PLEASE DO NOT

DATE ANYTHING

ORDER OF APPLICATION

DAY 1: _________________________

Application & Documents o Previous Employer(2) o Employee Log o W-9 o Emergency Contact o I-9

DAY 2: __________________________

Interview & Competency Test DAY 3: __________________________

Orientation o Transportation Contract o AHCA Good Morals o Field Nurse Responsibilities’ o Patient Notes & Updates o Statement of Commitment o Declaration Form o Job Description o Infection Control o Personnel Protective Equipment o Receipt o Confidentiality Statement o Safety Checklist o Prohibition Period o Pledge of Confidentiality o Orientation Checklist o Contract o Alzheimer’s o Hepatitis o Policy on Job o Waiver of Rights o Safe Adequate Care of Pt o Universal Precautions o Tax Exempt o Contract Agreement (2)

DAY 4: _________________________

Conclusion & Goals o ID o Evaluation

5700 Lakeworth Rd Suite 306 Greenacres, FL 33463 PH. 561-433-1991 FAX 561-433-1998

To: ________________________________ ___________________________________ ___________________________________ Dear Sir or Madam, ____________________________________________________ SS# ________________________________ is applying to our agency as _________________________________________________________________. Until we hav e thoroughly c hecked his /her references and test s his/her ability we cannot per mit his/her to work. Pleas e lend us your cooperation in completing the information requested. I authorize Nursing Care Services, Inc. to gather any in formation concerning my qualifications and past performance. Please reply to their questions. I hereby release you from any and all liability. ____________________________________ Applicant Signature TO BE COMPLETED BY PREVIOUS EMPLOYER: Position: _______________________________ Date From: __________________ To: _________________ Reason for leaving: ________________________________________________________________________ ________________________________________________________________________________________ Would you rehire? Yes______ No______ If no please advice why: _________________________________ ________________________________________________________________________________________ PLEASE ADVICE IF: ABOVE AVERAGE, SATISFACTORY, BELOW AVERAGE, OR COMMENTS Punctuality & Attendance ___________________________________________________________________ Appearance (Grooming) ____________________________________________________________________ Judgment ________________________________________________________________________________ Performance _____________________________________________________________________________ Ability to Perform _________________________________________________________________________ Organization of Time ______________________________________________________________________ Compatibility ____________________________________________________________________________ Accepts Direction__________________________________________________________________________ Signed: _____________________________Print Name: _____________________ Title: ________________ Date: ________________Phone:__________________

THANK YOU FOR YOUR COURTESY!!!!!!

5700 Lakeworth Rd Suite 306 Greenacres, FL 33463 PH. 561-433-1991 FAX 561-433-1998

To: ________________________________ ___________________________________ ___________________________________ Dear Sir or Madam, ____________________________________________________ SS# ________________________________ is applying to our agency as _________________________________________________________________. Until we hav e thoroughly c hecked his /her references and test s his/her ability we cannot per mit his/her to work. Pleas e lend us your cooperation in completing the information requested. I authorize Nursing Care Services, Inc. to gather any in formation concerning my qualifications and past performance. Please reply to their questions. I hereby release you from any and all liability. ____________________________________ Applicant Signature TO BE COMPLETED BY PREVIOUS EMPLOYER: Position: _______________________________ Date From: __________________ To: _________________ Reason for leaving: ________________________________________________________________________ ________________________________________________________________________________________ Would you rehire? Yes______ No______ If no please advice why: _________________________________ ________________________________________________________________________________________ PLEASE ADVICE IF: ABOVE AVERAGE, SATISFACTORY, BELOW AVERAGE, OR COMMENTS Punctuality & Attendance ___________________________________________________________________ Appearance (Grooming) ____________________________________________________________________ Judgment ________________________________________________________________________________ Performance _____________________________________________________________________________ Ability to Perform _________________________________________________________________________ Organization of Time ______________________________________________________________________ Compatibility ____________________________________________________________________________ Accepts Direction__________________________________________________________________________ Signed: _____________________________Print Name: _____________________ Title: ________________ Date: ________________Phone:__________________

THANK YOU FOR YOUR COURTESY!!!!!!

Employee’s Log Employee’s Name:_________________________________ Street Address:____________________________________ City/ State / Zip Code:______________________________ Job Title :________________________________________

Cell:______________________ Phone:____________________ S.S #:_____________________ Date of Hire:_______________

Description Yes Description Yes

IRS from W-4 or W-9 Signed Employment Application INS Form I-9 Signed Job Description HIPAA/ Confidential Form Probationary Period Copy of Check Employment References Review-Personnel Policy(Signed) Completed Orientation (Date) Transportation Responsibility Professional Liability Sheet Tax Exempt Form Confidentiality Statement(Mandatory) Independent/Contract Agreement HIV-AIDS Certificate(Mandatory) Affidavit of Good Moral Character C.P.R Card (Mandatory) Statement of Commitment Infection Control (Signed)

Description Number Exp. Date

Exp. Date

Exp. Date

Exp. Date

Exp. Date

Professional License

Certificate(CNA) Drivers License

Prof. Liability Insurance (1&3 million) Physical Exam, Free of Common Disease,

PPD/ Mantouz test or X-ray

Automobile Liability Insurance(PIP& PD)

HHA 40hrs./ CNA 20 hrs Form of Verification: RN / LPN / PT O.S.H.A (Mandatory) □ Yes □ No Comments:

Form W-4 (2010)Purpose. Complete Form W-4 so that youremployer can withhold the correct federal incometax from your pay. Consider completing a newForm W-4 each year and when your personal orfinancial situation changes.

Head of household. Generally, you may claimhead of household filing status on your taxreturn only if you are unmarried and pay morethan 50% of the costs of keeping up a homefor yourself and your dependent(s) or otherqualifying individuals. See Pub. 501,Exemptions, Standard Deduction, and FilingInformation, for information.

Exemption from withholding. If you areexempt, complete only lines 1, 2, 3, 4, and 7and sign the form to validate it. Your exemptionfor 2010 expires February 16, 2011. SeePub. 505, Tax Withholding and Estimated Tax.

Check your withholding. After your Form W-4takes effect, use Pub. 919 to see how theamount you are having withheld compares toyour projected total tax for 2010. See Pub.919, especially if your earnings exceed$130,000 (Single) or $180,000 (Married).

Basic instructions. If you are not exempt,complete the Personal Allowances Worksheetbelow. The worksheets on page 2 further adjustyour withholding allowances based on itemizeddeductions, certain credits, adjustments toincome, or two-earners/multiple jobs situations.

Two earners or multiple jobs. If you have aworking spouse or more than one job, figurethe total number of allowances you are entitledto claim on all jobs using worksheets from onlyone Form W-4. Your withholding usually willbe most accurate when all allowances areclaimed on the Form W-4 for the highestpaying job and zero allowances are claimed onthe others. See Pub. 919 for details.

Personal Allowances Worksheet (Keep for your records.)

Enter “1” for yourself if no one else can claim you as a dependentA A

● You are single and have only one job; orEnter “1” if:B ● You are married, have only one job, and your spouse does not work; or B

● Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.� �

Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse ormore than one job. (Entering “-0-” may help you avoid having too little tax withheld.)

CC

Enter number of dependents (other than your spouse or yourself) you will claim on your tax returnD D

E E

F F

Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) �H H● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

and Adjustments Worksheet on page 2.For accuracy,complete allworksheetsthat apply.

● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed$18,000 ($32,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.�

Cut here and give Form W-4 to your employer. Keep the top part for your records.

OMB No. 1545-0074Employee’s Withholding Allowance CertificateW-4Form

Department of the TreasuryInternal Revenue Service

� Whether you are entitled to claim a certain number of allowances or exemption from withholding issubject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Type or print your first name and middle initial.1 Last name 2 Your social security number

Home address (number and street or rural route) MarriedSingle3 Married, but withhold at higher Single rate.

City or town, state, and ZIP code

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

55 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)$66 Additional amount, if any, you want withheld from each paycheck

7 I claim exemption from withholding for 2010, and I certify that I meet both of the following conditions for exemption.● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

7If you meet both conditions, write “Exempt” here �

8

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature(Form is not valid unless you sign it.) � Date �

9 Employer identification number (EIN)Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) Office code (optional) 10

Enter “1” if you have at least $1,800 of child or dependent care expenses for which you plan to claim a credit

4 If your last name differs from that shown on your social security card,check here. You must call 1-800-772-1213 for a replacement card. �

Cat. No. 10220Q

Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)

Note. You cannot claim exemption fromwithholding if (a) your income exceeds $950and includes more than $300 of unearnedincome (for example, interest and dividends)and (b) another person can claim you as adependent on his or her tax return.

Nonwage income. If you have a large amountof nonwage income, such as interest ordividends, consider making estimated tax

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

G● If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible

child plus “1” additional if you have six or more eligible children.

