HHA Job App | MG Home Care

Hidden
Application Date*
MM slash DD slash YYYY
Hidden
Position Applied for*
Full Name*
Date of Birth*
MM slash DD slash YYYY
Address*
SSN*
Phone Number*
Email*

Job Experience
Please list the names of your present or previous employers/contractors in chronological order with present or most recent employers/contractors listed first. Be sure to account for all periods of time. If self-employed, give firm name and supply business references.
Name of Employer or Contractor*
Supervisor Name*
May we contact them?*
- Yes
- No
Address
Phone Number*
Employed from*
MM slash DD slash YYYY
Employed to*
MM slash DD slash YYYY
Job Title and Duties*
Reason for Leaving
Name of Employer or Contractor*
Supervisor Name*
May we contact them?*
- Yes
- No
Address
Phone Number*
Employed from*
MM slash DD slash YYYY
Employed to*
MM slash DD slash YYYY
Job Title and Duties*
Reason for Leaving
Please list any other experience

Education
Please describe your educational background in the table provided below.
Please select the highest degree completed*
- High School/ GED
- College/University
- Vocational School
School Name*
Years Completed
Graduation Year*
Degree/ Area of Study/ Training*

Personal References
Please list three personal references of individuals who are not related to you. For example, friends, or family members.
Reference #1
Person's Name*
Relationship*
Phone Number*
Email
Reference #2
Person's Name*
Relationship*
Phone Number*
Email
Reference #3
Person's Name
Relationship
Phone Number
Email

Emergency Contact Information
Please list two emergency contacts below.
Emergency Contact #1
Person's Name*
Relationship*
Phone*
Address
Emergency Contact #2
Person's Name*
Relationship*
Phone*
Address

Influenza Vaccination Policy
I am aware of the influenza policy and have had a chance to have my questions answered about influenza vaccination.*
- I agree to have the influenza vaccine for the influenza season. you have already received the influenza vaccine for this influenza season.
- I decline influenza vaccination for the influenza season. I understand that I may rescind this declination at any time.
Please specify reason(s) for the declination:*
- An Allergy
- A compromised immune system
- Previous adverse reaction
- Medical illness or contraindications
- Spiritual and/or religious beliefs
- Without providing reason

Hepatitis B Declaration Form
Hepatitis B is a major infectious occupational health hazard in the Health-Care industry. The critical risk for health personnel is contact with blood and other body fluids. Persons previously infected with hepatitis B virus are immune to the disease, for persons who have not had the disease, the Hepatitis B vaccine will provide immunity. The vaccine is given in three separate doses and failure to receive all doses may cause the vaccine to be ineffective and not result in immunity. Clinical studies have shown that 85 to 96 percent of those vaccinate evidence immunity. Periodic testing of vaccinated persons for antibody to Hepatitis B will confirm immune status. I understand that due to my risk or occupational exposure to blood or other potentially infectious material I may be at risk of acquiring Hepatitis B virus (HBV) infections, I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to my self. I have read the above information and have received verbal and written instructions regarding the efficacy, risk, and complications of receiving the vaccine. Any questions I had have been answered. I acknowledge that I am aware of the availability of the Hepatitis B vaccine and the benefit that such vaccination provides in the prevention of infection with the Hepatitis B virus
I have read the above information and have received verbal and written instructions regarding the efficacy, risk and complications of receiving the vaccine.*
- I decline Hepatitis B vaccination at this time because I have been previously immunized with a complete series (three injections) of the Hepatitis B vaccine or I have been diagnosed as having tine Hepatitis B virus disease and I am immune.
- I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk or acquiring Hepatitis B. If in the future I continue to have occupational exposure to blood or other potentially infectious material and I want to be Vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
- I accept vaccination with the hepatitis B vaccine.

