Apply for Certified Home Health Aide

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Summary
Title:Certified Home Health Aide
ID:1001
Location:Paramus, NJ
Department:Caregiver
Salary Range:$17-$20 per hour
Resume
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Contact Information
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* Last Name:
* Address 1:
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Amada Application
Personal Information
General Availability
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Skills and Preferences
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Education

High School

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College 1

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College 2

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Experience
Do not substitute resume. Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer. If you do not have at least one employer put N/A (not aplicable) for all fields.

Most recent

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Next Most recent

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Next Most recent

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Next Most recent

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Next Most recent

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References

Professional References Only. No Family or Personal Relationships.

Reference 1

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Reference 2

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Reference 3

Reference 4

Reference 5
Additional Questions
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Certification and Release
I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize Amada Senior Care to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.
RESTRICTIVE COVENANT
I agree not to do business directly with any individual or business entity that Amada Senior Care has introduced to me or by entering into employment with such individuals or businesses.
Yes   No
Photo/Video Release
The undersigned enters into this agreement with Amada Senior Care. I have been informed and understand that Amada Senior Care is producing photographs, a video program and/or promotional print pieces where my name likeness, image, voice, appearance and performance is being recorded and made a part of that production ("Product and or Promotional Material")
1) I hereby consent to any recording of myself and of my personal effects or domicile, which were incident to my appearance, on any medium whatsoever by Amada Senior Care its agents, or employees.
2) I authorize the use of such recordings without compensation and without notifying me for any promotional or commercial purposes by Amada Senior Care. This grant includes without limitation the right to edit, mix or duplicate and to use or re-use the Product and material in whole or part as Amada Senior Care may elect
3) Amada Senior Care or its designee shall have complete ownership of the Product and material in which I appear, including copyright interests, and I acknowledge that I have no interest or ownership in the Product, material or its copyright.
4) Amada Senior Care may use my name, voice, likeness and biography in conjunction with the product and or promotional material.
5) I warrant and represent and that all information and material furnished by me is my own or that I have full authority to use it for such purposes.
6) I expressly release and indemnify Amada Senior Care and its officers, employees, agents, and designees from any and all claims known and unknown arising out of, or in any way connected with, the above granted uses and representations.
7) The rights granted to Amada Senior Care herein are perpetual and worldwide.

I HAVE READ AND UNDERSTOOD THE CONTENTS HEREOF, AND AGREE TO ALL OF THEM.
Confidentiality/HIPAA Agreement
This Confidentiality/HlPAA Agreement between Amada Senior Care (hereinafter "Company") and, [PRINT NAME BELOW] (hereinafter "Employee'), is effective as of date below.

CONFIDENTIALITY/APPLICATION OF HIPAA
Employee agrees to maintain the confidentiality of all Company and Client information and affairs. All records containing Company' Client names, addresses and other information must be surrendered upon termination of Employment. Except as required in the performance of services hereunder, Employee will not, during the term of employment or after termination, use or disclose any confidential or proprietary information of Company or Client, or Client's patients, without first obtaining the consent of Company and, where appropriate, Client and patient. In addition, Employee agrees to maintain the confidentiality of information about Employee's wages and other compensation. Employee agrees to maintain the confidentiality of all Company and Client information and affairs. To the extent that Employee and Company may qualify as a "business associate" as defined by the Health Insurance Portability and Accountability Act of 1996 ('HIPAA"), and privacy regulations published by the U.S. Department of Health and Human Services contained at 45 CFR 160 and 164 ("HIPAA Regulations"), which may be periodically revised or amended, and other applicable laws, Employee and Company agree to protect and provide for the privacy and security of Protected Health Information ("PHI"), as defined by HIPAA. The parties agree as follows:
a. Employee and/or agents shall use appropriate safeguards to prevent the use and/or disclosure of all PHI relating to the patients, patients' family members, Clients' employees, Company's employees and other healthcare providers - made available by or obtained from Patient, Client or Company.
b. Employees disclosure of PHI shall be limited to only those purposes that are necessary to perform its employment obligations and specifically detailed in Employee's job responsibilities, unless otherwise agreed by the Parties.
c. Employee shall not: (a) use or further disclose any PHI except as provided with the prior written approval of Company and Client; or (b) use or further disclose any PHI in a manner that would violate the provision of HIPAA or its regulations. Employee shall immediately report to Company and Client in a timely manner any unauthorized use or disclosure of PHI of which the Employee becomes aware.
d. Upon termination of Employment, Employee shall return all PHI that Employee maintains in any form and retain no copies of such PHI without the prior written approval of Company and Client. If Employee is unwilling or unable to return such PHI, Employee shall destroy all PHI, regardless of whether its form is paper or electronic.
e. Employee will indemnify, hold harmless and defend Company and Client from and against any and all claims, losses, liabilities, costs and other expense incurred as a result or arising directly or indirectly out of or in connection with any unauthorized use or disclosure of PHI by Employee.
This provision is not intended to restrict or otherwise limit the application of HIPAA to the parties. This provision is intended only to outline the parties' general duties as required by HIPAA. Employee and Company recognize that they are fully subject to all provisions of HIPAA, regardless of whether these provisions are outlined in the above provision. This HIPAA provision shall survive the termination of this Agreement.

I HAVE READ AND UNDERSTOOD THE CONTENTS HEREOF, AND AGREE TO ALL OF THEM.
Authorization to Verify Employment
This Authorization to Verify Employment between Amada Senior Care (hereinafter "Company") and, [PRINT NAME BELOW] (hereinafter "Employee'), is effective as of date below.

AUTHORIZATION TO VERIFY EMPLOYMENT
I authorize Amada Senior Care and any of its subsidiaries, affiliates or related entities to conduct a thorough reference check process in connection with my application for employment, or with my employment thereafter with Amada Senior Care. In connection with such investigations, I authorize any and all corporations, companies, or agencies to furnish Amada Senior Care, or any agent acting on its behalf, with information concerning me relevant to my application, including information about my employment record, work performance, abilities or other qualities pertinent to my qualification for employment. I hereby release Amada Senior Care and any representatives of the company from all liability for damages of whatever nature arising from furnishing the requested information.
By signing below, I authorize Amada Senior Care, or any representatives thereof, to conduct a thorough reference with those listed on my application. I agree that a photocopy/fax of this form is as valid as the original.
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
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Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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