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2021-05-12_mschacter_Full English Application_ May12.docx
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Employment Application
Disclosure Statement:
Home Care Assistance is an equal-opportunity employer and is committed to providing a workplace free from harassment or discrimination. All employment decisions are made without regard to race, skin color, religion, gender, national origin, ancestry, sex, age, handicap, marital status, sexual orientation, physical or mental disability, pregnancy, military status, or any other basis prohibited by law.
Today’s Date: _______________________________________ Referred by? _________________
First Name: ______________________________ Last Name: ______________________________
Street Address: ____________________________________________________________________
City: ____________________________ Province: ___________ Postal Code: _________________
Home Phone: __________________________ Cell Phone: _________________________________
Email Address: ______________________________________________________________________
Social Insurance Number: ____________________ Expiration Date: _________________
Are you legally eligible for employment in Canada? ____________
Driver’s License Number: _________________________ Car Insurance: Yes No
IMPORTANT: All caregiver positions at Home Care Assistance are considered TEMPORARY (seasonal) due to the frail condition of our elderly clients. Continued employment is not guaranteed for any caregiver as all employment is at-will, indefinite and not for any specific period of time.
I understand and accept this condition of employment: _________________________________________
(Signature of Applicant)
What are you applying for? (Please check off all applicable options)
Day Shift Evening Shift Overnight Shift Live-In Shift
What are your availabilities at the moment? (Days of the week/Times) ____________________________________________________________________________________
____________________________________________________________________________________
If hired, on what date can you start work?
______________________________________________
Emergency Contact Information
Name: _______________________________________________________________________
Relationship: _________________________________________________________________
Cellphone Number: ___________________________________________________________
Home Number: ______________________________________________________________
Name: _______________________________________________________________________
Relationship: _________________________________________________________________
Cellphone Number: ___________________________________________________________
Home Number: ______________________________________________________________
Allergies
Please list any allergies that you have:
__________________________________________________________________________________________________________________________________________________________
RECORD OF PREVIOUS EMPLOYMENT (If you have filled out this section online already, please omit)
May we contact the employers listed above? Yes No
If no, please indicate which one: ________________________________________________________________
Have you ever been terminated or asked to resign from any job? Yes No
If yes, please explain why:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
REFERENCES (If you have filled out this section online already, please omit)
List below 2 people not related to you whom you have known for at least one year and who can provide information about your skills and experience
1) Name: ___________________________________________________________________________
Address: ____________________________________________________________________________
Phone: _______________________________ Relationship: _________________________________
Email: ______________________________________________________________________________
Number of years acquainted: _________________________________________________________
Is this a PERSONAL or BUSINESS reference? (Circle one)
2) Name: ___________________________________________________________________________
Address: ____________________________________________________________________________
Phone: _______________________________ Relationship: _________________________________
Email: ______________________________________________________________________________
Number of years acquainted: _________________________________________________________
Is this a PERSONAL or BUSINESS reference? (Circle one)
EDUCATION (If you have filled out this section online already, please omit)
College/University
School Name: _____________________________________________________________
Diploma/Degree Obtained: _________________________________________________
Location: __________________________________________________________________
Vocational School
School Name: _____________________________________________________________
Diploma/Degree Obtained: _________________________________________________
Location: __________________________________________________________________
EXPERIENCE – ELDERCARE/HOMECARE
Please check off the job(s) you are applying for:
Companion
PAB Received on: _________________________
PSW Received on: _________________________
LPN License Number: _________________________ Expiration Date: _____________________________
List all professional licenses or certificates that you have: ________________________________________________________________________________________________________________________________________________________________________
This job may require you to transfer up to 75 pounds of dead weight from/to a bed, commode, couch, wheelchair, etc.… Are you able to perform this task? Yes No
Please check off the job skills you have experience in and will perform:
Please check off the following conditions/diagnosis with which you have experience and job skills to care for a patient:
Please check off the Home Medical Equipment you have experience with:
Please check off the job responsibilities you are comfortable doing in addition to Eldercare:
Meal Preparation
Based on your level of comfort, which of the meals portrayed below are you comfortable preparing for your clients? Please place a where applicable.
Breakfast:
Lunch:
Dinner:
AUTHORIZATION TO RELEASE INFORMATION
It is the policy of Home Care Assistance to conduct reference checks for employment candidates. Your signature below indicates your agreement with and acknowledgment of the following
As an applicant for employment with Home Care Assistance, I authorize my current and past employers and current and past work associates to release to Home Care Assistance any reference and employment information, including but not limited to performance evaluations and attendance records and work-related personal characteristics (e.g. my character, dependability, honesty, integrity, interpersonal skills, etc.)
Home Care Assistance will maintain reference information in strictest confidence and solely for the purposes of the recruitment for which I have applied.
A photocopy of this signed Authorization is to be considered valid as an original.
