HHA Registry Form-2024 - w HIPAA DD 1

Full Name 姓名(必填)
mm/dd/yyyy
Address 地址(必填)

Authorization for Direct Deposit – Employee Form 員工直接存款授權

Deposit Amount 金額:
Please enter a number greater than or equal to 0.
Please enter a number from 0 to 100.
Account Type 賬戶類型

EMPLOYMENT APPLICATION FORM 工作申請表 HHA/PCA

Hidden
Please enter a number greater than or equal to 0.
feet ' inches
Sex 性別(必填)
Rehired? 重新入職?(必填)
Marital Status 婚姻狀況(必填)

緊急聯絡人信息

General Questions 請答回以下問題

1. Have you previously been employed at Golden Touch? 你是否曾經受僱於萬有護理公司?(必填)

If Yes 如果選擇是

2. Are you over the age of 18 你是否18 滿歲?(必填)
3. If hired, can you provide proof of citizenship or legal right to work in the United States? 如果受雇,你是否能提供在美國合法工作的證明?(必填)
4. Have you been convicted of a felony other than a traffic violation? 是否犯過除交通違規以外的重罪(必填)

PLEASE NOTE: a conviction record does not necessarily disqualify you for employment.
請注意:定罪記錄並不一定會取消您的就業資格

Language 語言
Availability 可工作時間
Availability Time Range 具體時間
Monday 週一 Time
Tuesday 週二 Time
Wednesday 週三 Time
Thursday 週四 Time
Friday 週五 Time
Saturday 週六 Time
Sunday 週日 Time
 
Work Area 工作區域(必填)

Work Related Questions 工作相關問題

1. Do you drive? 你是否會開車?(必填)
2. Do you smoke 你是否抽煙?(必填)
3. Are you ok with working in an environment where there's smoking? 你是否能在有人抽煙的環境中工作?(必填)
4. Are you ok with working in an environment where there are pets? 你是否能接受在有寵物的環境中工作?(必填)

EMPLOYMENT HISTORY 過往工作經驗

May we contact your employer? 是否可以聯繫?
May we contact your employer? 是否可以聯繫?

EDUCATION & TRAINING 培訓

Graduated 是否畢業
Graduated 是否畢業
Graduated 是否畢業

REFERENCES 推薦人

Influenza Vaccination Employee Statement 已打針或同意打針簽字表

Consent 已打針或同意打針簽字表 Vaccine to Golden Touch Home Health LLC Employees. I am aware of the influenza policy and have had a chance to have my questions answered about influenza vaccination. I understand the benefits and risks of the vaccine, and:為 Golden Touch Home Health LLC 員工接種疫苗。 我了解流感政策,並且有機會得到有關流感疫苗接種的問題的解答。 我了解疫苗的益處和風險,並且:

Declination of Influenza Vaccination for Health Care Personnel 不打針戴口罩簽字表

I have been advised that I should receive the influenza vaccine to protect myself and patients I serve I have read the Center for Disease Control and Prevention’s (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have read had the opportunity to discuss the statement and have my questions answered by a HR officer. I am aware of the following facts:
我被建議應該接種流感疫苗以保護自己和我所服務的病人 我已閱讀疾病中心的內容 控制與預防 (CDC) 的疫苗資訊聲明解釋了疫苗及其預防的疾病。 我讀過 有機會討論該聲明並讓人力資源官員回答我的問題。 我了解以下事實:
不打針戴口罩簽字表
Consent 不打針戴口罩簽字表

HEPATITIS B VACCINATION ACCEPT / DECLINE FORM 乙型肝炎疫苗接種接受/拒絕表

I am an employee of Golden Touch Home Health LLC and I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B at this time. I under-stand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me. 我是 Golden Touch Home Health LLC 的員工,我了解,由於我在職業上接觸血液或其他潛在傳染性物質,我可能面臨感染乙型肝炎 (HBV) 的風險。 此時我有機會接種B型肝炎疫苗。 我了解,如果拒絕接種該疫苗,我將繼續面臨感染B型肝炎(一種嚴重疾病)的風險。 如果將來我想接種B型肝炎疫苗,我可以免費接種該系列疫苗。