● If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

Tax credits. You can take projected taxcredits into account in figuring your allowablenumber of withholding allowances. Credits forchild or dependent care expenses and thechild tax credit may be claimed using thePersonal Allowances Worksheet below. SeePub. 919, How Do I Adjust My TaxWithholding, for information on convertingyour other credits into withholding allowances.

Nonresident alien. If you are a nonresidentalien, see Notice 1392, Supplemental FormW-4 Instructions for Nonresident Aliens, beforecompleting this form.

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Form W-4 (2010)

Complete all worksheets that apply. However, youmay claim fewer (or zero) allowances. For regularwages, withholding must be based on allowancesyou claimed and may not be a flat amount orpercentage of wages.

payments using Form 1040-ES, Estimated Taxfor Individuals. Otherwise, you may oweadditional tax. If you have pension or annuityincome, see Pub. 919 to find out if you shouldadjust your withholding on Form W-4 or W-4P.

2010

Page 2Form W-4 (2010)

Deductions and Adjustments WorksheetNote. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

Enter an estimate of your 2010 itemized deductions. These include qualifying home mortgage interest,charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, andmiscellaneous deductions

1

$1$11,400 if married filing jointly or qualifying widow(er)

$$8,400 if head of household 2Enter:2$5,700 if single or married filing separately ��

$3 Subtract line 2 from line 1. If zero or less, enter “-0-” 3$Enter an estimate of your 2010 adjustments to income and any additional standard deduction. (Pub. 919)4$5Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 6 in Pub. 919.)5$6Enter an estimate of your 2010 nonwage income (such as dividends or interest)6$7Subtract line 6 from line 5. If zero or less, enter “-0-”7

Divide the amount on line 7 by $3,650 and enter the result here. Drop any fraction8 8Enter the number from the Personal Allowances Worksheet, line H, page 19 9Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

1010

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)

Note. Use this worksheet only if the instructions under line H on page 1 direct you here.1Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, ifyou are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter morethan “3.” 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet 3

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to figure the additionalwithholding amount necessary to avoid a year-end tax bill.

Enter the number from line 2 of this worksheet4 4Enter the number from line 1 of this worksheet5 5Subtract line 5 from line 46 6

$Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here7 7$Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed8 8

Divide line 8 by the number of pay periods remaining in 2010. For example, divide by 26 if you are paidevery two weeks and you complete this form in December 2009. Enter the result here and on Form W-4,line 6, page 1. This is the additional amount to be withheld from each paycheck

9

$9

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on thisform to carry out the Internal Revenue laws of the United States. Internal Revenue Codesections 3402(f)(2) and 6109 and their regulations require you to provide thisinformation; your employer uses it to determine your federal income tax withholding.Failure to provide a properly completed form will result in your being treated as a singleperson who claims no withholding allowances; providing fraudulent information maysubject you to penalties. Routine uses of this information include giving it to theDepartment of Justice for civil and criminal litigation, to cities, states, the District ofColumbia, and U.S. commonwealths and possessions for use in administering their taxlaws, and using it in the National Directory of New Hires. We may also disclose thisinformation to other countries under a tax treaty, to federal and state agencies toenforce federal nontax criminal laws, or to federal law enforcement and intelligenceagencies to combat terrorism.

The average time and expenses required to complete and file this form will varydepending on individual circumstances. For estimated averages, see theinstructions for your income tax return.

4

Table 1All OthersMarried Filing Jointly

If wages from LOWESTpaying job are—

Table 2All OthersMarried Filing Jointly

If wages from HIGHESTpaying job are—

Enter online 7 above

If wages from HIGHESTpaying job are—

Enter online 7 above

Enter online 2 above

If wages from LOWESTpaying job are—

You are not required to provide the information requested on a form that issubject to the Paperwork Reduction Act unless the form displays a valid OMBcontrol number. Books or records relating to a form or its instructions must beretained as long as their contents may become material in the administration ofany Internal Revenue law. Generally, tax returns and return information areconfidential, as required by Code section 6103.

Enter online 2 above

0123456789

10

If you have suggestions for making this form simpler, we would be happy to hearfrom you. See the instructions for your income tax return.

$0 -7,001 -

10,001 -16,001 -22,001 -27,001 -35,001 -44,001 -50,001 -55,001 -65,001 -72,001 -85,001 -

105,001 -115,001 -

$7,000 -10,000 -16,000 -22,000 -27,000 -35,000 -44,000 -50,000 -55,000 -65,000 -72,000 -85,000 -

130,001 - and over

0123456789

101112131415

$0 -6,001 -

12,001 -19,001 -26,001 -35,001 -50,001 -65,001 -80,001 -90,001 -

$6,000 -12,000 -19,000 -26,000 -35,000 -50,000 -65,000 -80,000 -90,000 -

120,000 -120,001 and over

$0 -65,001 -

120,001 -185,001 -

$550910

1,0201,2001,280330,001 and over

$65,000120,000185,000330,000

$0 -35,001 -90,001 -

165,001 -

$550910

1,0201,2001,280370,001 and over

$35,00090,000

165,000370,000

105,000 -115,000 -130,000 -

Nursing Care Services, Inc.

TRANSPORTATION RESPONSIBILITY CONTRACT

It has been explained to me, that I am being offered employment by Nursing Care Services, Inc. With the understanding that I have per sonal transportation at my dis posal to be used for travel to and from the patient assignments. I further understand that I am re sponsible for auto liabilit y of $10,000.00/$20,000.00 for bodily injury and $50,000.00 in property damage. I also agree not to use my vehicle to transport any patient. ________________________________________________ ___________________

Employee Signature Date

AHCA Form 3110-0001 Revised December 2006 (Supersedes previous versions)Form Available at: http://ahca.myflorida.comPage 1 of 2

AFFIDAVIT OF GOOD MORAL CHARACTER FOR PURPOSES RELEVANT TO SECTION 400.512, F.S.,STATE OF FLORIDA

(To be signed by staff who enter the homes of clients and are required to have Level 1 screening. A copy must also be kept in theprovider’s personnel file.)

Authority: Pursuant to s. 400.512, F.S., The agency shall require employment or contractor screening as provided inchapter 435, using the Level 1 standards for screening set forth in that chapter, for home health agency personnel; personsreferred for employment by nurse registries; and persons employed by companion or homemaker services registered unders. 400.509, F.S.

STATE OF FLORIDACOUNTY OF: _________________________

Before me this day personally appeared _________________________________________________________who, being duly sworn, deposes and says:

As an applicant for employment with __________________________________________________________,

I hereby attest to meeting the requirements for employment that I am of good moral character that I have not been foundguilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense prohibited under any ofthe following provisions of the Florida Statutes or under any similar statute or ordinance of another jurisdiction:(a) Section 393.135, F.S., relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.

(b) Section 394.4593, F.S., relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.

(c) Section 415.111, F.S., relating to abuse, neglect, or exploitation of a vulnerable adult.

(d) Section 782.04, F.S., relating to murder.

(e) Section 782.07, F.S., relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of achild.

(f) Section 782.071, F.S., relating to vehicular homicide.

(g) Section 782.09, F.S., relating to killing of an unborn child by injury to the mother.

(h) Section 784.011, F.S., relating to assault, if the victim of the offense was a minor.

(i) Section 784.021, F.S., relating to aggravated assault.

(j) Section 784.03, F.S., relating to battery, if the victim of the offense was a minor.

(k) Section 784.045, F.S., relating to aggravated battery.

(l) Section 787.01, F.S., relating to kidnapping.

(m) Section 787.02, F.S., relating to false imprisonment.

(n) Section 794.011, F.S., relating to sexual battery.

(o) Former s. 794.041, F.S., relating to prohibited acts of persons in familial or custodial authority.

(p) Chapter 796, F.S., relating to prostitution.

(q) Section 798.02, F.S., relating to lewd and lascivious behavior.

(r) Chapter 800, relating to lewdness and indecent exposure.

(s) Section 806.01, F.S., relating to arson.

(t) Chapter 812, F.S., relating to theft, robbery, and related crimes, if the offense was a felony.

(u) Section 817.563, F.S., relating to fraudulent sale of controlled substances, only if the offense was a felony.

(v) Section 825.102, F.S., relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.

(w) Section 825.1025, F.S., relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.

Form AHCA 3110-0001, Revised December 2006 (Supersedes previous versions)Form Available at: http://ahca,myflorida.comPage 2 of 2

2

(x) Section 825.103, F.S., relating to exploitation of an elderly person or disabled adult, if the offense was a felony.

(y) Section 826.04, F.S., relating to incest.

(z) Section 827.03, F.S., relating to child abuse, aggravated child abuse, or neglect of a child.

(aa) Section 827.04, F.S., relating to contributing to the delinquency or dependency of a child.

(bb) Former s. 827.05, F.S., relating to negligent treatment of children.

(cc) Section 827.071, F.S., relating to sexual performance by a child.

