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Caregiver Application - Community Care
Application Type:
*
CDPAP PA
HHA / PCA
First Name
*
Middle Name
Last Name
*
Address 1
*
Apt #
City
*
State
*
New York
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Cell Phone
*
Email
*
Languages
*
English
Spanish
Albanian
Arabic
Bassa
Bengali
Burmese
Cambodian
Cantonese
Chin
Chinese
Creole
Farsi
French
Georgian
Greek
Hebrew
Hindi
Hindu
Hungarian
Italian
Karen
Karenni
Khmer
Korean
Mandarin
Nepali
Persian
Polish
Punjabi
Russian
Swahili
Tedim
Ukrainian
Urdu
Uzbek
Vietnamese
Yiddish
Zomi
County
*
Suffolk
Nassau
Westchester
Sullivan
Rockland
Orange
Putnam
Monroe
Wayne
Orleans
Ontario
Livingston
Erie
Genesee
Niagara
Queens
Bronx
Richmond
Kings
New York
Position
*
HHA
PCA
LPN
RN
PA (CDPAP)
Corporate Admin
Last 4 of SSN:
*
Emergency Contact Info:
Primary Emergency Contact Name:
*
Primary Emergency Contact Relationship
*
Primary Emergency Contact Number:
*
Primary Emergency Contact Address:
*
Secondary Emergency Contact Name:
*
Secondary Emergency Contact Relationship:
*
Secondary Emergency Contact Number:
*
Secondary Emergency Contact Address:
*
Human Resources
Are you at least 18 years old or older?
*
Yes
No
Are you currently employed?
*
Yes
No
Have you recently served in Military/National Guard/Reserve?
*
Yes
No
Have you ever worked for CCHHS?
*
Yes
No
How did you hear about us?
*
ZipRecruiter
Monster
Field Recruiter
Lawn Sign
Walk-In
Care.com
Craigslist
myCNA
Job Fair
Marketing Material
Employee Referral
LinkedIn
Facebook
Indeed
Name
Referral Person:
Primary Transportation
*
Car
Bus
Train
Other
Willing to travel?
*
Yes
No
Gender
Male
Female
W-4 / I-9 / IT-2104:
Citizenship Status:
*
A lawful permanent resident
An alien authorized to work
A non-citizen of the U.S.
A citizen of the U.S.
USCIS #:
USCIS #
SSN:
D.O.B
*
Are you eligible to work in the US?
*
Yes
No
Tax Filing Status:
*
Single or Married filing separately
Married filing jointly or Qualifying surviving spouse
Head of Household
Number of Dependents: (under age 17)
*
o
1
2
3
4
5
6
7
8
9
10
Other Dependents:
*
o
1
2
3
4
5
6
7
8
9
10
Do you reside in NYC?
*
Yes
No
Do you reside in Yonkers?
*
Yes
No
Direct Deposit:
Name of Bank
*
Account Type
*
Checking
Savings
Routing Number
*
Account Number
*
Equal Employment Opportunity:
EEO Status: Ethnicity
*
Hispanic or Latino
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Two or more races
EEO Status: Veteran
*
Yes
No
I do not wish to self-identify
EEO Status: Disability
*
Yes
No
I do not wish to self-identify
Medical - Have you received the following:
HEP-B vaccine:
*
I choose to decline and proceed
I choose to accept and receive the Hep B vaccine
I’ve already received the Hep B vaccine and can provide proof
Influenza Vaccine:
*
Yes
No
I decline
Covid-19 Vaccine:
*
Pfizer
Moderna
Johnson & Johnson
Not Vaccinated
Covid-19 Booster:
*
Pfizer
Moderna
Johnson & Johnson
N/A
Branch
*
Buffalo
Rochester
Smithtown
White Plains
Corporate
Queens
Education/Licensure: (if applicable)
Highest level of education received?
*
High school or equivalent
College
Trade School
Other
License / Certification:
HHA
PCA
CNA
LPN
RN
License / Certification Number:
Expiration Date:
Employment History: (if applicable)
Company Name:
*
Company Phone Number:
*
Start / End Date:
*
Reason for Leaving:
*
Reference/s: (if applicable)
Name:
*
Title:
Company:
*
Phone #:
*
Years Acquainted:
Name
*
Title
Company
*
Phone #
*
Years Acquainted
Background Check: (if applicable)
Country of Birth:
*
Maiden Name:
*
Mothers Maiden Name:
Race:
*
Hispanic or Latino
White
Black or African American
Asian
American Indian or Alaskan Native
Two or more races
Height: Ft:
*
Height: In:
*
Weight:
*
Eye Color:
*
Blue
Brown
Grey
Green
Hazel
Hair Color:
*
Black
Brown
Grey
Red
Blonde
White
Bald
Have you ever been convicted of a crime in NYS or any other jurisdiction?
*
Yes
No
Do you have a final finding of patient or residential abuse?
*
Yes
No
Consumer Info: (if applicable)
Consumer Name:
*
Consumer Address:
*
Relationship to Consumer:
*
Do you reside with the Consumer?
*
Yes
No
Are you the designated representative for the Consumer?
*
Yes
No
Is the Consumer under 21 years of age?
*
Yes
No
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