I 本人

RECEIPT OF EQUIPMENT 設備接收

ACKNOWLEDGMENT TO THE CAREGIVER HANDBOOK (Golden Touch Copy for Employee File)對看護者手冊的確認(萬有護理公司的員工檔案副本)

NOTICE AND ACKNOWLEDGEMENT FOR LIVE-IN CAREGIVER UNDER NEW YORK STATE LABOR LAWS根據紐約州勞動法對住家保母的通知和確認

Medical Benefit Coverage Waiver Request Form 免除醫療福利申請表

On behalf of myself and my eligible dependents (if any), I waive the option to enroll in health insurance offered at this time by or through my employer for the following reasons:

出於以下原因,本人及受撫養人現放棄參加由/ 通過我僱主提供的醫療保險:

Waiving Health Coverage 放棄醫療保險(Please select one of the following 請選擇以下一項)(必填)

HIPAA Privacy Authorization Form 隱私授權表格

This form is used to authorize consent for Golden Touch Home Health LLC and its’ affiliates to communicate PHI to the person or organization below.

此表格用於授權萬有護理公司及其附屬機構同意將客戶健康信息機密與以下 人員或組織進行溝通。

Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law for Home Care Aides Wage Parity and Other Jobs 根據《紐約州勞動法》第 195.1 條關於家庭護理助理工資平等和其他工作的工資率和發薪日的通知和確認

· Employee’s Rate(s) of Pay for Each Type of Work Shift: $18.55 per hour for Regular Rate
每種輪班類型的員工薪資:正常薪資每小時 18.55 美元

· Wage Parity Rates: $2.54 Per hour for supplemental wages*
工資平等率: 每小時 2.54 美元的補充工資*

· Overtime Pay Rate(s) for each type of work or shift: Single Pay Rate: $27.825 per hour This must be at least 1½ times the worker’s regular rate with few exceptions.
每種類型的加班費率 工作或輪班: 單次薪資:每小時 27.825 美元 除少數例外情況外,這必須至少是工人正常工資的 1.5 倍。

· Wage Parity Pay Rate: $0 per hour This must be at least 1½ times the worker’s regular rate with few exceptions.
工資平等工資率:每小時 0 美元 除少數例外情況外,這必須至少是工人正常工資的 1.5 倍。

· Multiple Pay Rates: $0 per hour This must be at least 1½ times the worker’s Weighted average of the multiple rates of pay for the week, with few exceptions.
多種工資率:每小時 0 美元 這必須至少是工人多重費率的加權平均值的 1.5 倍 支付一周的工資,少數情況例外。

Check one:選擇一項:
I have been given this notice in my primary language.

LS 62 Notice to Wage Parity Home Care Aides - (cont’d)
Benefit Portion of Minimum Rate of Home Care Aide Total Compensation
LS 62 家庭照顧者同工同酬通知 -(續)
家庭護理員總報酬最低費率的福利部分

Hourly RateType of SupplementName & Address of ProviderAgreement/ Plan Information
Supplement Number$ XXX(Pension, Welfare,or Other)Insert Name and Address of
Company or Organization Providing Benefit
Identify plan or agreement that creates the benefit,
e.g., Union Local No. 1 Collective Bargaining
Agreement or Insurance
Company X Benefit Plan
Supplement Number 1
1. Hourly Rate 薪酬
1. Type of Supplement 类型
1. Name & Address of Provider 提供者的名稱和地址
1. Agreement Plan Information 協定/ 計劃資訊
 
Supplement Number 2
2. Hourly Rate 薪酬
2. Type of Supplement 类型
2. Name & Address of Provider 提供者的名稱和地址
2. Agreement Plan Information 協定/ 計劃資訊
 
