JOB APPLICATION FORM

The purpose of the PPD (Purified Protein Derivative) Intradermal Skin Test is to aid in the detection and diagnosis of Tuberculosis or the Exposure to Tuberculosis.

Answer YES or NO to any of the following symptoms you have had persistently

I, To the best of my knowledge, the above answers are true.

A. Screening Questions for TB Test

Because the infectious status may not be known for every client, it is Important to prevent exposure to the blood and body fluids of all patients. This approach will limit any potential HIV/HBV exposures.

All health care workers should routinely use appropriately barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any patient are anticipated.
Gloves must be worn for touching blood and body fluids, mucous membranes or non-intact skin of all clients and for handling items or surface soiled with blood or body fluids. Gloves must also be worn for performing venipuncture and during vascular access procedures and should be changed after contact with each patient. Hands must be washed immediately upon removal or damaging of gloves.

Masks face shields and protective eyewear should be worn during procedures that are likely to generate droplets of mucous membranes of the mouth, nose and eyes. Long sleeve fluid repellant disposable gowns and/or aprons should be worn and removed immediately if contaminated with blood or other body fluids.

All sharp items should be considered potentially infectious and handled with extraordinary care. Used needles are not to be recapped, broken or purposely bent. All needles and sharps shall be placed In puncture resistant containers.

CATEGORY I: Tasks that involve exposure to blood, body fluids or tissue.

All procedures or other job-related tasks that involve an Inherent potential for mucous membrane or skin contace with blood, body fluids or tissue or a potential for spills or splashes of them, are Category I Tasks. Use of appropriate protective measures is required.
CATEGORY II: Tasks that involve no exposure to blood, body fluids or tissue, but employment may require performing unplanned Category 1 Tasks.

The normal work routine involves no exposure to blood, body fluids or tissues but exposure or potential exposure may be required as a condition of employment. Appropriate measures should be readily available to every employee engaged in Category II Tasks.

AmeriTouch Home Health Services Inc maintains confidentiality of operations, activities, and business affairs of AmeriTouch Home Health Services Inc and the clients according to 1996, Health Information Portability and Accountability Act (HIPAA). Due to the nature of the work, each employee will gain, directly or indirectly, sensitive and confidential information on clients/patients and staff members. The health care professional safeguard the client's right to privacy by judiciously protecting information of a confidential nature including medical treatment information, diagnosis, medical records, personal patient information, etc.

This information should be shared only with those persons who, due to their position, have a need to know. Sensitive or confidential information must never be used as the basis for social conversation or gossip. !f an employee is in doubt as to whether or not certain information may be shared, s/he should consult with his/her supervisor.

AmeriTouch Home Health Services Inc conduct "on hire and random/for cause" drug testing on its employees. AmeriTouch Home Health Sen/ices Inc maintains a drug free workplace policy with regard to the possession, use, distribution and sale of drugs and alcohol.

All employees are prohibited from the unlawful or unauthorized manufacture, distribution, dispensing, possession or use of a controlled substance or any alcoholic beverage while in the workplace or on Company paid time. Violation of this policy can result in disciplinary action, up to and including termination of employment. I acknowledge I have received a copy of AmeriTouch Home Health Services Inc policy on drug testing.

AmeriTouch Home Health Services Inc is committed to providing a work environment, that is free from all forms of discrimination and unlawful harassment including sexual harassment. This policy applies to all employees including management personnel. Sexual harassment is any unwelcome sexual advances either explicit or implicit as a term or condition of employment. Improper behavior may be verbal, visual, or physical in nature and/or the creation of a hostile environment.

Management will investigate complaints of sexual harassment promptly, impartially and without fear of retaliation to the employee. An employee should report the alleged incident immediately and confidentially to the appropriate manager of Human Resources.

AmeriTouch Home Health Services Inc does not reimburse or provide incentives to employees, physicians, durable equipment providers, family or other health professional for patient referrals for home health services. Employees found in violation of this policy will be subject to discipline up to termination of employment.

AmeriTouch Home Health Services Inc does not discriminate against clients or employees based on race, color, religion, age, sex, national origin, martial status, or disability.

AmeriTouch Home Health Services Inc employees will report suspected abuse, neglect and/or exploitation to the state departments of both the Texas Department of Family and Protective Services, the Department of Aging and Disability Services, and AmeriTouch Home Health Services Inc management.

AmeriTouch Home Health Services Inc employees suspected of abuse, neglect, or exploitation will be suspended immediately, an investigation will be conducted, and if the investigation validates the claim, the employee will be terminated.

AmeriTouch Home Health Services Inc is a non-subscriber to workers' compensation insurance. An employee who incurs an injury on the job that requires emergency medical treatment or is life threatening should proceed to the nearest emergency room. Emergency medical treatment (non life threatening) or non-emergency treatment should be referred to AmeriTouch Home Health Services Inc designated clinic.