(dd) Chapter 847, F.S., relating to obscene literature.

(ee) Chapter 893, F.S., relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offensewas a minor.

(ff) Section 916.0175, F.S., relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.

435.03 (3), F.S., Standards must also ensure that the person:

(a) For employees or employers licensed or registered pursuant to chapter 400 or chapter 429, and for employees and employers of developmentaldisabilities institutions as defined in s. 393.063, intermediate care facilities for the developmentally disabled as defined in s. 400.960, and mentalhealth treatment facilities as defined in s. 394.455, meets the requirements of this chapter.

(b) Has not committed an act that constitutes domestic violence as defined in s. 741.28, F.S.

SIGN EITHER (1) OR (2) BELOW:

(1) Under the penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of myknowledge and belief.

________________________________AFFIANT

(2) To the best of my knowledge and belief, my record may contain one of the foregoing disqualifying acts of offenses.

________________________________AFFIANT

This person is personally known to me or produced the following identification _______________________.

Sworn to and subscribed before me this ___________day of ________________________.Month/Year

______________________________ Notary State Seal:Notary Public (Type or Print Name)

______________________________Notary Public (Signature)

______________________________

FIELD NURSE RESPONSIBILITY Call Office:

Before 9:00 am daily to verify assignment or if unable to work. As soon as sign-up or re-instatement visit completed to give report 3:00- 4:30 pm daily to report on patients seen to receive assignments for next day. Whenever you identify a problem with a patient Whenever you do not see a patient and give a reason When beeped-respond As Soon As Possible (within 15-20 minutes)

Call Patients:

Day before Visit to prepare for fasting lab work. Before Visit Whenever you will not arrive at expected time

Call Physician:

When sign-up or Reinstatement visit is completed. Every 2 weeks status report For any unstable condition When patient is discharged

Turn in Office:

Notes with Time/ Travel Itinerary IX week. Sign-ups and reinstatements within 24-48 hours.

Also:

Write mod order for any order you receive. Documents Aide Supervisory Visit every 2 weeks Correct All deficiencies within 1 week.(including personnel file update requests) See Supervisor in office once a week t o update care plans, disc uss problems and obtain

Plan of Care on all your patients. Attend Team Conferences and in services. Check your Monthly Calendar. Place appropriate indexes in home folder. Document: Patient status on communication sheet and teachings on indexes each visit. Complete correct lab requisitions on contact lab of pick up site. Sign for all Biohazard waste supplies taken from or returned to office.

____________________________ ______________ Nurse Signature Date

5700 Lakeworth Rd Suite 306 Greenacres, FL 33463 PH. 561-433-1991 FAX 561-433-1998

PLEASE READ THIS NOTICE CAREFULLY TO: ALL EMPLOYEES FROM: ADMINISTRATOR RE: PATIENT NOTES AND UPDATES AS AN EMPLOYEE YOU ARE RESPONSIBLE FOR KEEPING PATIENTS FILES UPDATED AND ACTIVE AT ALL TIMES. ALL EMPLO YEES AR E REQUIRED TO BRING IN PAT EINTS NOTES IN A TIMELY F ASHION (WITHIN 7 D AYS OF VISIT) PAYROLL WILL BE NOTIFIED WEEKLY. BE AWARE THAT EVERY TUESDAY IS THE ASSIGN DAY TO TURN IN NOTES AND OTHER DO CUMENTS. ALL NOTES RECEIVED IN THE PAY PERIOD, CYCL E, WILL BE INCLU DED FOR PAYMENT. ALL NOTES WILL BE REVIEWED C AREFULLY, AND IMCOMP LETE NOTES WILL BE PROCESSED FOR PAYMENT UNTIL CORRECTED. DU E TO POLICY/CONTRAC T IN CONJUN CTION WITH VARIOUS GOVERNMEN TAL AGENCIES WE HAVE HAD THE NEED TO IMPLEMENT THIS POLICY. ________________________________ __________________________ EMPLOYEE SIGNATURE DATE

Nursing Care Services, Inc.

EMPLOYEE STATEMENT OF COMMITMENT

I have read and understand Nursing Care Services, Inc. Personnel policy Manual. In compliance with those policies I agree to confirm to the following:

I will always maintain professionalism in the home to which I am assigned.

I will immediately contact Nursing Care Services, Inc., regarding any areas of

discrepancy between the client’s assessment of the assignment requirements and my

understanding of my specific performance level as designated by Nursing Care

Services, Inc.

I have read and understand the Nursing Care Services, Inc., job description appropriate

to my level of performance. I will not accept assignments beyond my designated

performance level as determined by Nursing Care Services, Inc.

I will abide with the Nursing Care Services, Inc. Standard Code of Dress as described in

the Personnel Policy Manuel.

I will arrive in time for the assignments I have accepted. In the event of any emergency

this may cause me to be late. I will notify the Nursing Care Services, Inc., office of the

situation and expected arrival time.

I will not accept any money or gifts from Nursing Care Services, Inc.’s clients. I will

receive payment for services rendered directly from Nursing Care Services, Inc.

I will notify Nursing Care Services, Inc., immediately if I am unable to arrive for my

assignment within my due time or if I am unable to meet my assignment commitment, I

understand the Nursing Care Services, Inc., office will then contact the client. I also

understand that not calling Nursing Care Services, Inc., office when I am unable to meet

my assignment commitment will be grounds fro immediate termination.

I will not make or accept personal telephone call in the client’s home.

I will not transport a patient or family member in my personal vehicle.

I will not smoke in a patient’s home.

Signature: ________________________________________ Date: __________________

Witness: ________________________________________

5700 Lakeworth Rd Suite 306 Greenacres, FL 33463 PH. 561-433-1991 FAX 561-433-1998

EMPLOYEE DECLARATION FORM I, _________ ____________________HAVE READ AND UNDERSTAND THE POLICIES AND PROCEDURES OF T HE AGENCY AND HAVE HA D THE OPPORTUNITY T O HAVE AL L OF MY CONCERNS/QUESTIONS ANSWERED TO MY COMPLETE SATISFACTION. THIS INCLUDED BUT NOT TO MY LIMITED TO:

PATIENT RIGHTS AND RESPONSIBILTIES PATIENT ABUSE POLICIES AND PROCEDURE AND ABUSE HOT LINE NUMBER STANDARD OF ETHICAL CONDUCT JOB DESCRIPTION CONFIDENTIALITY OF PATIENT AND PROGRAM INFORMATION

I AGREE TO ABIDE BY ESTABLISHED POLICIES AND PROCEDURES, AND HAVE BEEN ADVISED THAT FAILURE TO DO SO WILL BE GROUNDS FOR REQUIR EMENT OF MY EMPLOYMENT. I ALSO AGREE THAT AS A REQUIREMENT OF MY EMPLOYMENT, R EGARDLESS OF STATUS (E.G FULL, PART TIME, PER DIEM, ETC.) THAT I WILL PROVIDE THE AGENCY WITH A 14 DAYS OF EMPLOYMENT. ________________________________ __________________________ EMPLOYEE SIGNATURE DATE ________________________________ __________________________ WITNESS SIGNATURE DATE

NURSING CARE SERVICES, INC. HOME HEALTH AIDE/ CNA JOB DESCRIPTION

REPORTS TO: REGISTERED NURSE QUALIFICATIONS: Must be complete at least forty (40) hours of training in: Communicatio ns skills, observation, reporting, documentation and documentation of patients status and the care provided, reading and recording temperature, pulse and respirat ion, basic infection control proc edures, basic elements of body functions. DUTIES: Maintenance of a clean, safe, and healthy environment, recognition of emergencies and knowledge of emergency procedures, physical, emotional and developmental c haracteristics of populations served, appropriate and safe techniques in pers onal hygiene and grooming, including bed bath, sponge, tub, or shower bath, s hampoo, tub or bed, nail and skin care , oral hygiene. Safe transfers techniques and ambulation, nor mal range of motion and positioni ng, adequate nutrition and fluid intake, the role of the aide in the home, differences in families, food and household management. Home Health Aides/CAN assisting with self-administrated medicati on, must receive a minimum of hours of training (which c an be part of the 75 hour home health training), prior to assuming this responsibility. Training must cover state l aw and rule requirements with respect to the assistance with self-administration of medica tions in the home, procedures for assisting the resident with self administration of medications, recognition of side effects and adverse reactions. Training must be performed by or under the general supervision of a registered nurse. The HIV and AIDS educational requi rements also must meet a minimum of 2 hours of i nitial training and 1 hour biennially of in-service train ing in HIV and AIDS. The training should inc lude universal precautions and infection control proc edures to ensure proper pr actices are followed. Training must be provided to obtain and maintain a certificate in cardi opulmonary resuscitation. Each home health aide must be able to read the prescription label and any instructions. Individuals who cannot read must not be permitted to assist with prescription medications. ENSURE HIPPA GUIDELINES AND PROCEDURES ARE MAINTAINED.