Supplement Number 3
3. Hourly Rate 薪酬
3. Type of Supplement 类型
3. Name & Address of Provider 提供者的名稱和地址
3. Agreement Plan Information 協定/ 計劃資訊
 
*If wage supplements are paid as a single payment owed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

List any additional benefits and attach listing to this document.
*如果工資補貼作為單一款項支付給多個 Taft-Hartley 多雇主計劃,僅列出以下內容: (1) 補貼支付總額 或福利包; (2)一攬子福利中包含的福利類型,例如退休金、健康和福利或其他; (3) 接收單位的名稱和地址 付款已發送; (4) 作為協議的相關 CBA 或同意書。

列出任何其他好處並將清單附加到本文檔中。

8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit 8850 工作機會信用預篩選通知和認證請求

Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.
Check if apply. 勾選以下符合您的項目。

W4 Employee’s Withholding Certificate W4 員工預扣稅證明

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Give Form W-4 to your employer. Your withholding is subject to review by the IRS. 填寫 W-4 表格,以便您的雇主可以從您的薪水中預扣正確的聯邦所得稅。 將 W-4 表格交給您的雇主。 您的預扣稅款須接受美國國稅局 (IRS) 的審查。

Claim Dependent and Other Credits
索賠受扶養人和其他信用

(optional選填): Other Adjustments 其他調整

USCIS Form I-9 Employment Eligibility Verification USCIS I-9 表格就業資格驗證

Department of Homeland Security U.S. Citizenship and Immigration Services 國土安全部美國公民及移民服務局
Check one of the following boxes to attest to your citizenship or immigration status: 選中以下複選框之一以證明您的公民身份或移民身份:(必填)

If you check Item Number 4., enter one of these:如果您選擇第4項,請輸入以下內容之一:

Form I-9 Acceptable Documents I-9 表格可接受的文件

LIST ALIST BLIST C
1. U.S. Passport or U.S. Passport Card
美國護照或美國護照卡
1. Driver's license or ID card issued by a State or
outlying possession of the United States
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
美國各州或邊遠領地核發的駕駛執照
或身分證 只要它包含照片或 姓名、
出生日期等信息, 性別、身高、眼睛顏色
和地址
1. A Social Security Account Number card,
unless the card includes one of the following
restrictions:
(1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
社會安全帳號卡,
除非該卡包含以下內容之一 限制:
(1) 不適用於就業
(2) 僅適用於工作 INS授權
(3) 僅適用於工作 國土安全部授權
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
永久居民卡或外國人
登記收據卡(I-551 表)
2. ID card issued by federal, state or local
government agencies or entities, provided it
contains a photograph or information such as
name, date of birth, gender, height, eye color,
and address
由聯邦、州或地方政府機構或實體簽發的
身份證 只要它包含照片或 姓名、
出生日期等信息, 性別、身高、眼睛顏色
和地址
2. Certification of report of birth issued by the
Department of State (Forms DS-1350,
FS-545, FS-240)
由出生證明書籤發的證明
國務院(表格 DS-1350,
FS-545、FS-240)
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a
machine readable immigrant visa
外國護照在機器可讀移民
簽證上包含臨時 I-551 印章
或臨時 I-551 印刷註釋
3. School ID card with a photograph
附照片的學校身分證
3. Original or certified copy of birth
certificate issued by a State, county,
municipal authority, or territory of
the United States bearing an official seal
由美國州、縣、市當局或領地
簽發並加蓋公章的
出生證明正本或核證副本
4. Employment Authorization Document
that contains a photograph (Form I-766)
就業授權文件
內含照片(I-766 表格)
4. Voter's registration card
選民登記卡
4. Native American tribal document
美洲原住民部落文獻
5. For an individual temporarily authorized
to work for a specific employer because
of his or her status or parole:
a. Foreign passport; and
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the
passport; and
(2) An endorsement of the
individual's status or parole as
long as that period of
endorsement has not yet
expired and the proposed
employment is not in conflict
with any restrictions or
limitations identified on the form.
對於因身分或假釋而暫時被授權
為特定雇主工作的個人:
a. 外國護照; 和
b. I-94 表格或 I-94A 表格包含以下內容:
(1)姓名與護照一致; 和
(2) 對個人身分或假釋的認可,
只要認可期限尚未到期,
且擬議的就業不與表格上
確定的任何限製或限制相衝突。
5. U.S. Military card or draft record
美國軍人卡或徵兵記錄
5. U.S. Citizen ID Card (Form I-197)
美國公民身分證(I-197表)
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of the
Marshall Islands (RMI) with Form I-94 or
Form I-94A indicating nonimmigrant
admission under the Compact of Free
Association Between the United States
and the FSM or RMI
密克羅尼西亞聯邦(FSM)
或馬紹爾群島共和國(RMI)
的護照,附有I-94 表格
或I-94A 表格,表明
根據美國與密克羅尼西亞聯邦
或馬紹爾群島自由聯繫
協定的非移民入境資格
6. Military dependent's ID card
軍人家屬身分證
6. Identification Card for Use of Resident
Citizen in the United States (Form I-179)
美國居民公民使用的身份證(I-179 表)
7. U.S. Coast Guard Merchant Mariner Card
美國海岸防衛隊商船水手卡
7. Employment authorization document
issued by the Department of Homeland
Security
For examples, see Section 7 and
Section 13 of the M-274 on
uscis.gov/i-9-central.
The Form I-766, Employment
Authorization Document, is a List A, Item
Number 4. document, not a List C document.
國土安全部簽發的就業授權文件
例如,請參閱 M-274 的第 7 節和第 13 節
uscis.gov/i-9-central。
I-766 表(就業授權文件)
是清單 A,項目編號 4. 的文件,
而不是清單 C 文件。
8. Native American tribal document
美洲原住民部落文獻
9. Driver's license issued by a Canadian
Citizen in the United States (Form I-179)
government authority
由加拿大公民在美國政府機構
簽發的駕駛執照(I-179 表)
For persons under age 18
who are unable to present
a document listed above:
對於無法出示上述文件的
18 歲以下人士:
10. School record or report card
學校記錄或成績單
11. Clinic, doctor, or hospital record
診所、醫生或醫院記錄
12. Day-care or nursery school record
日託或託兒所記錄

Employer Review and Verification: Documentation from List A OR a combination of documentation from List B and List C above
雇主審查和驗證:清單 A 中的文件或上述清單 B 和清單 C 中的文件組合

List A 列表 A
Document Title 證件名稱
Issuing Authority 簽發機關
Document Number (if any) 證件號碼
Expiration Date (if any) 過期日期
 
List B 列表 B
Document Title 證件名稱
Issuing Authority 簽發機關
Document Number (if any) 證件號碼
Expiration Date (if any) 過期日期
 
List C 列表 C
Document Title 證件名稱
Issuing Authority 簽發機關
Document Number (if any) 證件號碼
Expiration Date (if any) 過期日期
 

NEW YORK STATE DEPARTMENT OF HEALTH 紐約州衛生部

Criminal History Record Check 犯罪記錄檢查
Have you been convicted of a crime in New York State or any other jurisdiction? 您是否在紐約州或任何其他司法管轄區被定罪?(必填)
Do you have a final finding of patient or resident abuse?您是否有虐待患者或居民的最終調查結果?(必填)
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If subject individual is under 18 years of age(如果申請人未滿 18 歲)

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(Optional 選填) Preparer and/or Translator Certification 準備者和/或翻譯者認證

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
我證明,我已盡力協助填寫此表格,如有偽證,願受處罰。 知識資訊真實且正確。

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Preparer or Translator Name
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Preparer or Translator Address 準備者或翻譯者地址
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MM slash DD slash YYYY
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