I have carefully read and understand all of the provisions above and have voluntarily agreed to sign this authorization.
__________________________________ _________________________________
(Signature) (Printed Name)
_________________________________
(Date)
WORKPLACE SAFETY RULES
Your safety is the constant concern of Home Care Assistance. Every precaution has been taken to provide a safe workplace. Common sense and a personal interest in safety are still the greatest guarantees of your safety at work, on the road, and at home.
The cooperation of every Caregiver is necessary to make Home Care Assistance a safe place in which to work. Help yourself and others by reporting unsafe conditions or hazards immediately to the office. Give earnest consideration to the rules of safety presented to you by signs, discussions with your Supervisor, posted department rules, and regulations published in the safety booklet. Always think of safety as you perform your job, or as you learn a new one.
ACCIDENT REPORTING
Any injury at work, no matter how small, must be reported immediately to your Supervisor and receive first aid attention. Serious conditions often arise from small injuries if they are not cared for at once.
SPECIFIC SAFETY RULES AND GUIDELINES
To ensure your safety, and that of your co-workers, please observe and obey the following rules and guidelines:
Observe and practice the safety procedures established for the job
In case of sickness or injury, no matter how slight, report at once to your Supervisor. In no case should a Caregiver treat his/her own or someone else’s injuries.
In case of injury resulting in possible fracture to legs, back, or neck, or any accident resulting in an unconscious condition, or a severe head injury, the Caregiver is not to be moved until authorized personnel have given medical attention.
All caregivers must use seat belts and shoulder restraints whenever they operate a vehicle on company business. The driver is responsible for seeing that all the passengers in the front and rear seats are buckled up.
Never distract the attention of another Caregiver, as you might cause him or her to be injured
Where required, you must wear protective equipment, such as goggles, safety glasses, masks, gloves, hair nets, etc...
Do not operate machines or equipment until you have been properly instructed and authorized to do so by your Supervisor
Do not engage in such other practices as may be inconsistent with ordinary and reasonable common-sense safety rules
Lift properly – use your legs, not your back. For heavier loads, ask for assistance
Do not throw objects
Wear hard sole shoes and appropriate clothing. Shorts or mini dresses are not permitted
SAFETY CHECKLIST
It’s every Caregiver’s responsibility to be on the lookout for possible hazards. If you spot one of the conditions on the following list – or any other possible hazardous situation – report it to your Supervisor immediately:
Slippery floors and walkways
Tripping hazards
Poorly lighted stairs
Loose handrails or guard rails
Loose or broken windows
Open or broken windows
Unlocked doors and gates
Electrical equipment left operating
Open doors on electrical panels
Leaks of steam, water, oil, etc.…
Blocked fire extinguishers, hose sprinkler heads
Evidence of any equipment running hot or overheating
Roof leaks
ACKNOWLEDGMENT
I have received a copy of the Workplace Safety Rules and understand that it sets forth the terms and conditions of my employment as well as the duties, responsibilities, and obligation of my employment with Home Care Assistance.
SMOKING, DRUG AND ALCOHOL POLICY
For purposes of this policy the following terms shall have the following meanings:
Smoking is defined as the inhaling, exhaling, burning or carrying a lighted cigarette, cigar, pipe, or other lighted smoking equipment for any product containing tobacco.
Tobacco products are defined as any product containing tobacco, the prepared leaves of plants of the nicotine family, including, but not limited to, cigarettes, loose tobacco, cigars, snuff, chewing tobacco, or any other preparation of tobacco.
The Home Care Assistance smoking policy is:
Smoking is prohibited inside all client residences, Home Care Assistance buildings and company-owned passenger vehicles
Smoking is prohibited in any outdoor area within nine (9) metres of any main exit or entrance of all client residences and Home Care Assistance buildings
Managers and supervisors are responsible for informing all Home Care Assistance caregivers of the “Smoking Policy” and for administering appropriate disciplinary action for continual and/or flagrant violations of this policy
Alcohol means any alcohol or alcoholic beverage.
Drug means any drug, other than alcohol, including but not limited to illegal drugs and prescription or over-the-counter drugs
Illegal Drug means any controlled substance, drug, narcotic or immediate precursor which may subject an individual to criminal penalties, or a legal drug which has not been legally obtained or is being used by an individual for whom it was not prescribed, or is not being used in a manner, combination or quantity for which it was manufactured, prescribed, or intended.
Legal Drug means any over-the-counter drug or prescription drug which has been legally obtained and is being used in the manner, combination and quantity for which it was manufacture, prescribed, or intended.
Under the Influence means that a drug or alcohol is present in the caregiver’s bodily system.