All the personal care activities contained in a written assignment any a licensed health professional employee, or contractor, and which include activities such as:

Assisting the patient with personal hygiene Assisting the patient with ambulation/physical transfer Assisting the patient with eating Assisting the patient with dressing Assisting the patient with shaving Maintenance of a clean, safe and healthy env ironment, which may include light cleaning

and straightening of the bathroom , straightening the sleeping an d living area, washing the patients or clients dishes or laundry, and such tasks to maintain cleanliness and safety fo r the patient or client. Patient related activities as taught to the Home Health Aide/ CNA by licensed Health professional employee for specific patient. Such activities include:

Assisting the change of colostomy bag, reinforcement of dressing Measuring temperature, pulse, respiration, or blood pressure Measuring intake and output of fluids Assisting with prescribed range of motion exer cise (such exercise are limited to those

taught to the Home Health Aide/ CNA and the patient by a professional employee. Assisting prescribe ice cap or collar Doing simple urine tests for sugar, acetone and albumin

Measuring and preparing special diets Keeping records of personal health care activities Observing appearance and gross behavioral c hanges in the patient and reporting to the

registered nurse Supervision of self administrated medication in the home limited to: Obtaining medication

container from the storage areas for the patient, ensuring that the medication is prescribed for the patient, remind the patient that i s time to take t he medication as prescribed and observing the patient self administering the medication.

The Home Health Aide/ CNA may also provide the following assistance with self-administrated medication, as needed by the patient , in accordance with 400.488 F.S

Prepare necessary items such as juice, water, cups or spoons to assist the pati ent in the self-administration f medication.

Open and close the medication container or tear the foil of prepackaged medications Assists the resident in the self-administration process, such as steadying of the arm, head,

or other parts of the patients body so as to allow the self-administration of medication. Assist to the patient by placing unused doses of solid medication back into the medication

container. THE HOME HEALTH/ CAN SHALL NOT PERFORM THE FOLLOWING TASKS: (a) Changing of sterile dressing (b) Irrigating body cavities such as giving enema (c) Irrigating a colostomy or wound (d) Performing a gastric irrigation or enterable feeding (e) Catheterizing a patient (f) Administering medications (g) Applying heat by any method (h) Caring for a tracheotomy tube (i) Any personal health service which has not been included by the Registered Nurse in the

patient care plan In cases where a home health aide or CNA will provide assistance self-administered medications, an assessment of the medication fo r which assistanc e is to be provided shall be conducted by a licensed home health care prof essional to ensure the unlicensed caregiver provides assistance in ac cordance wit h thei r training and with medication prescription. A licensed health care professional shall inform t he patient/caregiver must given written consent for this agreement. Home Health Aide shall be supervised by the Registered Nurse or the Director of Nursing at all times. ___________________________________________________ ___________________ Home Health Aide/ Can Signature Date

EMERGENCY CONTACT INFORMATION

Employee Name: ____________________________________ Position: _______________________

House Phone: _________________________________ Cell Phone: __________________________

1. Emergency Contact

Name

Relationship

Telephone Cell: House:

Work:

Home Address Apt:

City: State: Zip Code:

2. Emergency Contact

Name

Relationship

Telephone Cell: House:

Work:

Home Address Apt:

City: State: Zip Code:

NURSING CARE SERVICES, INC. INFECTION CONTROL FORM

Date: ____________________ Employee Name: ____________________ Employee Number: __________________ Social Security: ________________________ Position: ___________________________ I hereby acknowledge that I have read and understand the Infection Control Policy, contained in the Policy and Procedures Manual of the Agency. I am familiar with the Procedures appropriate in my position as an employee with NURSING CARE SERVICES, INC. Employee Signature: ______________________________________________________ Witness: ________________________________________________________________

NURSING CARE SERVICES, INC. USE OF PERSONAL PROTECTIVE EQUIPMENT

I, the undersigned, unders tand and agree that as a c ondition of employment I am required to wear/use the following personal protective equipment supplied and/or required to my employer: COMPANY SUPPLIED: Masks, Gloves, Gowns COMPANY REQUIRED: __________________________________________________ Supplied by Employee: ____________________________________________________ ____________________________________________________ I agree to inform my employer immediately upon the failure of any of the above listed equipment so the same can be promptly repaired or replaced. In the event I sustain an on-the-job injury as a dire ct result of my failure to wear/use the personal protective equipment listed above, my worker s compensation benefits c ould be substantially reduced. Employee Signature: ____________________________ Date: ____________________ Administrator Signature: _________________________ Date: ____________________ Witness Signature: ______________________________ Date: ___________________

NURSING CARE SERVICES, INC. STATEMENT OF RECEIPT

The following statement should be signed and dated by eac h employee after receiving a copy of Company Policy and Safety rules. The signed and dated statement should then be made apart of his/her personnel file. I have received, read and underst and the Company Policy and Safety Rules and Regulations and agree to abide by them. I further understand that failure to do could result in dis ciplinary action or termination. ________________________________________ ___________ _________________

Signature Date

NURSING CARE SERVICES, INC. ID BADGE

Name of Employee: ____________________________________ Employee Number: _____________________________________ Hire Date: _______________________ On _______________________, 20__, ___________________________________________ Employee Name I received an Employee Identification Badge. This Badge is to be worn at all times when working for Nursing Care Services, Inc. Badge will remain the property of Nursing Care Services, Inc. in the event of employment separation; this badge is to be returned to Nursing Care Services, Inc. __________________________________________ ________________________

Employee Signature Date

NURSING CARE SERVICES INC. CONFIDENTIALITY STATEMENT

I have been formally instructed in maintain the confidentiality of the medical record and understand that the medical information regarding the patient, may not be disc ussed with anyone, either inside or outside the Agency,(except as needed to conduct the business of the day.) I understand that no Medical Record s are to be removed from the Agency unless a “Release of Information Form” has been comple ted and signed by the patient. It is cause for dismissal. I have been formally instructed in the Polic ies and Procedures of this facilit y, and have a ttended a formal Orientation and read and signed a Job Description for any specific classification. Employee’s Signature: ____________________________ Date: __________________

5700 Lakeworth Rd Suite 306 Greenacres, FL 33463 PH. 561-433-1991 FAX 561-433-1998

Employee Safety Checklist

Name of Employee: _______________________________

Date: ________________________ Department: ______________________________ Employee Safety Orientation. Employee is to check each box when instructions is completed and understood. 1. GENERAL SAFETY POLICY AND PROGRAM □ 2. PROPER BODY MECHANIC PROCEDURES □ 3. SAFETY RULES-GENERAL □ 4. SAFETY RULES-SPECIFIC TO JOB □ 5. EMPLOYEE COUNSELING □ (DISCIPLINE FOR SAFETY POLICY AND VIOLATION) 6. FIRE PREVENTION, LOCATION OF FIRE □ FIGHTING EQUIPMENT & LOCATION OF EXITS 7. PERSONAL PROTECTIVE EQUIPMENT &CLOTHING □ 8. HOW, WHEN, AND WHERE TO REPORT INJURIES □ 9. HOUSEKEEPING AND CLEANING UP SPILLS □ 10. WHEN & WHERE TO REPORT UNSAFE CONDITIONS □ ON _________________________, I REVIEWED THE ABOVE CHECKED ITEMS RELATING TO THE SAFETY & SAFE WORK PROCEDURES FOR THE AGENCY. ______________________________ ___________________ EMPLOYEE SIGNATURE DATE ______________________________ ___________________ ADMINISTRATOR SIGNATURE DATE

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9, Employment Eligibility Verification

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-8155.

All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I-9.

OMB No. 1615-0047; Expires 08/31/12

The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his or her own. However, the employee must still sign Section 1 personally.

Form I-9 (Rev. 08/07/09) Y

Read all instructions carefully before completing this form. Instructions

When Should Form I-9 Be Used?

What Is the Purpose of This Form?

The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States.

For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, Section 2 must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I-9 employees present to establish identity and employment authorization. Employees may present any List A document OR a combination of a List B and a List C document.Filling Out Form I-9

This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E-Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed.

1. Document title;2. Issuing authority;3. Document number;4. Expiration date, if any; and 5. The date employment begins.

Employers must sign and date the certification in Section 2. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. Employers are still responsible for completing and retaining Form I-9.

Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

Employers should note the work authorization expiration date (if any) shown in Section 1. For employees who indicate an employment authorization expiration date in Section 1, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of the Marshall Islands). For such employees, reverification does not apply unless they choose to present

If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time.

Employers must record in Section 2:

Preparer/Translator Certification

Section 2, Employer

Section 1, Employee

in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I-766)).

EMPLOYERS MUST RETAIN COMPLETED FORM I-9 DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

To order USCIS forms, you can download them from our website at www.uscis.gov/forms or call our toll-free number at 1-800-870-3676. You can obtain information about Form I-9 from our website at www.uscis.gov or by calling 1-888-464-4218.

