Initial Employment Consents

Touch of Class

Initial Employment Consents

Bloodborne Pathogens In-service Receipt

I have completed in-service training regarding Bloodborne Pathogens according to the guidelines required by OSHA and the State of Texas Regulations. I have received the handouts provided.

Hepatitis B vaccination series

I elect ____to have / ____not to have the series of Hepatitis B vaccinations given to me by the health provider assigned by my employer. I understand that this vaccination is given to me at no cost.

Emergency Preparedness – (Emergency Preparedness Response Plan). I understand that I am responsible for reading and understanding the policies described within it. I have been given a written copy of this policy.

I agree to abide by the policies and procedures contained in this Plan. I understand that the policies and procedures contained in this plan may be added to, deleted or changed by Touch of Class at any time. I understand that neither this policy nor any other communication by management is intended to, in any way, create a contract of employment.

If I have questions regarding the content or interpretation of the Emergency Preparedness Response Plan I will bring them to the attention of my supervisor.

Authorization Criminal History Check & Misconduct Reg. - I understand and agree to allow Touch of Class to do the required Criminal history and misconduct reg.check prior to employment and then on an annual basis.

Authorization for Annual Employability Status Check- I understand and agree to allow Touch of Class to do the required Employability Status check.

OIG - I acknowledge that I agree to allow Touch of Class to check of my name with the Office of Inspector General for the purpose of checking the Excluded Individuals and Entities database.

Release of Information – I give Touch of Class the right to contact and obtain information from all references, employers, educational institutions, and to otherwise verify the accuracy of the information contained in this application.

I hereby release from liability Touch of Class and its representatives from seeking, gathering, and using such information and other persons, corporations or organizations for furnishing such information.

A copy of this release shall be valid as the original.

HIPPA Employee – I have received a copy of the HIPAA and I understand that due to the nature of my position, I will have access to information of a confidential nature regarding the participant (s) with whom I work. I agree that any information regarding the individual (s) with whom I work will be kept strictly confidential. This includes the name of the individual (s) unless the participant has directed me otherwise. I will not participate in discussions regarding the individual or their service delivery unless it is with the participant and / or legal designated representative or supervisory staff at Touch of Class. The Agency is required by law to abide by the HIPAA Privacy Rule to maintain the privacy of the participant (s) health information. I agree to abide by the HIPAA Privacy Rule and have received information regarding HIPAA.

Participant Rights & Responsibilities - I have read and understand the policy on participant rights and responsibilities.

Abuse, Neglect & Exploitation – I have received a copy of the ANE Policies & Procedures.

Drug Use Policy – I have received and understand the agency policy for drug testing on any Touch of Class employees who have direct contact with clients

Worker’s Compensation – I have been made aware that Touch of Class does not have worker’s compensation and have received the policy and procedure regarding this issue.

Receipt of Policy & Procedure Manual- I have received the policy and procedure manual and will bring any questions I have to the attention of my supervisor.

Solicitation -I have read and understood the solicitation policy.

Rights of the Elderly - I have received and understand the policy regarding the Rights of the Elderly.

Grievance – I received and understand the Grievance policy.

Disposal Tips – I have been informed of and understand the proper methods of disposal for generated wastes.

Transportation PolicyI have received and understand the Transportation Policy.

Back Support– I have also received the Policy regarding Back Support.

I want a back support provided by Touch of Class.

I acknowledge that Touch of Class has offered a Back Support and I voluntarily waive receipt of support

False Claims - I have read and understand the Employee Education about False Claims Recovery. I have also received a copy of the above information.

Non Disclosure of Conf Info– I have received and understand the policy regarding solicitation.

Voluntary Resignation - In the event that you leave or are removed from your assigned position, for whatever the reason, you need to report to the main office of Touch of Class immediately no later than the end of the following business day, if you desire to continue working with Touch of Class. In the event that you do not report to our office, we will assume that you have voluntarily resigned from employment with our agency. I understand and agree with this policy.

Timesheet Agreement - I have received and read the timesheet agreement and agree to abide by all sections. Should I have any questions or comment, I will contact TOC personnel or my supervisor.

Statement of Employability – I have read and signed a copy of this statement provided on a separate piece of paper. I have received a copy for my records as well.

The above information has been given to me by Touch of Class to inform me of the agency’s policies and procedures. If at anytime I have questions regarding any of Touch of Class policies I am to contact my supervisor.

Employee Date

Touch of Class Representative Date

The following information is also a part of your employee packet, please make sure that this information has been completed.

Job Description – Read and sign. A copy has been provided with your consent copies.

New Hire Form – Complete and sign.

Direct Deposit – Complete and return to Staffing Manger if you are interested in direct deposit.

W4 – Complete and return to Staffing Manager

I9 – Complete and return to Staffing Manager

Orientation Timesheet – Complete and return to Staffing Manager. This sheet will be turned into payroll after 90 days of employment with Touch of Class.

Reference Checks – Provide two employment references and return to Staffing Manager

Provided a copy of your ID

Provided a copy of your Social Security Card

Provide Current American Red Cross or American Heart Association CPR Card

Basic Training Form

Employee Date

Touch of Class Representative Date

Habilitation Attendant I

I. Summary of Position

Working with Participants to help them become as independent as possible.

II. Qualifications

Be at least 18 years of age
Be neither legal nor foster parents of the minor child receiving the service
Not be spouse of the Participant receiving the service
Current CPR certified through American Red Cross or American Heart Assoc.

III. Description of Duties and Responsibilities

Working with Participant’s schedule
Documentation of habilitation work done

C. Attending required in-services

The following are based on the Participant’s IPP goals:

Knowledge of the CLASS program and the TOC Policies and procedures
Perform personal care tasks as necessary
Health related tasks as necessary
Food and nutritional assistance as necessary
Money management as necessary
Household tasks as necessary
Community integration assistance as necessary
Assistance with personal decision making
Assistance with facilitation of self advocacy
Assistance with leisure time and recreational activities
Follow-up with any therapy goals as directed
Any other tasks as dictated by the IPP goals

Performance Requirements

Compliance with guidelines of CLASS Manual and TOC Policies and Procedures
Current CPR certification

Responsible to: Staffing Manager

I have read, understand, and will comply by this job description. I acknowledge receipt of a copy.

______

Employee Signature Date

______

Supervisor Signature Date

New Hire Form / Status Change

Please Circle One

OFFICE LOCATION; ______

Effective Date of Hire or Change: ______(Must Be Entered)

Background Search Done On: ______(Must Be Entered on all New Hires)

Employee:______

Last Name First Name MI

Address:

Number and StreetApt #

______

City State Zip

Social Security Number:Date of Birth:

Participant:

Marital Status: _Exemptions:

Check Disbursement1. Direct Deposit2. Access Card

3. Pick-Up4. Mail Out

Reason for change: Please Circle One

1. New Hire 3. Promotion/Demotion 5. Resignation

2. Merit Increase 4. Discharge 6. Other

Additional comments:

______

EmployeeSignatureDate

Supervisor SignatureDate

Direct Deposit Authorization

I, ______, hereby authorize Touch of Class to begin Direct Deposit of my

Print Name

payroll check to my bank account number:

______at ______Bank, ABA #______.

A voided check is attached for reference.

This authorization remains in effect until written notice is given to Touch of Class by me. If my bank account information changes, I will promptly notify Touch of Class so that my payroll check will be deposited into the correct account.

______

Employee SignatureDate

ATTACH VOIDED CHECK HERE:

Please note a deposit ticket will not suffice. Some banks use a different

Routing number on deposit tickets than on checks

Basic Training of Habilitation Attendants and In-Home Respite Providers

Material Covered /

Time Spent

/ Method /

Instructor

Qualifications

1. Consumer Directed Care

Client Rights & Responsibilities
People First Language
Quality of Life
Listening Skills

20 Minutes

/ D, H
2. Touch of Class
a. Policies & Procedures
b. Mission and Objectives
c. Emergency Response Procedure
d. False Claims Recovery /

20 Minutes

/ D, H
3. CLASS Waiver
a. CLASS Program/Terms
b. CLASS Service Delivery Model / 20 Minutes / D, H
4. Overview of Related Conditions
Cerebral Palsy, Spina
bifida, Head and spinal cord
injuries, muscular dystrophy,
epilepsy, autism, etc. / 15 Minutes / D, H

5. Commonly Provided Task

Assisting with ADL’s per Hab
Plan: ie: Feeding, bathing,
dressing, toileting, transfers,
exercise, fostering
independence, etc. / 25 Minutes / D, H
6. Attendant Paperwork
a. 3625
b. Timesheets
c. Hab Notes
d. Therapy Hab Notes
e. Respite
f. Timesheet Agreement
g. Bloodborne path/Hep B vacc.
h. Consents /

20 Minutes

/ D, H

Legend: D=Discussion H=Hand Out

Employee SignatureDate

______

TOC RepresentativeDate

Orientation Time Sheet

Date:

Employee’s Name:

Date of Orientation:

Time In:Time Out:

This will be submitted after your 90 day Evaluation.

______

Employee SignatureDate

______

Supervisor SignatureDate

Reference Check

Reference #1

Applicant’s Name:

Past Employer:_____

Phone #:______

Dates of Employment:

Position Held:______

Eligible for employment:Yes

If NO, please explain:

If NO, date applicant was notified:

Date checked:Checked by:

Supervisor Signature

Reference #2

Applicant’s Name:

Past Employer:______

Phone #:______

Dates of Employment:______

Position Held:______

Eligible for employment:Yes

If NO, please explain:

If NO, date applicant was notified:

Date checked:Checked by:

Supervisor Signature

STATEMENT OF EMPLOYABILITY

By execution of this document, I ______, hereby acknowledge that I have been informed by Touch of Class (agency name) that a criminal history check will be performed on my name. I have informed this agency of all names (i.e., maiden name, aliases) that I have used in the past.

I hereby profess that I have not been convicted of any of the following crimes which are a permanent automatic bar to employment by this agency:

An offense under Section 19, Penal Code (criminal homicide);
An offense under Section 20, Penal Code (kidnapping and false imprisonment);
An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
An offense under Section 21.08, Penal Code (indecent exposure);
An offense under Section 21.11, Penal 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, Penal Code (injury to a child, elderly individual or 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 fraud); and
An offense under Section 42.09, Penal Code (cruelty to livestock animals) or
An offense under Section 42.092, Penal Code (cruelty of non-livestock animals); (eff. Sept. 1, 2011)
An offense under Section 36.06. Penal Code (obstruction or retaliation): (eff. Sept. 1, 2011) and

A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed under this subsection.

I also hereby profess that I have not been convicted of any of the following crimes within the past 5 years (applicable only to those hired on or after September 1, 2007 unless otherwise noted):

An offense under Section 22.01, Penal Code (assault punishable as a Class A Misdemeanor or felony) [applicable to those hired on or after September 1, 2003];
An offense under Section 30.02, Penal Code (burglary) [applicable to those hired on or after September 1, 2003];
An offense under Chapter 31, Penal Code (theft punishable as a felony)[applicable to those hired on or after September 1, 2001]
An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution punishable as a Class A Misdemeanor or felony) [applicable to those hired on or after September 1, 2003];
An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or felony) [applicable to those hired on or after September 1, 2003];.
An offense under Section 37.12, Penal Code (false identification as peace officer); or
An offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).

I understand that if I have been placed on deferred adjudication community supervision for an offense listed above, successfully completed the period of deferred adjudication community supervision, and received a dismissal and discharge according to Section 5(c), Article 42.12, Code of Criminal Procedure, I am not considered convicted of that offense.

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.

I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

______

Signature of Applicant

______

Printed Name Date

Revised 11.2011