Each Home Care Assistance caregiver commits and urges all other caregivers to commit, that while performing services for Home Care Assistance clients they:
Shall not in any way be impaired because of being under the influence of alcohol or a drug
Shall not possess, consume, or be under the influence of alcohol and/or an illegal drug
Shall not sell, offer, or provide alcohol or a drug to another person
I HAVE READ ALL THE ABOVE, ASKED ALL THE QUESTIONS I DESIRED, AND UNDERSTAND AND AGREE.
__________________________________ _________________________________
(Signature) (Printed Name)
_________________________________
(Date)
FRANCHISEE EMPLOYEE ACKNOWLEDGMENT FORM
I, the undersigned, am an employee of Home Care Assistance (Montreal) Inc. (the “Franchisee”).
I understand and acknowledge that Franchisee is a franchisee of HCA Franchise Corporation d/b/a Home Care Assistance Group Inc. (“HCA”). I further understand and acknowledge that, regardless of the relationship between HCA and Franchisee. I am and will be an employee of Franchisee. I am not and will not be an employee of HCA.
I will look solely to Franchisee for all of my compensation and any benefits. I understand and agree that I will not be eligible to receive any kind of compensation or benefits from HCA and will not be eligible to participate in any of HCA’s employee benefit plans or programs.
I further understand and acknowledge that all decisions regarding discipline or the termination of my employment with Franchisee shall be made by Franchisee, not HCA.
__________________________________ _________________________________
(Signature) (Printed Name)
_________________________________
(Date)
ABOUT YOU!
Please fill out the following questions: (If you have filled out this section online already, please omit)
How long have you been a caregiver? ___________________________________________
How far are you willing to travel from your home to work with a client? ______________
What is your experience working with the elderly? ________________________________
______________________________________________________________________________
______________________________________________________________________________
What are your hobbies & interests? ______________________________________________
______________________________________________________________________________
What languages do you speak? _________________________________________________
What do you most look forward to in providing home care services? _________________
______________________________________________________________________________
______________________________________________________________________________
I enjoy trying new things like: ____________________________________________________
What makes you responsible and reliable? ________________________________________
_____________________________________________________________________________
I would be a great employee because: ___________________________________________
______________________________________________________________________________
CAREGIVER / AGENCY AGREEMENT
This Caregiver/Agency Agreement (this “Agreement”) is made by and between Home Care Assistance (Montreal) Inc., herein represented by ____________________________, duly authorized for the purposes hereof as he/she so declares (“HCA”) and ______________________________________________________, domiciled and residing at
______________________________________________________ (the “Caregiver”) (collectively the “Parties”);
Terms of the Agreement
The Caregiver is hereby retained by HCA to provide caregiver and support services to clients of HCA on a scheduled basis (the “Services”). Services shall be performed in accordance with a schedule prepared by HCA and approved by the Caregiver.
HCA agrees to pay the Caregiver $________ per hour for Services rendered. Caregiver shall receive the wages herein prescribed on a biweekly basis. Caregiver shall not incur or charge HCA any other fees or expenses without the prior authorization of HCA.
This Agreement shall commence on the date as mutually agreed upon by the parties (the “Effective Date”).
No Solicitation
Caregiver shall not, during the Agreement and for a period of THREE (3) years immediately following termination of this Agreement pursuant to section 5 thereof, either directly or indirectly, call on, solicit, or take away, or attempt to call on, solicit, or take away, any of the customers or clients of HCA on whom Caregiver called or became acquainted with during the terms of this Agreement, either for their own benefit, or for the benefit of any other person, firm, corporation or organization.
If Caregiver desires to work with a particular client other than in accordance with this Agreement at any time within THREE (3) years following the conclusion of Caregiver’s services for said client, Caregiver shall pay HCA a fee of FIVE THOUSAND DOLLARS ($5,000.00) prior to commencing any services for said client in consideration of HCA introducing the client to the Caregiver.
Absences
The Caregiver must inform a representative of HCA of any planned absence at least TWO (2) weeks in advance. Once the Caregiver has been scheduled for services, permission for any absence for non-medical reasons is at the sole discretion of HCA.
Client Interaction
Under no circumstances is Caregiver allowed to speak directly or indirectly to the client or a representative thereof regarding matters of pay. If the client attempts to solicit the Caregiver, the Caregiver must inform HCA of the interaction within TWENTY-FOUR (24) hours. Caregiver must never discuss personal concerns with the client and must report any such concerns to a representative of HCA.
The Caregiver may only accept money from a Client for the purpose of doing errands for them. All receipts and change must be promptly given back to the Client. In the event that the Caregiver uses his/her own money for errands for the Client, they must keep all receipts and provide copies to the office immediately following the shift. The caregiver will then be reimbursed for the expenses on their pay. The Caregiver may not accept any gifts (monetary or other) from clients. If the Client wants to give their Caregiver a gift, the Client must contact Home Care Assistance office to discuss.
Termination
The Agreement may be terminated without any compensation, payment, or severance whatsoever on the happening of any of the following events:
The death of the Caregiver;
By the Caregiver providing FIFTEEN (15) day written notice;
By HCA upon a written notice;
In the event the Caregiver fails to provide the FIFTEEN (15) day written notice as provided in Section 5 a) ii) hereinabove, HCA reserves the right to deduct the sum of THIRTY-FIVE DOLLARS ($35.00) from the Caregiver’s wages as compensation to HCA for payment of the Caregiver’s Background Check;
Indemnity
In the event of any fraud, misrepresentation, or negligent act by the Caregiver in the course of the provision of the Services, the Caregiver agrees to compensate HCA and HCA shall not be held liable for any loss, costs, damages, expense and liability whatsoever in connection with such acts.
Caregiver acknowledges and agrees that in the event of a breach or threatened breach of Section 2, 3, or 4 of this Agreement, HCA shall be entitled, in addition to any other remedies which it may have hereunder or at law or in equity, to a temporary and/or permanent injunction against Caregiver without the necessity of showing actual or threatened damage.
Overtime
Overtime is calculated over a two-week period for all authorized work exceeding 40 hours per week. HCA reserves the right to balance overtime from one week to the next by reducing hours in the following week so that the total number of hours worked does not exceed 80.
Affiliation with a Company or Organization Aside from HCA
According to the Ministériel Arrêté 2021-017, we are required to know if you work for any organization tied to the public health system. If so, you must list your other employed information below.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Cost of Background Check
The caregiver will not be required to pay for the background check up front.
To cover the background check, a $25 charge will be deducted from the caregiver’s first paycheck.
The caregiver will receive a copy of the background check after it is completed via the RCMP website.
General Provisions
The failure of a Party to enforce at any time or for any period of time the provisions of this Agreement shall not be constructed to be a waiver of such provisions or of the right of such party thereafter to enforce each and every provision.
No changes to this Agreement or any of the provisions hereof, nor any representation, promise or condition relating to this Agreement shall be binding upon HCA unless made in writing and signed on behalf of HCA by a duly authorized officer.
If any provision of this Agreement or part hereof is held by a court of competent jurisdiction to be invalid or unenforceable for any reason, the remainder of the provisions shall remain in full force and effect.
The Agreement will be governed by and construed in accordance with the laws of the Province of Quebec.
This Agreement is drafted in the English language at the request of all parties. Cette convention est rédigée en langue anglaise à la demande des parties.
Present or Last Employer
________________________
Company Name
________________________
City
________________________
Name and Title of Last Supervisor
________________________
Phone Number
________________________
Email | Employment Information
From ________ To ________
(Mo./Yr.) (Mo./Yr.)
Salary
Start _________ Final __________
Reason for Leaving:
____________________________
____________________________
____________________________ | Your Position and Duties
Position:_____________________
Primary Duties: ______________________________
______________________________
______________________________
______________________________
______________________________
Previous Employer
________________________
Company Name
________________________
City
________________________
Name and Title of Last Supervisor
________________________
Phone Number
________________________
Email | Employment Information
From ________ To ________
(Mo./Yr.) (Mo./Yr.)
Salary
Start _________ Final __________
Reason for Leaving:
____________________________
____________________________
____________________________ | Your Position and Duties
Position:_____________________
Primary Duties: ______________________________
______________________________
______________________________
______________________________
______________________________
Assistance in Ambulating | Bed Bath | Feeding Tube | Patient Transferring
Assistance in Bathing | Bed Pan | Hoyer Lift Transfer | Range of Motion Exercise
Assistance in Dressing | Catheter Care | Oxygen Administration | Skin Care
Assistance in Toileting | Colostomy Care | Patient Positioning | Transfer Weight __________
LPN Additional Skills: | Drawing Blood | Injections in Butterflies | Vital Signs
Infection Control | Insulin Injections | Wound/Dressing Changes
Aggression | Dementia: Years? _________ | Incontinence | Post-Surgery Care
Aphasia | Depression | Palliative | Shortness of Breath
Brain Degenerative Disorder | Diabetes | Panic Attacks | Speech Impairment
Cancer | Fractures | Paralyzed | Stroke
Congestive Heart Failure | Hearing Impairment | Parkinson's | Visual Impairment
Blood Pressure Kit | Glucose Monitor | Hoyer Lift | Thermometer | Wheel Chair
Gait Belt | Hospital Bed | Oxygen Tank | Walker
Cleaning | Cooking | Housekeeping | Laundry
Cleaning Client’s Room & Bath Only | Errands | Ironing | Special Diet
HCA Representative | Caregiver
_____________________________________
(Signature) | _____________________________________
(Signature)
_____________________________________
(Printed Name) | _____________________________________
(Printed Name)
_____________________________________
(Date) | _____________________________________
(Date)