undergone, procure the below required testing elsewhere, or undergo the below required testing through ProStat, Inc. if I choose to undergo the below testing through ProStat, Inc., I agree to make payment to ProStat, Inc. (“Lender”) for all testing performed and items purchased, pursuant to the below fee schedule:

Date Performed Cost ❏ Drug Test ____/____/______ $20.00 ❏ Criminal Background Check ____/____/______ $8.00 ❏ ChildLine Verification ____/____/______ $8.00

(Only if providing home care services) ❏ FBI Clearance ____/____/______ $27.50

(Only if NOT a PA Resident for past 2 years) ❏ Uniform Top #1 Size: S, M, L, XL, XXL ____/____/______ FREE ❏ Uniform Top #2 Size: S, M, L, XL, XXL ____/____/______ $16.00

Total Repayment Due to ProStat, Inc.: $_______________

Method of Payment:

❏ Check/Money Order: #____________________ Amount Paid: $________________ ❏ Payroll Deduction:

I, ___________________________________, agree to pay Lender $__________. I wish to have Lender deduct this amount from my pay. I further understand that I will still be responsible to make payment to Lender, if for whatever reason Lender is unable to collect my payment from my paycheck.

Borrower Signature: ___________________________________ Date: __________________ Lender Witness: ____________________________________ Date: _________________ ---------------------------------------------Do Not Write Below This Line---------------------------------------- Paid in Full: ____/____/______ Payment Authorization by: ________________________


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Drug Screen Form Required (Print From(s) Portal and Insert Here)


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WOTC Paperwork Required (Print From(s) Portal and Insert Here)


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Provisional Offer of Employment Employee Name: _____________________________________________ Date: ______________ Dear Employee: We am pleased to offer you a Provisional Offer of Employment for the position of ___________ (TITLE). Continued employment will require satisfactory job performance and compliance with existing and future company, state, and federal regulations and policies. Prior to your first day of employment, you will need to complete the “orientation and onboarding process”. Please monitor your email for directions on the onboarding process. The onboarding process includes but is not limited to: completion of Section I of the I-9, entering government ID’s, necessary health screenings, contact and personal information, completion of federal withholdings, and the Direct Deposit Authorization form. ProStat, Inc. may use direct deposit as the method of salary payments for employees. Federal law requires that all employees complete an electronic I-9 verifying their eligibility to work in the United States. Our Human Resources Office will need to photocopy original documents in compliance with the Immigration and Naturalization Act. A list of acceptable documents for I-9 verification is available by visiting our website at (http://www.fau.edu/hr/files/I9_List_of_Acceptable_Documents.pdf). You are scheduled to attend New Hire Orientation on _______________________________________. Report to your local office at this date and time. Day Month Year Time Welcome to ProStat, Inc. we are very excited at the prospect of you joining our team. Please signify acceptance of this offer by signing and returning this letter to your supervisor. Sincerely, ProStat, Inc.

…………………………………………………………………………………………………………………………………… This offer is contingent upon the final review and approval of the Human Resources Department to include, but not be limited to: 1) the successful completion of a thorough background check to include a criminal background investigation, professional/personal reference validation, and relevant license verification, 2) the surrender of a saliva or other sample for the purpose of conducting a drug-screening test, and 3) the submission of a post-hire medical questionnaire conducted in compliance with the Americans with Disabilities Act (ADA) 42 U.S.C.A. §12112(d)(3). I, _______________________________________________(Employee Name), accept the position of ___________(TITLE) at the conditions and terms stated above, effective __________________(DATE) with the full understanding that while I am employed by ProStat, Inc., I will be an employee “at will” and that I or ProStat, Inc. may terminate employment at any time. _______________________________________________________________________________________

(EMPLOYEE SIGNATURE) (DATE)


http://www.fau.edu/hr/files/I9_List_of_Acceptable_Documents.pdf

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APPENDIX B ACKNOWLEDGMENT OF RECEIPT

