A physical examination is required of all job applications, which includes testing for drug use, to verify fitness to work after a job offer is extended, but prior to beginning work. The results of such an examination will not be used to disqualify an applicant except to the extent that any disability discovered would, even with reasonable accommodation, preclude the safe adequate performance of the job in question.

I certify that the above information is complete and true to the best of my knowledge. I understand that discovery of misrepresentation or omission of facts on my application may result in immediate dismissal.

I understand that in making this application for employment, People Care or any agent acting on the behalf may request an investigative consumer report containing information obtained through personal interviews with third parties such as neighbors, friends, business associates, financial sources, and acquaintances. This inquiry includes information as to character, general reputation, personal characteristics, and mode of living, whichever may be applicable.

I further understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of the investigation.

I authorize all persons, schools, companies, corporations and law enforcement agencies to release any information concerning my background, and I hereby release them and People Care from any and all claims of liability in law and inequity that may arise out of obtaining such information.

I understand that this application does not constitute an employment contract with People Care and me and that, if hired, my employment is for no fixed duration and can be terminated at any time with or without notice or cause either at my option or People care's.

* Date

* Date

NYS Department of Health ACKNOWLEDGEMENT AND CONSENT FORM FOR FINGERPRINTING AND DISCLOSURE OF CRIMINAL HISTORY RECORD INFORMATION THIS FORM IS TO BE RETAINED BY THE AGENCY- DO NOT FORWARD TO THE DOH CHRC UNIT. chrc@health.state.ny.us

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

Section 2 - Attestation
1.	I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI).
2.	I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI.
3.	I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary to be provided to the agency to which I applied for a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I have a criminal history, as maintained by DCJS or the FBI, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. I have been advised that by law, DOH is authorized and may be to provide the results of the criminal history record check through a criminal history record summary to the agency. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be disclosed to persons authorized by law.
4.	I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place.
5.	I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI.
6.	I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information.
7.	I certify to the best of my knowledge and belief that I (check as appropriate): Have Have not been convicted of a crime in New York State or any other jurisdicti Do Do not have a final finding of patient or resident abuse If you have checked either "Have" and/or "Do", please provide a brief explanation. (Optional)
8.	My current mailing or home address is indicated in Section 1 of this form
9.	I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own (not applicable for Expedited Review submitted pursuant to CHRC Form 104).
NOTE: a criminal conviction will not necessarily be a bar to employment. People Care will carefully determine eligibility on a case by case basis, considering factors such as the nature of and details concerning the conviction(s); the duties and responsibilities of the position applied for; when the conviction(s) occurred, etc.

* Date

Date

* Date

Name of Employee

Social Security Number

Reason for declining

* Date

People Care, Inc. strongly encourages all staff to get flu vaccine during flu season.

I have had the opportunities to discuss the statement and have my questions answered by a healthcare provider .I am aware of the following.

I understand the following :

• The purpose of the need for the vaccine.
• The risk and benifits of the vaccine.
• The CDC Advisory Committee on Immunization Practices, and the New York State Department of Health have dstrongly recommended that the vaccine be given to all perones who have been screened and determined to be candidates for the vaccine.
• I understand that I cannot get the flu from the Influenza vaccine.

Nevertheless, I have decided to decline the vaccine for one of the following reasons and understand thet I must provide valid documentation as proof from an authorized source:

Religious Reasons

Medical Reasons

Others

If I am exempt from receiving the Influenze vaccine, I understand that I must wear a surgical or procedure mask within three(3) feet of the patient .I understand that if I am non-compliant with wearing the mask, a written warning will be given for the first offence and second offence will result in tremination of employment.

I also understand that the RN Field Nurse supervisor will observe that I am compliant with use of mask while delivering care to my patient.

I know that failure to follow the recommendations about vaccination may endanger my health, and the health of others Imay come in contact with should I become infected.

I know that I may re-address this issue with my health care provider at any time and accept vaccination in the future.

I acknowledge that have read this documentation inits enitrity an fully understand it .

* Date

* Date