USCIS Forms and Information

What Is the Filing Fee?

There is no associated filing fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below.

The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).

Privacy Act Notice

This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

A blank Form I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later.

Photocopying and Retaining Form I-9

Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.C. If an employee is rehired within three years of the date

this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B; and:

1. Examine any document that reflects the employee is authorized to work in the United States (see List A or C);

2. Record the document title, document number, and expiration date (if any) in Block C; and

3. Complete the signature block.

A. If an employee's name has changed at the time this form is being updated/reverified, complete Block A.

B. If an employee is rehired within three years of the date this form was originally completed and the employee is still authorized to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

Employers must complete Section 3 when updating and/or reverifying Form I-9. Employers must reverify employment authorization of their employees on or before the work authorization expiration date recorded in Section 1 (if any). Employers CANNOT specify which document(s) they will accept from an employee.

For more detailed information, you may refer to the USCIS Handbook for Employers (Form M-274). You may obtain the handbook using the contact information found under the header "USCIS Forms and Information."

Note that for reverification purposes, employers have the option of completing a new Form I-9 instead of completing Section 3.

Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from our website at www.uscis.gov/e-verify or by calling 1-888-464-4218.

General information on immigration laws, regulations, and procedures can be obtained by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our Internet website at www.uscis.gov.

This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

Section 3, Updating and Reverification

Form I-9 (Rev. 08/07/09) Y Page 2

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

Form I-9 (Rev. 08/07/09) Y Page 3

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9, Employment Eligibility Verification

OMB No. 1615-0047; Expires 08/31/12

Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination.Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)Print Name: Last First Middle Initial Maiden Name

Address (Street Name and Number) Apt. # Date of Birth (month/day/year)

StateCity Zip Code Social Security #

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

Employee's Signature Date (month/day/year)

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) 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.

Address (Street Name and Number, City, State, Zip Code)

Print NamePreparer's/Translator's Signature

Date (month/day/year)

Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and expiration date, if any, of the document(s).)

ANDList B List CORList ADocument title:

Issuing authority:

Document #:

Expiration Date (if any):Document #:

Expiration Date (if any):

and that to the best of my knowledge the employee is authorized to work in the United States. (State(month/day/year)employment agencies may omit the date the employee began employment.)

CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on

Print Name TitleSignature of Employer or Authorized Representative

Date (month/day/year)Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

B. Date of Rehire (month/day/year) (if applicable)A. New Name (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.

Document #: Expiration Date (if any):Document Title:

Section 3. Updating and Reverification (To be completed and signed by employer.)

l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

Date (month/day/year)Signature of Employer or Authorized Representative

I attest, under penalty of perjury, that I am (check one of the following):

A lawful permanent resident (Alien #)

A citizen of the United States

An alien authorized to work (Alien # or Admission #)

A noncitizen national of the United States (see instructions)

until (expiration date, if applicable - month/day/year)

Form I-9 (Rev. 08/07/09) Y Page 4

Administrative AssistantLoreta Padron

SUPRA Home Health, Inc. 12251 Taft ST. Pembroke Pines, FL. 33026

For persons under age 18 who are unable to present a document listed above:

LISTS OF ACCEPTABLE DOCUMENTS

LIST A LIST B LIST C

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

8. Employment authorization document issued by the Department of Homeland Security

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

1. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States

9. Driver's license issued by a Canadian government authority

1. U.S. Passport or U.S. Passport Card

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)3. Foreign passport that contains a

temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

3. School ID card with a photograph

5. In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form

6. Military dependent's ID card

4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

7. U.S. Coast Guard Merchant Mariner Card

5. Native American tribal document

8. Native American tribal document

7. Identification Card for Use of Resident Citizen in the United States (Form I-179)

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Both Identity and Employment

Authorization

Documents that Establish Identity

Documents that Establish Employment Authorization

OR AND

All documents must be unexpired

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

6. U.S. Citizen ID Card (Form I-197)

Form I-9 (Rev. 08/07/09) Y Page 5

NURSING CARE SERVICES, INC. NOTIFICATION OF PROBATION PERIOD

Employee Name: _________________________________ Job Title: ______________________ Social Security Number: ____________________________ Date of Hire: ___________________ Probation Date: __________________________ To: ___________________________________ I, ____________________________________, in accepting employment with Nursing Care Services, Inc., accept and understand that the first (90) days of em ployment will be considered my Probation Period. If any reason my employment is terminated dur ing this period, I understand and accept that this account will not be charged with unemployment benefits that I may be eligible to receive under the State of Florida Unemployment Compensation Law. I also understand and accept that at the end of th e (90) day’s Probationary period will receiv e a written evaluation of my work performance. Shou ld the Agency fails to provide this writ ten evaluation, it shall be understood and accepted all inv olved that the probationary period will have been completed satisfactory. __________________________________________ __________________________

Employee Signature Date __________________________________________ __________________________

Administrator/Designee Signature Date

NURSING CARE SERVICES, INC. PERSONAL HEALTH INFORMATION

PLEDGE OF CONFIDENTIALITY Employee Name: ___________________________________________ I, the undersigned have read and understand the Nursing Care Services, Inc. (Hereinafter “Nursing Care Services, Inc.”) policy on confidentiality of personal health informati on(PHI) as described in the Confidentiality Policy which is in accordance with relevant state and federal legislation. I also acknowledge that I am aware of and underst and the Policies of the Nursing Care Services, Inc. regarding the securi ty of personal health information includi ng the policies relating to the use, collection, disclosure, storage and destruction of personal health information. In consideration of my employment or association with Nursing Care Services, Inc. an as in integral part if the terms and conditions of my employment or associ ation, I hereby agree, pledge and undertake that I will not at any time, during my employment or association with Nursing Care Services, Inc., or after my employment or association ends, access or use personal health information, or reveal or dis close to any persons within or outside Nursing Care Services, Inc., any personal health information except as may be required in the course of my duties and responsibilities and in accordance with applicab le Legislat ion, and Nursing Care Services, Inc. policies governing proper release of information. I understand that my obligations outlined above will continue after my employment/ contract/ association/ appointment with Nursing Care Services, Inc. ends. I further understand that my obligati ons concerning the protection of c onfidentiality of PHI relate to all personal health information whether I acquir ed the informati on thr ough my employment or contract or association or appointment with Nursing Care Services, Inc. I also understand that unauthorized use or disclosure of such information will result in a disciplinary action up to and including termination of employment or contract or association or appointment, the imposition of fines pursuant to relevant stat e and federal legislation, and a report to my professional regulatory body. _____________________________________________ ___________________ SIGNATURE OF INDIVIDUAL MAKING PLEDGE Date I have been informed of the contents of Nursing Care Services, Inc.’s Personal Health Information Confidentiality Policy And the consequences of a breach. ______________________________________________ ___________________ SIGNATURE OF INDIVIDUAL ADMINISTRATING PLEDGE Date I have discussed the Personal Health Information Confidential Policy and the consequences of a breach with the above named.

NURSING CARE SERVICES, INC. ORIENTATION CHECKLIST: PROFESSIONAL STAFF

1. GENERAL ORIENTATION

______ AGENCY ORGANIZATIONAL STRUCTURE ______ PHILOSOPHY, GOAL & OBJECTIVES, MISSION ______ TOUR OF FACILITY

a. LOCATION OF ADMINISTRATIVE OFFICES b. LOCATION OF EMERGENCY LIGHTS/EXITS c. EMERGENCY EVACUATION ROUTES d. LOCATION OF FORE EXTINGUISHERS

______ INTRODUCTION TO STAFF/ CLIENTS ______ SCOPE OF SERVICES ______ EMPLOYMENT POLICIES/ JOB DESCRIPTION ______ COMPLAINTS POLICY/GRIEVANCE FORM ______ PAYROLL ______ CORPORATE COMPLIANCE PLAN

2. CLINICAL ORIENTATION ______ CLIENTS RIGHTS AND RESPONSIBLITIES ______ ADMISIION/DISCHARGE CRITERIA/THERAPY SERVICES ______ MEDICAL EMERGENCIES ______ PSYCHIATRIC EMERGENCIES ______ DOCUMENTATION REQUIREMENTS/ TIME FRAMES ______ CLINICAL RECORDS

3. CONFIDENTIALITY/ HIPPA GUIDELINES ______ CLIENT/ FAMILY/SIGNIFICANT OTHER ______ PROGRAM/ STAFF ______ INFORMATION

4. SAFETY/ RISK MANAGEMENT/ INFECTION CONTROL ______ ACCIDENT/ INCIDENT REPORTING ______ OSHA ______ UNIVERSAL PRECAUTIONS ______ BIOHAZARDOUS/ INFECTION WASTE ______ HIV UPDATE ______ TB UPDATE ______ EMERGENCY PREPAREDNESS ______ FIRE DRILL ______ CARE OF ENVIROMENT I HAVE READ AND UNDERSTAND THE POLICIES AND PROCEDURES OF THE AGENCY AND I HAVE THE O PPORTUNITY TO HAVE ALL MY Q UESTIONS/ CONCERNS A DDRESSED T O MY COMPLETE SATISFACTION. I AGREE T O ABIDE AND UP HOLD ALL POLICIES AND PROCEDURE AND HAVE BEEN ADVICE THAT FAILURE TO SO MAY RESULT IN TERMINATION OF EMPLOYMENT. I ALSO A GREE THAT AS A CONDITION OF EMPLOYMENT THAT I WIL L PROVIDE THE AGENCY WITH A FOURTEEN (14) DAY WRITTEN NOTICE OF INTENT TO TERMINATE EMPLOYMENT. ___________________________________ _ _________________________ Employee Date ___________________________________ _ _________________________ Witness Date

NURSING CARE SERVICES, INC. CONTRACT AGREEMENT

THIS AGREEMENT (“Agreement’) made this __________________________________________ Effective ____________________, by and between _____________________________________ (“The Company”). A Florida Corporation whose address is ________________________________ ______________________________________ & ______________________________________ Field Registered Nurse Hereinafter referred to as (“Contractor”).