I have received a copy of ProStat’s Employee Handbook. I will read and become familiar with its contents. If I do not understand any policy or procedure outlined in this manual, I will contact my supervisor or the Human Resources Department for clarifications. This Handbook is only a guideline for employees and is not all-inclusive of the policies or procedures that may affect my employment. I understand that ProStat has the right to interpret, revoke, change, or supplement this Handbook or any other personnel policy at any time and without any notice. Neither this Handbook nor any other communication by a management representative, either written or verbal, is intended to in any way create an employment agreement, contract or a guarantee of continued employment or of a specific number of working hours. Rather, this Handbook merely describes ProStat’s general philosophy concerning policies and procedures. My signature indicates that I have read and understand this Acknowledgment of Receipt and I have received a copy of the Employee Handbook. I agree to maintain complete confidentiality of confidential or trade secret information that I become aware of during the course of my employment. I also authorize ProStat to withhold from my pay any amounts that I may owe ProStat as a result of loans or other advance payments made to me by ProStat during the course of my employment. I have read this Acknowledgment and understand its contents. EMPLOYEE NAME:__________________________________________________

(please print)

SIGNED:___________________________________________________________ (employee signature)

DATE:_____________________________________________________________


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CONSENT FOR CRIMINAL HISTORY BACKGROUND CHECK AUTHORIZATION FORM Employee First, Middle, and Last Name: _______________________________________________ Employee Maiden Name: ____________________________________ SSN: _____-_____-_______ Driver’s License Number: ________________ State: ________ Date of Birth: _____/_____/______ Employee Street Address: __________________________________________________________ City: _______________________________________ State: __________ Zip: ______________ Primary Tel: (______)_______-__________ Alternate Tel: (_______)_______-__________ Please answer the questions below.

1. I have been a resident of Pennsylvania for the two (2) years immediately preceding the date as signed below. ( ) YES ( ) NO

2. If you have answered “NO” and have NOT been a resident of Pennsylvania for the two (2) years

preceding the date as signed below, please list any states (or countries) in which you had held residency in within the previous ten (10) years: 1)________________ 2) ________________ 3) ________________ 4) _______________

3. Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to

a crime? ( ) YES ( ) NO

4. If you have answered “YES”, Please explain: ______________________________________ I hereby give permission for ProStat, Inc. and its representatives to obtain information relating to my potential criminal history record. The criminal history background check may include arrest and conviction data. I understand this information will be used in part to determine my eligibility for employment with ProStat, Inc. I also understand, that if I accept employment, the criminal history background check may be repeated at any time as long as I remain employed. I also understand that I will have an opportunity to review the criminal history as reported if I request in writing within 10 calendar days of notification of any problems or concern regarding information received. I, the undersigned, hereby and forever agree to hold prostat, Inc., their officers, employees and agents harmless from any and all causes of actions, suits, liabilities, costs, debts, and sums of money, claims and demands whatsoever resulting from an investigation of my potential criminal history background in connection with my eligibility for employment. Employee Signature:___________________________________________ Date: ________________


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POST OFFER MEDICAL HISTORY QUESTIONNAIRE

Employee Name: ________________________________________ Position: ___________________

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.

To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic Information,’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

I AGREE TO INDEMNIFY AND HOLD HARMLESS PROSTAT, INC. AND ITS SUBSIDIARIES, TOGETHER WITH ALL THEIR TRUSTEES, OFFICERS, EMPLOYEES AND AGENTS FROM ALL LOSSES, CLAIMS, DAMAGES, AND LIABILITIES ARISING FROM THE USE OF THE INFORMATION CONTAINED IN THIS FORM AND IN MY EMPLOYEE HEALTH FILE BY ANY THIRD PARTY.

Employee Signature: _________________________________ Date:_____________________ Notice: In compliance with the Americans with Disabilities Act of 1990 (ADA) you have received a conditional offer of employment. This medical history statement is required. The answers to the medical history statement will be kept confidential as required by the ADA and HIPPA. The job offer, which you have received is conditioned upon satisfactory completion and review of this medical history statement; any required medical examination or follow up and job assignment availability.