Notify AmeriTouch Home Health Services Inc of an injury within 24 hours to complete paperwork. Medical expenses for injuries are covered with the exception of the following: employee's willful intent to hurt self or others, intoxication or drug use, horseplay, acts of God, and/or acts of a third party.

AmeriTouch Home Health Services Inc utilizes a progressive discipline process in cases of misconduct or unacceptable performance. This includes verbal warning, written warning and final warning, Disciplinary action may begin at an advanced stage of the process or may result in immediate termination based upon the nature and severity of the offense, employee's past record and other circumstances.

By execution of this document, I acknowledge that I have been informed by the AmeriTouch Home Health Services Inc and agree that AmeriTouch Home Health Services inc, may conduct a State of Texas Criminal History Check and search the Nurse Aide Registry and the Employee Misconduct Registry to determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this agency.

Criminal History Check

I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that I have been employed on an emergency basis and that my employment is temporary pending the results of the Criminal History Check.

(A) A person for whom the facility is entitled to obtain Criminal History Information may not be employed in a facility if the person has been convicted of an offense listed in this subsection: ♦ An offense under Chapter 19, Penai Code (Criminal Homicide) ♦ An offense under Chapter 20, Penal Code (Kidnapping & Unlawful Restraint) ♦ An offense under Section 21.02, Penai Code (Continuous sexual ause of a young child or children) ♦ An offense under Section 21.08, Penal code (Indecent exposure) ♦ An offense under Section 21.11, Penai Code (Indecency with a Child) ♦ An offense under Section 21.12, Penal Code (improper relationship between educator and student) ♦ An offense under Section 21.15, Penal Code (Improper photography or visual recording) ♦ An offense under Section 22.011, Penal Code (Sexual Assault) ♦ An offense under Section 22.02, Penal Code (Aggravated Assault) ♦ An offense under Section 22.021, Penal Code (Aggravated sexual assault) ♦ An offense under Section 22.04, Pena! Code (Injury to a Child, Elderly Individual or a Disabled Individual) ♦ An offense under Section 22.041, Penal Code (Abandoning or Endangering a Child) ♦ An offense under Section 22.05, Penal Code (Deadly conduct) ♦ An offense under Section 22.07, Penal Code (Terroristic threat) ♦ An offense under Section 22.08, Penal Code (Aiding Suicide) ♦ An offense under Section 25.031, Penal Code (Agreement to Abduct from Custody) ♦ An offense under Section 25.08, Penal Code (Sale or Purchase of a Child) ♦ An offense under Section 28.02, Penal Code (Arson) ♦ An offense under Section 29.02, Penal Code (Robbery) ♦ An offense under Section 29.03, Penal Code (Aggravated Robbery) ♦ An offense under Section 33.021, Penal Code (Online solicitation of a minor) ♦ An offense under Section 34.02, Penal Code (Money Laundering) ♦ An offense under Section 35A.02, Penal Code (Medicaid fruad) ♦ An offense under Section 42.09, Penal Code (Cruelty to animals) OR ♦ A conviction under the laws of another state, federal iaw or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection. ♦ An offense the Agency determines to be contraindicated to employment with the consumers the agency serves. (B) A person may also be barred from employment the duties of which involve direct contract with a client in a facility if convicted of any of the following crimes within the past 5 years: ♦ An offense under Section 22.01, Penal Code (Assault), that is punishable as a Class A misdemeanor or as a Felony ♦ An offense under Section 30.02, Penal Code (Burglary) ♦ An offense under Section 31, Penal Code (Theft), that is punishable as a Felony ♦ An offense under Section 32.45, Penal Code (Misapplication of Fiduciary Property or Property of a Financial institution), that is punishable as a Class A Misdemeanor or a Felony; or ♦ An offense under Section 32.46, Penal Code (Securing Execution of a Document by Deception) that is punishable as a Class A Misdemeanor ora Felony. ♦ An offense under Section 37.12, Penal Code (False identification as a peace officer) or ♦ An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (Disorderly conduct) (C) in addition to the prohibitions on employment prescribed by Subsections (A) & (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted: ♦ Of an offense under Section 30.02, Penal Code (Burglary); or ♦ Under the laws of another state, federal law or the Uniform Code of Military Justice for an offense containing elements that are PTHC04/11 substantially similar to the elements of an offense under Section 30.02, Penal Code. (D) In addition to the prohibitions on employment prescribed by Subsections (A), (B) and ( C), a nurse aide listed as unemployable per amendment to TAC 40, 94.10 (I) and 94.11 ( c) (d) and is listed on the NAR or EMR stating a finding of abuse, neglect or misappropriation will not be rectified therefore, is unemployable. (E) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision. (F) I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential.