* Required Information

EDUCATION (start from the latest)

School Location Date Graduated Attainment

WORK EXPERIENCE

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REFERENCES

Please list 3 people who can attest to your direct knowledge of experience working with Individuals with Developmental Disabilities

Name: Cell Phone:
Job Title: Email:
Years Known:
Name: Cell Phone:
Job Title: Email:
Years Known:
Name: Cell Phone:
Job Title: Email:
Years Known:

Job Specific Information

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT FALSIFICATION OF INFORMATION COULD LEAD TO TERMINATION AND I RELEASE THE AGENCY, REFERENCES AND PREVIOUS EMPLOYERS FROM LIABILITY IN REGARD TO THIS APPLICATION. I ALSO AUTHORIZE COMFORT HOMECARE INC TO RUN BACKGROUND CHECKS, VERIFY COLLEGE DEGREES, CONTACT REFERENCES, AND OTHER INFORMATION PERTAINING TO THIS APPLICATION. FURTHER, I UNDERSTAND THAT ANYONE WHO WILL BE DOING BACK UP IS SUBJECT TO COMFORT HOMECARE INC RULES AND STATE REGULATIONS REGARDING HIRING AND TRAINING. FAILURE OF BACKUP PROVIDERS TO MEET OUR STANDARDS COULD DISQUALIFY THEM FROM PROVIDING SERVICES.

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To help us determine the compatibility of potential Host Home Providers and people we serve, please answer the following questions so that we can learn more about you and your home.

Name: Phone:
Address: Country
Email How you heard about us?

How many people live in your home? Please include any individuals in services currently in your home.

(Anyone over the age of 18 that lives in your home will need to fill out a background check form)

Home Setting

If not, you will need to get it. We will need a copy of it.

If yes, please list the primary vehicle used for transporting yourself and the people in your home:

*If yes, please provide a copy of the policy. If not, you will need to get it

What are you looking for in the person who would live in your home?

Age
Skill Level
Abilities
Personality
Sex
Other

MOTOR VEHICLE AND CRIMINAL HISTORY CHECK
Please present Driver’s License and Social Security Card upon submittal.

First Name: Home Phone:
Last Name: Middle Name: Work Phone:
Other Name Used: Last Date Used:
Address: Email:
State: Zip Code: Cell Phone:
SSN: Sex:
DOB: Driver License #:

Last addresses for the last seven years: (List addresses beginning with the most recent)

Street: To - From City Country State Zip Years

Authorization to Release Information and Records

I, (‘APPLICANT’) understand that COMFORT HOMECARE INC will use information, to obtain one or more consumer reports and/or investigative consumer reports (“Report”) as part of the hiring or acceptance process. I also understand that if hired or accepted, to the extent permitted by law, COMFORT HOMECARE INC may obtain further Reports so as to update, renew or extend my employment or contract. I authorize all persons who may have information relevant to this investigation to disclose it to Esther House and/or their agent. I release and agree to hold harmless all persons providing such information to COMFORT HOMECARE INC, its officers, directors, employees and agents from liability on account of such disclosure. I also release and discharge COMFORT HOMECARE INC and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original. I understand COMFORT HOMECARE INC investigation may include obtaining information regarding my credit background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to COMFORT HOMECARE INC, the following information and/or copies of documents from my military service record: 00214, service record, and any disciplinary records

I understand if COMFORT HOMECARE INC makes a conditional decision to disqualify me based on all or in part on my Report, I must be notified by COMFORT HOMECARE INC seven business days of their receipt of the Report. I hereby consent to this investigation and authorize COMFORT HOMECARE INC to proceed to my background. In order to verify my identity for the purposes of Report preparation, I am voluntarily releasing my date of birth, social security number and the other information and fully understand that all employment decisions are based on legitimate non-discriminatory reasons. Additionally, I make this authorization to be valid for as long as I am an applicant, employee, or contractor with COMFORT HOMECARE INC

The name, address and telephone number of the consumer reporting agency designated to handle inquiries regarding the investigative consumer report is: ADP | 301 Remington Street, Fort Collins, CO, 80524, and can be reached by phone at 800- 367-5933 or online at www.adpselect.com By signing below, I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, and any related state summary of rights.

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FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION

Disclosure

As an applicant for employment, Independent Contractor or a current employee of COMFORT HOMECARE INC you are a consumer with rights under the Fair Credit Reporting Act. When any of the following circumstances exist, COMFORT HOMECARE INC may choose to obtain and use information contained in either a consumer report and/ or investigative consumer report from a consumer reporting agency about you: (1) when considering your application for employment, (2) when making a decision whether to offer you a contract or employment, (3) when deciding whether to continue your Independent Contract or continue your employment (if you are hired), or (4) when making other contract-related or employment-related decisions directly affecting you. For explanation purposes, a “consumer reporting agency” is a person or business which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing consumer reports for others, such as COMFORT HOMECARE INC

A “consumer report” means any written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment or contract purposes.

An “investigative consumer report” means a consumer report or portion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, associates or others with whom you are acquainted or who may have knowledge concerning any such items of information. An investigative consumer report may be requested by the employer. You may request, in writing within a reasonable time, additional disclosures regarding the nature and scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act.

Authorization By signing below, I,, hereby voluntarily authorize COMFORT HOMECARE INC to obtain either a consumer report or an investigative consumer report about me from a consumer reporting agency and to consider this information when making decisions regarding my contract eligibility or employment at COMFORT HOMECARE INC. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above.

COMFORT HOMECARE INC STATEMENT OF CONFIDENTIALITY

With constant flow of personal, confidential information pertaining to the people receiving services at COMFORT HOMECARE INC. This information needs to be passed to providers so that they can be better equipped to serve that individual. With this knowledge, we have a great responsibility to respect and maintain confidentiality about these personal matters.

Information should be shared only with people who are directly involved with the person receiving services. This includes the Interdisciplinary Team, health care professionals, and the day program employees serving this person. To share the information with others may violate confidentiality.

People with developmental disabilities may not have the skill or intellectual capacity to defend themselves if they do not agree with or believe what is said about them. so please be sensitive to anything that can undermine hard-earned dignity for the people receiving services at COMFORT HOMECARE INC.

I have read, understand, and have had any questions regarding the above information answered.

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I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.

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