Employee Affirmation: I herewith affirm that the employer has made me an offer of employment. The purpose of this inquiry is to determine whether I currently have the physical qualifications necessary to perform the job that has been offered; to determine whether and what accommodations may be necessary; and to determine whether I can perform the job without posing a significant/direct threat to the health and safety of myself and others. This information will be kept confidential in a separate medical file, apart from my personnel file. I hereby affirm that the medical questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job.

Employee Name: ____________________________________ Position: _____________________

POST OFFER MEDICAL HISTORY QUESTIONNAIRE Page 1 of 4


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Instructions: Please answer “YES” or “NO” as to whether or not you currently are being or have been previously medically treated for the following list of injuries and/or conditions.

Head Injury ( ) YES ( ) NO Neck Injury ( ) YES ( ) NO Difficulty Moving neck ( ) YES ( ) NO Shooting Pain Down from Neck or Upper Back through Arms ( ) YES ( ) NO Back Injury ( ) YES ( ) NO Difficulty Moving Back ( ) YES ( ) NO Shooting Pain Down from Back through Lower Extremities ( ) YES ( ) NO Hip Injury ( ) YES ( ) NO Difficulty Moving Hip ( ) YES ( ) NO Leg Injury ( ) YES ( ) NO Difficulty Moving Leg ( ) YES ( ) NO Knee Injury ( ) YES ( ) NO Difficulty Moving Knee ( ) YES ( ) NO Foot Injury ( ) YES ( ) NO Fractured or Broken Bones ( ) YES ( ) NO Ruptured Disc(s) ( ) YES ( ) NO Bulging Disc(s) ( ) YES ( ) NO Amputated Foot, Leg, Arm or Hand or Loss of Use Thereof ( ) YES ( ) NO Shoulder injury ( ) YES ( ) NO Rotator Cuff Injury ( ) YES ( ) NO Difficulty Moving Shoulder ( ) YES ( ) NO Arm Injury ( ) YES ( ) NO Difficulty Moving Arm ( ) YES ( ) NO Elbow Injury ( ) YES ( ) NO Wrist Injury ( ) YES ( ) NO Hand and/or Finger Injury ( ) YES ( ) NO Difficulty Lifting ( ) YES ( ) NO Difficulty Stooping ( ) YES ( ) NO Difficulty Bending ( ) YES ( ) NO

If Yes to any of the above, please fill-in space provided below. (Additional sheet(s) may be used if needed.)

Medically Treated Injury/Condition

Date(s) Nature of Injury/Condition

Please list any injuries or conditions not listed above for which you have been treated for in the past 5 years. (Additional sheet(s) may be used if needed.) Medically Treated/ Injury/Condition Date(s) Nature of Injury/Condition Employee Signature: ______________________________________ Date:__________________



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Employee Name: ________________________________________ Position: _____________________

Please select the answer to each question. If you answer “YES” to any of the questions, please explain in detail in the space provided. (Additional sheet(s) may be used if needed.)

1. Do you have any work restrictions or limitations? ( ) YES ( ) NO If “YES”, please list: _______________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. Are you presently under any medical treatment by a doctor or any other health care provider? ( ) YES ( ) NO If “YES”, please list: _______________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Are you presently taking any prescription or nonprescription medication(s) that would interfere with your job duties? ( ) YES ( ) NO If “YES”, please list: _______________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 4. Do you have any physical or mental difficulties that could interfere with the performance of your job duties? ( ) YES ( ) NO If “YES”, please list: _______________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 5. Are you aware of any condition or injury that might impair or limit your ability to perform any this job? ( ) YES ( ) NO If “YES”, please list: _______________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Employee Signature: _________________________________________ Date:___________________



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POST OFFER MEDICAL HISTORY QUESTIONNAIRE ATTESTATION OF TRUTHFULNESS

Employee Name: ________________________________________ Position: ____________________

By my signature below, I attest that all the information I provided on this form is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability. Employee Signature: ________________________________________ Date: ___________________

------------------------------------------DO NOT WRITE BELOW THIS LINE------------------------------------------- ProStat, Inc. Use Only