WITNESSETH

WHEREAS, Contractor is an independent agent, and WHEREAS, Contractor wishes to contract with Com pany who will provide qualified services as described below to Company. NOW THEREFORE, in consideration of the mutual covenant s, promises and agreements contained herein and other valuable consideration, the sufficiency of which is hereby acknowledge, the patient agree as follows:

Company hereby engage Contractor, and Contract or accepts engagements, to provide to Company the following services:

Conform to all applicable A gency Policies including personal qualifications and experience for the position.

Agrees to Provide Company a minimum of _______ hrs. per week to the Company. Rights Responsibilities, func tions and objectives of each party in the coordination,

supervision and evaluation of the care or services provided. Services will be controlled through Quality A ssurance Program as well as daily notes

review and patient satisfaction questionnaire form. Be the case manager unless otherwis e expect ed. Case Manager s hall include initial

assessment of the patient and family for appr opriateness of acceptance for home health services, establishment and period review of plan of care, Implementation of medical treatment when ordered, referra l, follow up, provision and supervision of nursing care, coordination of services given by other heal th care providers, and documentation of all activities and findings.

Know the philosophies, purposes, policies and standards of the Ho me Health and their nursing service department and provider for t here explanation and im plementation to the Home Health Aide.

Assess in depth upon the admission of the pati ent, the patient’s physical and emotional status, level of competency, home environment, and safety fa ctors. Family or household member’s ability to assist with care and the need of the patient. There are incorporated into the admission notes.

Formulate a nursing care plan with goals i ndicated and the means of implementing the correct procedures to attain these goals.

Records all clinical and progr ess notes and enters them in to the patient’s permanent record files.

Weekly review the utilization and progress of the patient with the supervisor and attending physician necessary.

Has knowledge of patient’s condition at all times and informs the physician and the Nursing Director immediately of any change in the patient’s c ondition that warrants attention. Also observes, evaluated and reports to the physic ian the patient’s reaction to drugs and treatments.

Page 1

Interprets to the patient and family the ex pectations of the diagnosis and the nat ure of the treatment consistent with the action and wishes of the physician. Interprets to the physician social and physical factors in the environment that affect patient care.

Observe and evaluated potential danger of dis abling conditions and indic ates preventive and corrective measures.

Is responsible for the execution of the physi cians and keeps the ph ysician informed of all pertinent information concerni ng the patient’s condition and re sponse to treatment. Give skills of care patients.

Extends physical therapy services in carrying out the rehabilitation of nursing care. Obtains laboratory specimens when indicated per Meds orders. Meet weekly with Nursing Director surveying, analyzing, and determining staff

requirements for her assigned patients. Coordinates treatment with physical therapy personnel. The home health aide patient services sha ll be evaluated by the case manager in the

patients home as frequently as necessary to assure safe, adequate care or at least every 3 months.

Helps the family accept responsibilities for providing care. Teaches and supervises family members regarding care of the patient.

Assures the responsibility for orientation of new personnel and participates in in-services training programs.

Schedules his/ her daily itinerary primarily based the priority of care needed, length of time visits will require, proximity to other patients to be visited and other related factors.

A weekly itinerary is to be projected for the regularly scheduled visits, allowing time for new admissions, emergency cases, and Home Health Aide introduction.

Must advise the office of any itinerary c hanges and where she c an be contracted at all times while in the field. She should call the office between 9:00/10:00AM and 2:00/4:00PM each day.

Responsible for the certification and recertification of the Plan of Treatment. Performs other related duties as assigned by the Administrator. Assure that progress reports as assigned by the Administrator Assure that progress reports are made to t he physician for a patient under medical care

when that patients condition changes or there are deviations from the Plan of Treatment. The Registered Nurse is r esponsible for all clin ical records for each patient receiving care,

and may assign selected portions of Patients’ care to Licensed Practical nurses and Home Health Aides. In such circumstances, The R egistered Nurse retains responsibility for the care given. Supervisory visits shall be made to the patient’s residence.

PAYMENT:

Company shall pay Contractor a fee of ___________ per/Hr. { } Per Visit { } on a bi-weekly basis for services performed pursuant to the agreement. CONFIDENTIALITY OF PROPERTY INFORMATION Contractor agree, during or after the terms of this Agreement, to review, examine, inspect or obtain client information only for the purposes described above, and to otherwise hold such information confidential and secret pursuant to the terms of Agreement. Page 2

BE IT KNOWN That the Company has or shall furnish t o the Contractor certain confidential information, described on attached document and may further allow repres entative of the Company, all of the following condition.

The Contractor agrees to hold a ll confidential or proprietary information or trade secrets (“Information”) in trust and confidence and agrees that it shall be used only for the contemplate purpose, and shall not be used for any other purpose or disclosed to any third party under circumstances whatsoever.

No copies may be made or retained of any written information supplied. Upon demand by the Company, a ll information, including wr itten notes, photographs, and

memoranda shall be promptly returned to t he Company. The Contractor shall retain no copies or written documentation relating hereto.

All clients inf ormation or any other inform ation shall not be disclosed to any employee, consultant or third party unless said party agreed to execute

Be bound by the terms of this Agreement, and di sclosure by the Company is first approved. Its is understood that the undersigned shall hav e no obligations with respect to any

information known by the Contractor or as may be generally known within the industry prior to date on this Agreement, or that shall become common knowledge within t he industry thereafter.

The Contractor acknowledge the informati on disclosed herein is proprietary or trade secrets and in the event of any breach, The Company shall be a ti tled to injunctive relief as a cumulative and not necessarily or exclusive remedy to a claim for monetary damages.

LIMITED EFFECT OF WAIVER BY COMPANY

Shall waive breach of any prov ision of this Agreement by the Contractor. That waiver will not operate or be constructed as a waiver of further breach between The Contractors.

SEVERABILITY IF:

For any reason, any provision of this agreement is held invalid. All other provisions of this Agreement is held inv alid or cannot be enforced than to t he full extend permitted by law any prior Agreement between the Company (and any predecessor thereof) and the Contractor shall be deemed reinstated as if Agreement has not been executed.

Assumption of Agreement by Company’s Successors and assignees. The company’s rights and oblig ations under the Agreement will ins ure the benefit and

the biding upon the Company’s succes sors and assigned and shall continue and be binding upon parties from year to year unless terminated by either party with (30) days written notice. If the Contra ctor fails to perform acc ounting to the Agreement, The Company will terminate services with (24) hours notice.

Contract will be reviewed annually.

Signed this _________________ day of _____________________ 20______ Contractor Signature: ____________________________________ Administrator Signature: __________________________________ Witness: _______________________________________________

Prepared by the Florida Health Care Association with the assistance of the Alzheimer Resource Center of Tallahassee, Florida to meet the statutory requirement of 400.4785(1) (a) F.S.

ALZHEIMER’S DISEASE (AD) AND RELATED DEMENTIAS History Alzheimer’s disease (AD) was first discovered in 1906 by a German doctor named Alois Alzheimer. It is a disorder of the brain, causing damage to brain tissue over a period of time. The disease can linger from 2 to 25 years before death results. AD is a progressive, debilitating and eventually fatal neurological illness affecting an estimated 4-5 million Americans. It is the most common form of dementing illness. Alzheimer’s disease is characterized clinically by early memory impairment followed by language and perceptual problems. This disease can affect anyone - it has no economic, social, racial or national barriers. Causes There is no one cause for Alzheimer’s disease. AD may be sporadic or passed through the genetic make-up. The disease causes gradual death of brain tissue due to biochemical problems inside individual brain cells. The symptoms are progressive, but there is great variation in the rate of change from one person to another. Although in the early stages of Alzheimer’s the victim may appear completely healthy, the damage is slowly destroying the brain cells. The hidden process damages the brain in several ways: • Patches of brain cells degenerate (neuritic plaques) • Nerve endings that transmit messages become tangled (neurofibrillary tangles) • There is a reduction in acetylcholine, an important brain chemical (neurotransmitter) • Spaces in the brain (ventricles become larger and filled with granular fluid) • The size and shape of the brain alters - the cortex appears to shrink and decay Understandably, as the brain continues to degenerate, there is a comparable loss in mental functioning. Since the brain controls all of our bodily functions, an Alzheimer victim in the later stages will have difficulty walking, talking, swallowing and controlling bladder and bowel functions. They become quite frail and prone to infections such as pneumonia. Dementia vs. Normal Aging As a person grows older, he/she worries that forgetting the phone number of a best friend must mean he/she is becoming demented or getting Alzheimer’s disease. Forgetfulness due to aging or increased stress is not normal aging and is not dementia. “Dementia” is an encompassing term for numerous forms of memory loss. There are many types of dementia such as Alzheimer’s disease, Multi-Infarct dementia or Parkinson’s disease. When a person has dementia, he/she will lose the ability to think reason and remember and will inevitable need assistance with everyday activities such as dressing and bathing. Changes in personality, mood are also symptoms of dementia. Many dementias are treatable and reversible. Alzheimer’s disease is the most common form of untreatable, irreversible dementia.

Alzheimer’s Disease - Stages of Progression Alzheimer’s Disease can be characterized as having early, middle, and late stages through which the patient gradually progresses, but not at a predictable rate. The range of the course of the disease is 2-25 years. NOTE: Stages very often overlap. Everyone progresses through these stages differently. First Stage: This is a very subtle stage usually not identified by either the impaired person or the family as the beginning signs of the disease. Subtle changes in memory and language along with some confusion occur at this time. The family usually denies or excuses the performance deficiencies at this stage. • Forgetfulness/memory loss • Impaired judgment • Trouble with routines • Lessening of initiative • Disorientation of time and places • Depression • Fearfulness • Personality change • Apraxia (forgetting how to use tools and equipment) • Anomia (forgetting the right word or name of a person) Second Stage: As Stage 1 moves onto Stage 2, there is usually a particular significant event which forces the family (and impaired person) to consider that something is really wrong. At this time, they usually go to a doctor to diagnose the problem. • Poor short-term memory • Wandering (searching for home) • Language difficulties • Increased disorientation • Social withdrawal • More spontaneity, fewer inhibitions • Agitation and restlessness, fidgeting, pacing • Developing inability to attach meaning to sensory perceptions: (taste, touch, smell, sight,

hearing) • Inability to think abstractly • Severe sleep disturbances and/or sleepiness • Convulsive seizures may develop • Repetitive actions and speech • Hallucinations • Delusions

Third (Final Stage): This stage is the terminal stage and may last for months or years. The individual will eventually need total personal care. They may no longer be able to speak or recognize their closest relatives. • Little or no memory • Inability to recognize themselves in a mirror • No recognition of family or friends • Great difficulty communicating • Difficulty with coordinated movements • Becoming emaciated in spite of adequate diet • Complete loss of control of all body functions • Increased frailty • Complete dependence COMMON PROBLEMS WITH DEMENTIA Delusions

Suspiciousness: accusing others of stealing their belongings People are “out to get them”

Fear that caregiver is going to abandon (results in AD person never leaving caregiver’s side) Current living space is not “home” Hallucinations Seeing or hearing people who are not present Repetitive actions or questions They forget they asked the question Repetitive action such as wringing a towel Wandering Pacing Sundowning: trying to get “home” Generally feeling uncomfortable or restless Increased agitation at night Losing thing/Hiding things Simply do not remember where items are Might hide things so that people don’t “steal” them Inappropriate sexual behavior Person with AD loses social graces and is only doing what feels good Agnosia: inability to recognize common people or objects

A wife of forty years will become a stranger to the person with AD; he might even think she is the hired help Might not recognize a spatula or the purpose of the spatula and/or cannot verbalize the name or purpose of the object

Apraxia: loss of ability to perform purposeful motor movements Cannot tie a shoe or manipulate buttons on a shirt Catastrophic reactions (Causes) AD person often becomes excessively upset and can experience rapidly changing moods. The person becomes overwhelmed due to factors such as too much noise, too many people around, unfamiliar environment, routine change, being asked to many questions, being approached from behind. (Reactions) AD person may become angry, agitated, weepy, stubborn or physically violent. It is best to attempt to avoid catastrophic reactions rather than dwell on how to handle them. HANDLING DISTURBING BEHAVIORS One of the most difficult challenges for caregivers is how to handle some of the disturbing behaviors that Alzheimer’s can cause. Symptoms such as delusion, hallucinations, angry outbursts, suspiciousness, failure to recognize familiar people and places are often the most upsetting behaviors for families. The following points may help in responding to disturbing symptoms. First, try to understand if there is a precipitating factor causing the behavior. Were there household changes, too much noise or activity, was the daily routine upset? Time of day can also affect behavior (Sundowning). Being aware of these factors can help to better plan activities or anticipate problems. 1. Keep tasks, directions and routine simple without being condescending 2. Always give the person plenty of time to respond 3. Attempt to remain calm and remind yourself that the behavior is due to the disease 4. Avoid arguing 5. Write down the answers to frequently asked questions, then remind them to look at the

message 6. Reduce environmental noise: television, radio, too many people talking 7. Use distraction when unacceptable behavior starts: bring them into a different room, start

talking about childhood or another favorite topic, show them magazines, ask them to help you do something like dusting or sweeping

8. Do not overreact or scold for problem behavior: redirect or distract 9. Be reassuring with touch, eye contact and tone of voice 10. Find the familiar: old pipe, favorite chair, family pictures 11. Avoid denying hallucinations: try non-committal comments like, “You spoke with your

mother, I miss my mother too” 12. Be sure to inform physician of hallucinations, no matter how tame 13. Restless behavior or pacing is usually unavoidable, however you can make the environment

safe by installing locks that are above reach, remove unnecessary obstacles, make sure the person is wearing some kind of identification

Alzheimer Resource Center of Tallahassee: (850) 561-6869 Website: www.arc-tallahassee.org

Alzheimer’s Foundation of America Website: http://www.alzfdn.org

NURSING CARE SERVICES, INC.

Employee Name: ___________________________________________ Date: ________________________ By my signature I attest that I have received all documentation regarding Alzheimer’s disease, (AD) and related dementia. Employee Signature: __________________________________________ Date: ________________________

NURSING CARE SERVICES, INC. HEPATITIS “B” VACCINATION CONSENT

1. The vaccine will be administrated in a series if three (3) doses: the initial dose, the

second dose, a month later, and the final dose (6) six months after the first. I understand I must complete the series if doses for full immunization.

2. Id I receive the vaccine, I have a 90-95% chance of developing antibodies to the Hepatitis B surface antigen and there immunity to the infection of the Hepatitis B virus.

3. The vaccine may not be effective if am already incubating the Hepatitis B virus.

4. The duration of immunity is unknown at this time and I may require a booster in five (5) years.

5. The vaccine only protects against the Hepatitis B virus and does not confer immunity against the Hepatitis A or non-A/ non-B agents.

6. After receiving the information concerning the Hepatitis B vaccination. I understand the benefits and risks of the Hepatitis B vaccination and have had the opportunity to ask questions.

I, ______________________________________, request to be vaccinated with the Hepatitis B vaccine.

HEPATITIS B VACCINATION DECLINATION I, ______________________________________, decline the Hepatitis B vaccine. By doing so I understand that due to my occupations exposure to blood or other infectious materials, I may be at risk of acquiring the Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at not charge to myself. However, I decline the vaccine at this time. I understand that be declining this vaccine, I Continue to be at risk of acquiring Hepatitis B. If in the future I choose be vaccinated wit the Hepatitis B vaccine, I can receive the vaccine series at no charge. ______________________________________________ ________________________

Signature Date ______________________________________________ ________________________

Witness Date

NURSING CARE SERVICES, INC.

POLICY ON JOBS

As an employee of NURSING CARE SERVICES, INC., I understand that the job I’m being hired to perform belongs to ________________________________________. I also understand that it is illegal for me to transfer any case to another Agency or take ownership of any job that I’m employed in. Should I act underhandedly and take over such a job so that I may be paid directly by the client, to the exclusion of my employer, or transfer any case to another Agency. I will be in violation of State, Federal and Agency rules and will accordingly pay $10,000.00 to: ___________________________________________. ______________________________________________ ________________________ Signature Date ______________________________________________ ________________________ Administrator Date

NURSING CARE SERVICES, INC.

WAIVER OF RIGHTS

I, the undersigned, underst and that the hazards of my job; have been fully explained to me by my supervisor: ______________________________________ I further acknowledge that my employee has s upplied me and/or I have supplied the following Personnel Protective Equipment: I understand that it is necessary for me to use this Personnel Protective Equipm ent to fully protect myself from the hazard of my job. I realize that i n the event I do not use this Personnel Protective Equipment, I may be denied up to 25% of the i ndemnity portion of my cl aim. As provided by the State’s Workers Compensation statutes. _______________________________________ _____________________________ Employee Date _______________________________________ _____________________________ Witness Date

NURSING CARE SERVICES, INC.

PERSONNEL POLICIES SAFE AND ADEQUATE CARE OF PATIENT

Nursing Care Services, Inc. hereby sets forth the following guidelines to be adhering to by all employees of this company. Upon arrival at a patient’s home, the nurse/employee shall make ph ysical checks of the essential safety devices such as proper locks on doors, proper ventilation, proper beds/chair, proper bedding, adequate bathroom systems, and adequate kitchen with all electrical devices; to be sure they are in good working condition. The employee shall also check the appropriate box es on our “Patient Safety Checklist” and make the appropriate boxes on our Patient S afety C hecklist and make the appropri ate report to our offices as soon as possible. Upon receipt of such report, The Director of Nurs ing shall take necessary action to ensure that any safety deficiencies are corrected. __________________________________________________ ___________ _______________

Employee Date

NURSING CARE SERVICES, INC. UNIVERSAL PRECAUTIONS

It is the policy of our Agency that home health care providers will adhere to the following when delivering care to all patients. By adhering to t he following univ ersal precautionary measures, the risk of transmission of disease is decreased when the infection status of the patient is unknown. Gloves must be worn when delivering patient care, handling spec imens, doing domestic cleaning, and handling items that may be soiled with blood or bloody fluids. Gloves or aprons must be worn during procedur es or while managing a patient situation when there will be exposure to body fluids, blood, draining wounds or mucous membranes. Masks and p rotective eyewear or face shield must be worn during procedures that are likely to generate of body fluids, blood or when the patient is coughing excessively. Gloves are to be worn when handling all s pecimens to prevent contamination from body specimen’s fluids or blood. Hand washing: Hands must be wa shed before gloving and after gl oves are removed. Hands and other skin surfaces must be washed immediately and thoroughly of contaminated with body fluids or blood and after all patient care activities. Home health care providers who have open cuts, so res or dermatitis on their hands, must w ear gloves for all patient contact. _____________________________________________________ ___________________

Employee Date

Nursing Care Services Inc.

Employee Evaluation Sheet – Probation/Annual

Name of Employee: _________________________________ Date of Employment: ______________________ Position: ______________________________ Immediate Supervisor: _________________________________

EVALUATION

Exceptional Satisfactory Non-satisfactory Personal Experience Punctuality Attitude to work Attitude to other workers and staff

Attitude to patients Confidentiality Responsibility Initiative/Duties Moral/Ethics

Comments: ____________________________________________________________________________________________________________________________________________________________________________________ Employee / Contractor Signature: _______________________________________________________________ _________________________________________________ ___________________________ Signature of Administrator or D.O.N Date

# ITEMS TO EVALUATE MET NOT MET

1 EMPLOYEE PRESENTATION TO CLIENT

2 UNDERSTANDING OF TASKS FROM ASSIGNMENT SHEET

3 BATH: SHOWER, TUB, BED,CHAIR

4 GROOMING/CARE FOR CLIENTS DENTURES

5 DRESSINGS

6 MOBILITY/TRANSFER/HOYER LIFT

7 ROM

8 PERINEAL CARE/EMPTY URINARY DRAINAGE BAGS

9 TEMPERATURE: ORAL TYMPANIC RECTAL

10 PULSE: APICAL RADIAL

11 RESPIRATION

# OTHER INSTRUCTIONS: MET NOT MET

1 APPLY CREAM OR OINTMENTS TO ESPECIFICS INSTRUCTIONS

2 HOUSEKEEPING

3 MEALS SET UP/PREPARATIONS

4 GET HELP TO MOVE CLIENT UP IN BED

ADITIONAL TREATMENTS OR OBSERVATIONS:

EVALUATION:____________________________________

EMPLOYEE:___________________________________________________ DATE:__________________

RN SUPERVISOR:______________________________________________ DATE:__________________

AHCA Form # 3100-0008, October 2009 Section 59A-35.090(3)(b)2, Florida Administrative Code Page 1 of 4 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

Authority: As specified in subsection 408.809(2), Florida Statutes (F.S.), proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health, the Agency for Persons with Disabilities, or the Department of Children and Family Services satisfies the requirements provided that such proof is accompanied, under penalty of perjury, by an affidavit of compliance with the provisions of sections 435.04 and 408.809(5) F.S.

Please complete the following and attach to the proof of level 2 compliance described above.

Name:

As an applicant for employment with:

Address of Health Care Provider:

I hereby attest to meeting the requirements for employment and that I have not been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:

Criminal offenses found in section 435.04, F.S

a) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.

(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.

(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.

(d) Section 782.04, relating to murder.

(e) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.

(f) Section 782.071, relating to vehicular homicide.

(g) Section 782.09, relating to killing of an unborn quick child by injury to the mother.

(h) Section 784.011, relating to assault, if the victim of the offense was a minor.

(i) Section 784.021, relating to aggravated assault.

(j) Section 784.03, relating to battery, if the victim of the offense was a minor.

AFFIDAVIT OF COMPLIANCE WITH Background Screening

Requirements

AHCA Form # 3100-0008, October 2009 Section 408.809(2), Florida Statues Page 2 of 4 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

(k) Section 784.045, relating to aggravated battery.

(l) Section 784.075, relating to battery on a detention or commitment facility staff.

(m) Section 787.01, relating to kidnapping.

(n) Section 787.02, relating to false imprisonment.

(o) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.

(p) Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person.

(q) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.

(r) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.

(s) Section 794.011, relating to sexual battery.

(t) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority.

(u) Chapter 796, relating to prostitution.

(v) Section 798.02, relating to lewd and lascivious behavior.

(w) Chapter 800, relating to lewdness and indecent exposure.

(x) Section 806.01, relating to arson.

(y) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.

(z) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.

(aa) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.

(bb) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.

(cc) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.

(dd) Section 826.04, relating to incest.

(ee) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.

(ff) Section 827.04, relating to contributing to the delinquency or dependency of a child.

(gg) Former s. 827.05, relating to negligent treatment of children.

(hh) Section 827.071, relating to sexual performance by a child.

(ii) Section 843.01, relating to resisting arrest with violence.

(jj) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.

AHCA Form # 3100-0008, October 2009 Section 408.809(2), Florida Statues Page 3 of 4 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

(kk) Section 843.12, relating to aiding in an escape.

(ll) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.

(mm) Chapter 847, relating to obscene literature.

(nn) Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang.

(oo) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor.

(pp) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.

(qq) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.

(rr) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.

(ss) Section 944.47, relating to introduction of contraband into a correctional facility.

(tt) Section 985.701, relating to sexual misconduct in juvenile justice programs.

(uu) Section 985.711, relating to contraband introduced into detention facilities.

(4) Standards must also ensure that the person:

(a) For employees or employers licensed or registered pursuant to chapter 400 or chapter 429, does not have a confirmed report of abuse, neglect, or exploitation as defined in s. 415.102(6), which has been uncontested or upheld under s. 415.103.

(b) Has not committed an act that constitutes domestic violence as defined in s. 741.30.

Criminal offenses found in section 408.809(5), F.S

(a) Any authorizing statutes, if the offense was a felony.

(b) This chapter, if the offense was a felony.

(c) Section 409.920, relating to Medicaid provider fraud, if the offense was a felony.

(d) Section 409.9201, relating to Medicaid fraud, if the offense was a felony.

(e) Section 741.28, relating to domestic violence.

(f) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.

(g) Section 810.02, relating to burglary.

(h) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.

(i) Section 817.234, relating to false and fraudulent insurance claims.

(j) Section 817.505, relating to patient brokering.

(k) Section 817.568, relating to criminal use of personal identification information.

(l) Section 817.60, relating to obtaining a credit card through fraudulent means.

AHCA Form # 3100-0008, October 2009 Section 408.809(2), Florida Statues Page 4 of 4 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

(m) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.

(n) Section 831.01, relating to forgery.

(o) Section 831.02, relating to uttering forged instruments.

(p) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.

(q) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.

(r) Section 831.30, relating to fraud in obtaining medicinal drugs.

(s) Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony.

Affidavit Under penalty of perjury, I, , hereby swear or affirm that I meet the

requirements for qualifying for employment in regards to the background screening standards set forth in

sections 435.04 and 408.809(5),F.S. In addition, I agree to immediately inform my employer if convicted

of any of the disqualifying offenses while employed by any health care provider licensed pursuant to

Chapter 408, F.S.

Signature Title Date