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    I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection, I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; I can decline hepatitis B vaccination or accept and agree to be vaccinated at no charge to me.

    I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B,a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me

    I understand that by accepting to be vaccinated with the Hepatitis B vaccine there will be no charge to me.
    I will come back at letter times to take it if I change my mind



    Previous Employment: (begin with most recent position)


    Please furnish the names and addresses of two people to whom you are not related and by whom you have not been employed.

    *This is not a test. This is rather a check list to assist us in placing you in appropriate assignments for in home care

    I certify that my answers are true and complete to the best of my knowledge.

    I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, or medical history and other related matters as may be necessary for an employment decision. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with my application.

    In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge

    For Department Use Only


    As part of my application for contractual employment with Caring For Seniors Home Care I consent that Caring For Seniors Home Care may request from any of my former employers all information that Caring For Seniors Home Care may need concerning me, my character, my skills, or my work performance. I am correspondingly authorizing all my former employers to reveal all such information to Caring For Seniors Home Care upon request.


    I understand that the State of Maryland Regulations COMAR (d) (e) and COMAR requires that Caring For Seniors Home Care access the Central Registry of Abuse Reports to obtain any disclosable information concerning me that may be contained therein.This is my authorization for Caring For Seniors Home Care to seek any disclosable information regarding me from the Central Registry of Child Abuse and Elder Abuse which is maintained by the local Department of Social Services


    The nature of services provided by the Caring For Seniors Home Care requires information to be handled in a private, confidential manner.
    Information about our business or our contractual employees or clients will only be released to people or agencies outside of Caring For Seniors Home Care with written consent. Following legal or regulatory guidelines provide the only exceptions to this policy. All reports, memorandum, notes, or other documents will remain part of the Caring For Seniors Home Care confidential records.
    The names, addresses, phone numbers or salaries of our contractual employees will only be released to people authorized by the nature of their duties to receive such information and only with the consent of management or the contractual employee.
    The undersigned contractual employee agrees to abide by this confidentiality agreement

    Contractor and/or Employee Check off List



    Independent Contractor and/or Employee Safety and Health

    Caring For Seniors Home Care recognizes its responsibility to provide the independent contractors and/or employees with a safe and healthy environment in which to work. Caring For Seniors Home Care is responsible for detecting and correcting unsafe working conditions and practices. Training independent contractors and/or employees in proper procedures and safety rules, ascertaining that each independent contractor and/or employee knows, understands and follows the safety rules pertaining to his/her job. Encouraging safety suggestions, discussing matters of safety, responding to all suggestions and questions clearly and promptly, completing proper reports n all incidents/accidents, and keeping informed of new developments which affect its independent contractors and/or employees.

    This policy is designed to provide a safe and healthy workplace, reduce risks of injury or disability for independent contractors and/or employees, enhance productivity, lower health costs and point out specific actions to be taken if a problem arises.

    Accident/Incident Form
    Caring For Seniors Home Care’s First Report of Injury
    Caring For Seniors Home Care’s Order for Medical Attention
    Maryland Medical Laboratory Test Order
    OSHA Form 200
    Declination of Heptavax
    Declination of Mantoux

    A.   In the event of a work-related injury/illness/accident, it is the independent contractor and/or employee’s responsibility to report the incident to his/her immediate supervisor as soon as possible, but not later than 24 hour after the occurrence.
    B.   Fire Safety – Periodic fire drills are conducted to familiarize independent contractors and/or employees with proper evacuation procedures. The ideal time element to evacuate the current locations is three minutes or l less.
    C.  Automobile Safety –
    1.  All independent contractors and/or employees who utilize their automobiles during the course of the business day and/or (evening) are required to use seat belts in compliance with Maryland law.
    2.  Automobile insurance also is required in compliance with Maryland law
    D. Street Safety –
    (Definitions – Caregiver: Independent Contractor and/or Employee)

    1.  Caregivers are requested to report any unsafe areas or conditions inside as well as outside to their supervisor.
    2.  Caregivers as well as escorts are advised to limit/eliminate the wearing of expensive/flashy jewelry while on duty and to carry a limited amount of cash.
    3.  Caregivers are to follow work schedules and to immediately report any change of the schedule to his/her supervisors to maintain reasonable contact (at least once a day) during working hours to ensure safety. Staff nurses are required by the collective bargaining agreement to call the office between 3:30 and 4:30 pm daily unless other arrangements are made with the supervisor. When caregivers determine that an area is unsafe, they are to contact Caring For Seniors Home Care to request an escort. The caregiver arranges the meeting time/place and method of identification for himself/herself and the escort.
    4.  In the event of a street crime, caregivers should follow all policies and procedures for work related accident/incidents as well as notifying the local police department as soon as possible after the event.