I HAVE REVIEWED THE INFORMATION PROVIDED BY THE ABOVE-SIGNED EMPLOYEE ON THIS POST-OFFER MEDICAL HISTORY QUESTIONNAIRE AND AFFIRM THAT I HAVE KNOWLEDGE OF ANY MEDICAL CONDITIONS/INJURIES DISCLOSED HEREIN BY THE EMPLOYEE. EMPLOYER NAME(PRINT): _________________________________________________ EMPLOYER SIGNATURE: ___________________________________________________ DATE: ____________________



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PHYSICIAN’S STATEMENT

Medical Release Authorization: I, ____________________________(Employee Name), do hereby authorize, the Medical Practice of Dr. __________________________, to release to ProStat, Inc., its affiliates, and any of its Client hospitals or institutions any information acquired in my medical examination that is relevant to my employment. Employee Signature: __________________________ Today’s Date: ______________

Social Security Number: ________________________ Date of Birth: ______________

Physician to complete this section:

I have examined the individual named above and to the best of my knowledge, he/she is in good physical and mental health and free of communicable disease. Employee is fit for duty without restrictions including of performing max-assist patient transfers; being able to lift 50 lbs, independently and repeatedly, and to function in his/her profession at full capacity.

By signing below, I certify that the above information is valid.

Physician’s Printed Name: _____________________________ Tel: ___________________

Physician’s Signature: ______________________________ Date of Exam: _____________

Address: ___________________________________________________________________


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Mantoux Tuberculin Skin Test Record Form Patient Information:

Name: _____________________________________________ Job Title: _______________________

Address: ____________________________________________________________________________

City/Town: _________________________________________ State: ________ Zip: ______________

Home Tel: __________________________________ Work Tel: _____________________________ Patient Questionnaire:

1. Are you currently pregnant or nursing? (_)Yes (_)No 2. Have you completed a Mantoux (PPD) test within the past year? (_)Yes (_)No 3. If “Yes”, when? ______________ 4. Have you ever had a positive reaction?* (_)Yes (_)No 5. If “Yes”, did you receive a Chest X-Ray? (_)Yes (_)No 6. Do you consent to having a PPD Skin Test? (_)Yes (_)No

Signature: _______________________________________________ Date: ____________________ STEP 1: Skin Test Information STEP 2: Skin Test Information

Administrator’s Administrator’s Name: _______________________ Name: _______________________

Date/Time Date/Time Administered: _________________ Administered: _________________

Arm Administered: _____________ Arm Administered: _____________

Manufacturer: _________________ Manufacturer: _________________

Expiration Date: ________________ Expiration Date: ________________

Lot#: _________________________ Lot#: _________________________

STEP 1: Results STEP 2: Results

Induration: _________________mm Induration: _________________mm

Date/Time Read: _______________ Date/Time Read: _______________

Comments and Adverse Reaction(s) Comments and Adverse Reaction(s)

If any: ________________________ If any: ________________________

Name of Reader: _______________ Name of Reader: _______________

Signature: _____________________ Signature: _____________________

*It is highly unlikely that a side effect to the test will occur. If such an event does happen, the most common reaction is pain or redness at the test site. In very rare cases, a person who is hypersensitive to the solution could have a severe allergic reaction near the injection site. Such rare reactions may include blistering or a skin wound.


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W-4 (2017) Required (Print From(s) Portal and Insert Here)


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I-9 (2017) Required (Print From(s) Portal and Insert Here)


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Acceptable List of Documents for Proof of Residency for Applicants 18 Years of Age or older: IMPORTANT: All IDs for proof of residency must be dated within the past 2 years of hire date. Please Note: All documents must show the same name and date of birth, or an association between the information on the documents. Additional documentation may be required if a connection between documents cannot be established (e.g. Marriage Certificate, Court Order of name change, Divorce Decree, etc.) Check each form(s) used to prove residency:

❏ W-2 Form ❏ PA Drivers License ❏ PA State ID ❏ Employment Records ❏ Unemployment Records ❏ Two (2) Professional References ❏ Current Utility Bills (Water, gas, electric, cable, etc.) ❏ Tax Records ❏ Lease Agreement ❏ Mortgage Documents ❏ Current Weapons Permit

Copies of all “checked” documents must be made and retained in the employee’s file. Person completing this form: ___________________________Date: ____________ PUB 195US (9-14)


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ACA NOTICE TO EMPLOYEES (Print From(s) Portal and Insert Here)


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DIRECT DEPOSIT REQUEST FORM ProStat, Inc. requires DIRECT DEPOSIT of your paycheck. Please complete and sign the bottom of this form and return it to this office along with a VOIDED check or deposit slip. Should you not have a checking or savings account a debit card will be issued to you and paychecks will be deposited to the debit card. If you have any questions please call 610-736-9000. Thank you, ProStat, Inc.

------------------------------------Employee to complete below.---------------------------------------- Employee Name _________________________________ Social Security Number _________________________________ Bank Name _________________________________ Bank Address _________________________________

_________________________________

Bank Phone Number _________________________________ Contact Name _________________________________ Routing Number _________________________________ Account Number _________________________________ Account Type Checking ________Savings___________ Effective Date _________________, 20_____ I hereby grant ProStat, Inc. permission to directly deposit my payroll check into my bank account beginning with the effective date noted above. EMPLOYEE SIGNATURE __________________________DATE ______________


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Pre-Placement-Checklist

Office Location: __________________________________ Employee Name: ______________________________ Title: _________ Date: _______________ Instructions: Check each task as completed and provide any additional information that’s requested below. This form is to be completed post-offer BUT prior to the individual working his or her first shift. A copy of this form must accompany the weekly payroll packet. 1. Application:

❏ Face-To-Face Interview (Completed) - Date ___________________ ❏ Application/RSS eDocs/Interview & New-Hire documents (Reviewed & Completed)

2. Background Investigations:

❏ ePatch Criminal Background (Full Results Required/“Under Review” is not acceptable) ❏ Verification of Residency:________________________________________(Source/s) ❏ Positive Reference Form #1 (Completed) - Name: _____________________________ ❏ Positive Reference Form #2 (Completed) - Name: _____________________________ ❏ (If PCA) MVR (Results) ❏ OIG (Results) ❏ Megan’s Law (Results) ❏ Medi-Check (Results) ❏ EPLS (Results) ❏ E-Verify (Completed) ❏ Verification of PA Nursing License/CNA Certification/HHA Certification (If Applicable)

❏ FBI Clearance (Results) (If Applicable) 3. Tuberculin Testing:

❏ PPD #1 (Results) - Date Read: _________________ ❏ PPD #2 (Results) - Date Scheduled/Read: _________________

❏ Chest X-Ray (Results) (If past positive PPD) ❏ Quantiferon (Results) (If past positive PPD)

❏ Flu Shot (Medical Staffing Only) ❏ Physician’s Statement (Always for Medical Staffing but also PCAs if Applicable)

4. Other: ❏ LPN/RN Nursing License or CNA Certification (If CNA, LPN, or RN) ❏ CPR Certificate (If LPN/RN) ❏ Discipline Specific Competency Testing: ________% (Results) ❏ Core Competency Testing: ________% (Results) (If CNA, LPN, or RN) ❏ Photo ID emailed to Corporate: ____________(Date Emailed) ❏ Child Abuse Training Scheduled: ________________(Due Date) ❏ (If PCA) DCW Eval Scheduled: _______________(Eval Date)

5: Record of Documents:

❏ All applicant & employee forms uploaded to CSS (Reviewed Date) ______________ This form was completed by: _________________________________ Title: ____________________ Manager Signature: _______________________________________ Date: _____________________


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Maintenance Sheet

*Office/Branch: ___________________________________ *Today’s Date: _______________ *Title: (_)DCW (_)CNA (_)LPN (_)RN (_)SLP (_)Other: ____________________________

❏ New Hire: _____________________(date) Previous Employee? (_) YES (_) NO ❏ Termination:________________________ (date) AND Attach Event Report ❏ Change of Home Address (complete below) ❏ Change in Pay Rate to $___________ ( ) Annual ( ) Hourly / Effective Date: ____________ ❏ Change of Email Address (complete below) ❏ Change of Telephone # (below) ❏ Change of Withholding (Complete below AND attach Revised W-4)