Medical Questionnaire
Height*
Weight*
Please enter a number from 1 to 999.
1. Have you ever had a back injury?*
2. Have you ever had a hematite intervertebral disc in your back?*
3. Have you ever had a back surgery for a removal of a disc?*
4. Have you ever had a neck injury?*
5. Have you ever had a hematite disc in you neck?*
6. Have you ever had a neck surgery for removal of a disc?*
7. Have you ever had a knee injury?*
8. Have you ever had a surgery on either of your knees?*
9. Have you ever had a shoulder injury?*
10. Have you ever had a surgery on either of you shoulders?*
11. Have you ever had an elbow injury?*
12. Do you have or have you ever had an amputation of your foot, leg, arm or hand?*
13. Do you have or have you ever had epilepsy?*
14. Do you have or have you ver had diabetes?*
15. Do you have or have you ever had cardiac disease (heart trouble)?*
16. Do you have or have you ever had Marie-Strum pell disease?*
17. Do you have or have you ever had total loss of sight of one or both eyes or a partial loss of corrected vision of more than 75% bilaterally?*
18. Do you have or have you ever had a cerebral disability from poliomyelitis?*
19. Do you have or have you ever had a cerebral palsy?*
20. Do you have or have you ever had multiple sclerosis?*
21. Do you have or have you ever had Parkinson's disease?*
22. Do you have or have you ever had vascular disorder?*
23. Have you ever had psychoneurotic disability following treatment in a recognized Medical or mental institution, in excess of 6 months?*
24. Do you have or have you ever had hemophilia?*
25. Do you have or have you ever had ankylosis of a major weight-bearing joint?*
26. Do you have or have you ever had hyperinsulinism?*
27. Do you have or have you ever had chronic osteomyelitis?*
28. Do you have or have you ever had thrombophlebitis?*
29. Do you have or have you ever had a total dizziness?*
30. Do you have or have you ever had a magmatic fever?*
31. Do you have or have you ever had a varicose veins or leg ulcer?*
32. Do you have or have you ever had tuberculosis?*
33. Do you have or have you ever had allergies or asthma?*
34. Do you have or have you ever had skin trouble?*
35. Do you have or have you ever had reactions to serum or drugs?*
36. Do you have or have you ever had kidney trouble?*
37. Do you have or have you ever had muscular dystrophy?*
38. Do you have or have you ever had ulcers?*
39. Do you have or have you ever had a head injury?*
40. Do you have or have you ever had a mental retardation?*
41. Do you have or have you ever had cancer?*
42. Do you have or have you ever had any permanent physical condition which constitutes a 20% impairment of a member of the body as a whole?*
43. Are you new or have you ever been obese (30% over normal body weight)?*
44. Do you have or have you ever had arthritis or rheumatism?*
45. Have you ever been treated/advised to seek treatment for alcoholism?*
46. Have you ever had a hernia? If the answer is yes, where is the location of the body?*
47. Have you ever been treated for substance abuse or addiction?*
48. Have you ever had any injury, surgery, or disability which has not been described in the questions above?*
State in detail the nature of the injury, surgery or disability:*
49. Do you have or have you ever had a high blood pressure?*
Consent*
MG HOME CARE SERVICES LLC. and its insurance carrier intend to rely upon the information provided by you in this Questionnaire. It is your obligation to provide truthful and complete information in response to the questions presented below. If it is later determined that you gave an intentional false response, you may be disqualified from receiving workers' compensation benefits. In addition, you may be subject to termination of employment in the event that it is later determined that you deliberately falsified your responses to this Questionnaire.
I understand

Employment Eligibility Verification
I attest, under penalty of perjury, that I am:*
- A citizen of the United States
- A noncitizen national of the United States
- A lawful permanent resident
- An alien authorized to work
Consent*
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am:

Consent*
By checking the following checkbox you are agreeing with all the terms and conditions listed on MG Home Care Consent Policies for HHA/CNA.
Click the following link to see the policies:
Polcies for HHA/CNA

I agree to the terms and conditions below
Signature*
Initials*

Home Health Aide – Job Application

Step 1 of 12 - Personal Information

Job Experience

Education

Personal References

Reference #1

Reference #2

Reference #3

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2

General Information

Availability Questionnaire

Influenza Vaccination Policy

Hepatitis B Declaration Form

Medical Questionnaire

Employment Eligibility Verification