    E.   Media Coverage –

    In the event of a situation which causes the death and/or injury of a Caregiver, which also results in media coverage, the following order will be followed in addressing the media.
    Vice President of Patient Services
    No other Caregiver is to act as a spokesperson for Caring For Seniors Home Care unless designated by one of the aforementioned persons.

    F.   Caregivers are encouraged to report potential hazards to his/her immediate supervisor. Examples are faulty wiring or plumbing, inadequate or faulty lighting, obstructed pathways and poor air quality

    G.  Protective Equipment – Caring For Seniors Home Care requires that protective covering is used by Caregivers – gloves (sterile and non-sterile), goggles particulate respirators, face masks/shields, aprons and isolation gowns. In the event of an eye splash, rinsing the eye with cool water, consulting a physician is recommended. The Caregiver is also required to notify his/her supervisor and follow the procedures for infectious exposure.

    H.  Body Mechanics – Caregivers who are called upon to lift clients are trained in proper body mechanics to prevent injury to the clients as well as themselves.

    I.  Waste disposal – Disposal of used needles is addressed in Hazardous Waste Management.

    J.   Caring For Seniors Home Care will require that a vaccine/skin test be obtained at that time. OSHA guidelines will be adhered to in the event of exposure to blood borne pathogens/droplet nuclei. Medical records of all Caregivers will be retained for the duration of contractual employment plus 30 years. Training records will be kept for three years form the date of training.

    K.   Post Offer Physical Exam – Each Caregiver will submit to or provide proof of the following medical exams/tests:

    Urine Screen for drug/alcohol
    Mantoux skin test for Tuberculosis
    (within the last 6 months)
    Physical examination conducted by a licensed health
    provider (within the last 12 months)

    L.  Annual Tuberculosis screening is offered to all provider staff. Caregivers who refuse testing must sign a declination form and must provide proof of absence of TB infection (i.e. certificate for health care provider). To maintain employment, caregivers must provide documentation of TB free status annually from a health care provider. Routine chest films are not required for positive reactors unless symptoms suggestive of tuberculosis develop.

    M.  To be vaccinated with Hepatitis B vaccine or decline Hepatitis B vaccination. If a declination is desired, then person requesting not to be vaccinated must sign a Hepatitis B Vaccination Declination.


    Conflict of Interest

    The affairs of Caring For Seniors Home Care shall be conducted in accordance with the
    highest standards of integrity. There can be no deviation from complete honesty
    in business transactions. Use of funds or internal business information for
    improper purposes and dishonest practices are absolutely forbidden. This policy
    applies to all personnel.

    To ensure that all Staff, Independent contractors and/or Employees avoid conflicts
    of interest within the performance of their duties.

    A Conflict of Interest is defined as making use of any knowledge or information
    acquired through one’s professional relations with one’s patients/clients or in the
    conduct of business, to one’s own advantage or profit.

    Staff (Administrator-Asst. Administrator-RN supervisor-Admissions Coordinator)

    1.  All members of the above described Staff shall:
    a. Act in the course of their duties solely in the best interests of Caring For Seniors Home Care without consideration to the interests of any other Agency, Organization or Association with which they are associated and refrain from taking part in any transaction where such person(s) do not believe in good faith that they can act with undivided loyalty to the Agencyb. Disclose any material, financial or other beneficial interest to any entity engaged in the delivery of goods or services to Caring For Seniors Home Care and/or its members.c. Disclose any transactions which would result in any benefit to themselves, their immediate families, or any entity in which they hold a significant financial ownership or other interest, and refrain from participation in any action on such matters, except upon approval of all upper management after full and frank disclosure.d. Refrain from utilizing any inside information as to the business activities for the benefit of themselves, their immediate families or any entity with which they may be associated.2. All Staff shall be required to sign a confidentiality statement which includes content related to.
    a. Confidentialityb. Non-competitionc.Recruitment/Solicitation of Personnel3. All Staff agree to devote their best efforts to Caring for Seniors Home Care and not directly or indirectly be engaged in or connected with any other commercial pursuits whatsoever without written authorization of Caring For Seniors Home Care