(_) Single (_) Married # of Dependents: _____ Additional Weekly Withholdings: $______ Local Tax: ______________________ Withhold: _______% OCP Tax: (_)Take (_)Paid

❏ Change of GHP Benefits (_) Add (_) Change (_) Discontinue – Attach Change Form ❏ Direct Deposit: (_) Add (_) Change – attach completed Direct Deposit Form

(_) Discontinue ❏ Pay Card: (_) Add (_) Change - attach completed Pay Card Enrollment Form

(_) Discontinue ❏ Other: _________________________________________________________________

______________________________________________________________________________ *Employee Name (first, middle, last) *SSN *Date of Birth ______________________________________________________________________________ Street Address Apt # ______________________________________________________________________________ City State Zip County ______________________________________ ____________________________________ Email Address Tel

*This form was completed by: __________________________________________

Printed Name

“*” Indicates the field MUST be completed.


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New Hire Checklist (Send to Corporate with Payroll Package)

Office:__________________________________ Today’s Date:_____________ Employee Name:__________________________________ Title: _______________ SSN: _______________________________ Date of Birth: ___________________ Date First Shift Worked:_____________________ Pay Rate $__________ per hour Check each box to indicate that you have reviewed and included a copy of the document with your payroll package. All documents must be legible and fully and properly completed. Incomplete forms will be returned to office for proper completion.

❏ Maintenance Sheet (Complete W-4 Information) ❏ W-4 (Send Copy) ❏ Re-Payment Authorization - Add up deductions & provide total / circle shirt size. ❏ Direct Deposit Form or Money Card Application (if applicable.)

❏ Direct deposit please provide copy of voided check. ❏ Money card, please provide card application.

❏ E-Verify - Case Verification Form ❏ Consent for Criminal History Background Check - Completed ❏ Form 8850, 9061, and 9175- Pre-Screen Notice and Cert. Request for the WOTC - All pages ❏ I-9 Form - Signed by person who witnessed supporting documents.

Supporting documentation provided: ❏ Social Security Card/Birth Certificate;and ❏ Drivers License/State Photo ID; or ❏ Passport; or ❏ Other:_______________-Verify document is valid per I-9 Form instruction.

❏ Pre-Placement Checklist - Completed _____________________________________ ____________________________________ Person Completing this form Manager's Signature --------------------------------------------------Do not write below this line----------------------------------------------------

❏ Reviewed by Payroll: ___________Initials / Date _________________

❏ Reviewed by HR: ___________Initials / Date _________________

❏ Reviewed by QC: ___________Initials / Date _________________


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Temp Credential Checklist

Temp Name: ___________________________________________ Title: _________________ Date & Time of 1st Shift or Orientation: ____________________________________________ Please find the included copies of the requested Temp Documentation for your records.

❏ (_)CNA Certification, (_)LPN License, or (_)RN License _____________(Expire Date) ❏ Verification of PA Certification or Licensure: _______________(Document Date) ❏ CPR Training Certificate (LPN & RN Only): ____________(Date Expires) ❏ Criminal Background Check: (_)ePatch / (_)FBI ___________(Document Date) ❏ OIG Results: ____________(Document Date) ❏ EPLS Results: ____________(Document Date) ❏ Megan’s Law Results: ____________(Document Date) ❏ MediCheck Results: ____________(Document Date) ❏ Drug Testing Results: ____________(Document Date) ❏ TB Testing Results: ____________(Expire Date) ❏ Physical / Health Statement Results _____________(Document Date) ❏ Flu Shot Evidence: ____________(Document Date) ❏ Declaration of Residency ❏ Acknowledgement of Elder Justice Act Notice ❏ Abuse & Neglect Training Acknowledgement ❏ Other: _________________________________________________________________

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Medical Staffing Application & New Hire Packet · Resume establishing a minimum of one (1) year...

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Transcript of Medical Staffing Application & New Hire Packet · Resume establishing a minimum of one (1) year...