* Required Information










Pre-Employment Medical History and Mobility Evaluation

Before an offer of employment can be made, the section below must be completed. Skillcare Home Health Services Inc, is an equal opportunity employer who affirmatively seeks to employ qualified handicapped individuals. The following evaluation will assist us in efforts to reasonably accommodate our work environment to your needs.


In making application for employment:

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.

I understand, if I am an unlicensed person who has face-to-face patient/client contact, that the agency will perform a criminal history check per State Regulations as well as a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in DADS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Department of Aging and Disability Services(DADS) and they review and investigate allegations of abuse,neglect, or misappropriation of resident property by nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All DADS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Regis try before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore,unemployable.


I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/ Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.

Skillcare Home Health Services Inc. maintains confidentiality of operations, activities, and business affairs of Skillcare 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. If an employee is in doubt as to whether or not certain information may be shared, she should consult with his/her supervisor.
Drug Test Policy
Skillcare Home Health Services Inc. conduct "on hire and random/for cause" drug testing on its employees. Skillcare Home Health Services 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 Skillcare Home Health Services Inc. policy on drug testing.
Harassment Policy
Skillcare 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 behaviour 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.
Non Solicitation/Illegal Remuneration
Skillcare 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.
Non Discrimination
Skillcare Home Health Services Inc. does not discriminate against clients or employees based on race, color, religion, age, sex, national origin, martial status,or disability.
Abuse, Neglect, And Exploitation
Skillcare 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 Skillcare Home Health Services Inc. management. Skillcare 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.
Worker's Compensation
Skillcare 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 Skillcare Home Health Services Inc. designated clinic. Notify Skillcare 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 wilful intent to hurt self or others, intoxication or drug use, horseplay, acts of God, and/or acts of a third party.
Disciplinary Action Policy
Skillcare 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 offence, employee's past record and other circumstances.
Agency Policies

I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. I understand that copies of the policy and procedure manuals are available, and that ii is my responsibility to read, understand and confirm to all applicable agency policies including personnel policies It is also my responsibility to comply with periodic changes and revisions.


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 s kin and mucous membrane exposure when contact with blood or other body fluids of any patient are anticipated.

G loves must be worn for touching blood and body fluids, mucous membranes or non-intact skin of a ll 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 eye wear should be worn during procedures that are likely to generate droplets of mucous membranes of the mouth, nose and eyes. Long sleeve fluid repellent 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 contact 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 I 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.


I have read the above and have been instructed in the techniques of universal precautions and the Skillcare Home Health Services Inc, exposure control plan for bloodborne pathogens. If I choose to disregard the above standards, I realize I am doing so against Skillcare Home Health Services Inc, policy and OSHA standards.

I understand the potential dangers of recapping needles and of the failure to take adequate precautions to prevent or decrease the risk of exposure to blood and body fluids.

I also understand infractions of this policy will result in disciplinary action against me ranging from verbal counselling to termination.


I have received a copy of the Skillcare Home Health Services Inc, Employee Handbook. This handbook contains policies, procedures, practices and regulations which I have read and understand and will comply with during my employment with Skillcare Home Health Services Inc

RECEIPT OF EMPLOYEE HANDBOOK I have received a copy of the Skillcare Home Health Services Inc, Employee Handbook. This handbook contains policies, procedures, practices and regulations which I have read and understand and will comply with during my employment with Skillcare Home Health Services Inc I understand that no supervisor, manager or representative of Skillcare Home Health Services Inc other than the Administrator of Skillcare Home Health Services Inc has the authority to make any agreement contrary to the terms of this handbook.

I understand that the information contained in this handbook applies to all employees of Skillcare Home Health Services Inc,

I further understand that it is presented as a matter of information only and its contents should not be interpreted as a contract between Skillcare Home Health Services Inc and any of its employees.

I hereby agree not to discuss, copy, print or distribute data about any patient, supplier or employee unless it is for official business purposes. Salaries, wages, expenses, funding sources, medical information and any other such data are not to be discussed under any circumstances. This information can only be used within the context of professional discussions, official business and legitimate need to know.