    Independent Contractors and/or Employees:

    1.  As a condition of employment, all personnel shall be asked to sign a Confidentiality Letter in which they agree to devote their best efforts to Caring For Seniors Home Care and not, directly or indirectly, be engaged in or connected with any other commercial pursuits whatsoever without written authorization of the management staff of the agency.

    2.  No patient, commercial, financial or technical information, ideas, know-how, patient/client lists, procedure manuals, contracts, policies, medical records or other materials concerning business practices (collectively referred to as “Confidential Information” Shall not be, directly or indirectly, discussed with or disclosed to any person except as required in the course of employment or pursuant to court order.

    3.  Any and all patient information, notes, diagrams, descriptions, reports, notebook pages, memorandums and other writings received from any Agency and any copies containing confidential information shall remain the property of and on the premises unless removal is required in the course of employment or prior written consent is received from the Agency.

    4.  No position or material financial interest shall be held, directly or indirectly, in any outside concern from which the Agency secures goods or services or that provides services competitive with the Agency.

    5.  No competition shall be engaged in, directly or indirectly with Caring For Seniors Home Care in the purchase or sale of property or property rights, interests or services, nor shall any independent contractor and/or employee serve as a Director, manager or consultant to any competitor of Caring For Seniors Home Care

    6.  During the term of employment and during the hours of work for which compensation is being received, the independent contractor and/or employee shall devote all his/her time, attention, knowledge and skills solely to the business and interests of the Agency.

    7.  During the term of employment, the independent contractor and/or employee shall not be interested, directly or indirectly, in any manner as partner, officer, director, stockholder, advisor, and employee or in any other capacity in any business similar to the Agency without the consent of the Agency.

    8.  Any independent contractor and/or employee found to have a conflict as described above and who has not received the consent or approval of the Administrator shall be dismissed for cause and all accrued benefits shall be forfeited.

    9.  In the event that employment is terminated for any reason, for a period of one year from the date of termination within the state of Maryland the independent contractor and/or employee shall not, directly or indirectly, either by act or in concert with others:
    • attempt to employ or solicit for employment competitive with the Agency, or any of the Agency’s personnel• seek to influence any independent contractor and/or employee to leave the employment of Caring For Seniors Home Care and or patient to terminate services provided by Caring For Seniors Home Care

    10.  In the event of any breach of the prior representations by an independent contractor and/or employee in violation of his/her obligation as an agent of Caring For Seniors Home Care, compensation shall be made by the violator for the direct or indirect losses incurred thereby.

    11.  Such compensation shall not be construed to limit or exclude any other remedies that might become available to Caring For Seniors Home Care, nor shall any compensation entitle the independent contractor and/or employee to further breach the representations.

    ***** Please Sign and Date, acknowledging that you have received*****


    Independent contractor/employee name (please print)

    The undersigned hereby agrees not to directly or indirectly compete with the business of Caring For Seniors Home Care and its successors and assigns during the period of contractual employment while in the employment of Caring For Seniors Home Care and its clients and following termination of contractual employment and not withstanding the cause or reason for termination.
    The term “not compete” as used herein shall mean that the Contractual Employee shall not own, manage, operate, consult to or be contractual employed in a business substantially similar to or competitive with the present business of Caring For Seniors Home Care or such other business activity in which Caring For Seniors Home Care may substantially engage during the term of contractual employment.
    The Contractual Employee acknowledges that Caring For Seniors Home Care shall or may in reliance of this agreement provide Contractual Employee access to trade secrets, customers and other confidential data and that the provisions of this agreement are reasonably necessary to protect Caring For Seniors Home Care and its good will.
    Contractual Employee agrees to retain said information as confidential and not to use said information on his or her own behalf or disclose same to any third party.
    This agreement shall be binding upon for the benefit of the parties, their successors, and or personal representatives.