Peaceful Home Care LLC

Peaceful Home Care

845 Sir Thomas Court, Suite A-2

Harrisburg, PA 17109

Phone Number: 717-810-1977

EMPLOYMENT APPLICATION FORM

Peaceful Home Care does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.

PLEASE PRINT AND COMPLETE THE ENTIRE APPLICATION.

IF ANY OF THE FOLLOWING QUESTIONS ARE NOT ANSWERED IN A COMPLETE AND ACCURATE FASHION, A SIGNIFICANT DELAY AND / OR THE INABLILITY TO PROCESS THIS APPLICATION MAY OCCUR.

Email address We'll never share your email with anyone else.

DATE

LAST NAME

FIRST NAME

MAIDEN/PRIOR ALIASES

ADDRESS

CITY, STATE, ZIP

PHONE

CELL

SOCIAL SECURITY NUMBER

DATE OF BIRTH

(A CRIMINAL BACKGROUND CHECK AND CHILD ABUSE CLEARANCE IS REQUIRED)

POSITION APPLIED FOR

AVAILABLE TO WORK

FULL TIME

PARTTIME

TEMPORARY/EXPLAIN

ARE THERE ANY DAYS OR HOURS YOU WOULD BE UNABLE OR UNWILLING TO WORK?

YES

IF YES,SPECIFY

DATE AVAILABLE TO START

SALARY DESIRED

LEAST ACCEPTABLE SALARY

HOW DID YOU HEAR ABOUT PEACEFUL HOME CARE? (PLEASE BE SPECIFIC)

HAVE YOU EVER FILLED AN APPLICATION OR BEEN EMPLOYED WITH PEACEFUL HOME CARE?

YES

IF YES, PLEASE EXPLAIN

DO YOU HAVE THE LEGAL RIGHT TO BE EMPLOYED IN THE UNITED STATES?

YES

WORK HISTORY

LIST THE NAMES OF ALL EMPLOYERS,GIVING THE MOST RECENT POSITION FIRST. PLEASE GIVE THE MONTH AND YEAR FOR EACH POSITION LISTED. IN ADDITION, BE SURE TO LIST ALL HEALTH OR HUMAN SERVICE PROVIDERS FOR WHICH YOU HAVE WORKED. IF YOU NEED ADDITIONAL SPACE, PLEASE CONTINUE ON ANOTHER SHEET OF PAPER.

EMPLOYER NAME

ADDRESS

PHONE ( )

JOB TITLE

SUPERVISOR

REASON FOR LEAVING

DATES EMPLOYED FROM (MO/YR)

TO (MO/YR)

SALARY STARTED

SALARY ENDED

DUTIES

EMPLOYER NAME

ADDRESS

PHONE ( )

JOB TITLE

SUPERVISOR

REASON FOR LEAVING

DATES EMPLOYED FROM (MO/YR)

TO (MO/YR)

SALARY STARTED

SALARY ENDED

DUTIES

EMPLOYER NAME

ADDRESS

PHONE ( )

JOB TITLE

SUPERVISOR

REASON FOR LEAVING

DATES EMPLOYED FROM (MO/YR)

TO (MO/YR)

SALARY STARTED

SALARY ENDED

DUTIES

EMPLOYER NAME

ADDRESS

PHONE ( )

JOB TITLE

SUPERVISOR

REASON FOR LEAVING

DATES EMPLOYED FROM (MO/YR)

TO (MO/YR)

SALARY STARTED

SALARY ENDED

DUTIES

HAVE YOU SIGNED A RESTRICTIVE COVENANT/NON-COMPETE AGREEMENT OR CONFIDENTIALITY STATEMENT AT A PRIOR JOB?

YES

IF YES, PLEASE EXPLAIN

HAVE YOU EVER BEEN DISCIPLINED OR DISCHARGED BY AN EMPLOYER FOR CLIENT ABUSE OR NEGLECT?

YES

IF YES, PLEASE EXPLAIN

HAVE YOU EVER BEEN CONVICTED (OR PLEAD GUILTY) OF ANY CRIME (FELONY, MISDEMEANOR, OR SUMMARY OFFENSE) INCLUDING DRIVING WHILE INTOXICATED?

YES

IF YES, PLEASE EXPLAIN

(INFORMATION REGARDING CONVICTIONS WILL NOT NECESSARILY DISQUALIFY YOU FOR EMPLOYMENT, BUT WILL BE REVIEWED IN LIGHT OF THE DUTIES AND RESPONSIBLILITIES OF THE POSITION BEING SOUGHT)

DRIVER'S LICENSE NUMBER & STATE*

CURRENTLY VALID

*A VALID LICEENSE AND ACCEPTABLE DRIVING RECORD ARE REQUIRED FOR MANY POSTIONS & PROOF OF INSURANCE*

EDUCATION

HIGH SCHOOL

NAME

ADDRESS

YEARS COMPLETED

GRADUATED?

YES

MAJOR

DEGREE

UNDERGRADUATE COLLEGE

NAME

ADDRESS

YEARS COMPLETED

GRADUATED?

YES

MAJOR

DEGREE

GRADUATE / PROFESSIONAL

NAME

ADDRESS

YEARS COMPLETED

GRADUATED?

YES

MAJOR

DEGREE

PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

LIST ANY PROFESSIONAL LICENSES

LICENSE NUMBER

HAS YOUR PROFESSIONAL LICENSE EVER BEEN SUSPENDED OR REVOKED?

YES

IF YES, PLEASE EXPLAIN

RELATED INFORMATION

PLEASE LIST ANY OTHER QUALIFICATIONS, PROFESSIONAL ORGANIZATIONS, AND/OR VOLUNTEER EXPERIENCES THAT ARE APPLICABLE TO THE POSTION FOR WHICH YOU ARE APPLYING. YOU MAY EXCLUDE ANY WHOSE NAME WOULD INDICATE THE RACE, RELIGION, CREED, COLOR, NATIONAL ORIGIN, OR ANCESTRY OF ITS MEMBERS.

IF YES, PLEASE EXPLAIN

REFERENCES

IF YES, PLEASE EXPLAIN

ARE YOU CURRENTLY EMPLOYED?

YES

IF YES, MAY WE CONTACT YOUR PRESENT EMPLOYER?

YES

GIVE THREE WORK-RELATED REFERENCES:

NAME

ADDRESS

PHONE

OCCUPATION

NAME

ADDRESS

PHONE

OCCUPATION

NAME

ADDRESS

PHONE

OCCUPATION

AUTHORIZATION OF RELEASE OF INFORMATION

I hereby give Peaceful Home Care, and any of its affiliates and divisions, the right to thoroughly investigate my past employment, education, police record, activities, and I release from all liability all persons, companies, and corporations supplying such information. I indemnify Peaceful Home Care against any liability which might result from conducting such an investigation. I understand that any false answers or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Peaceful Home Care and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon Peaceful Home Care unless made in writing by the Owner / President / Chief Executive Officer. If any employment relationship is established, I understand I have the right to terminate my employment at any time for any reason or no reason at all, with or without prior notice, and that Peaceful Home Care retains the same right.

Peaceful Home Care does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.

The direct care workers of Peaceful Home Care are required to complete a minimum of 40 hours of training and a competency evaluation, or a state certification program. Training includes information regarding personal hygiene, safe transfer techniques, infection control, and basic nutrition. They also receive a minimum of 16 hours of supervised practical training before having direct contact with a consumer or verification of prior experience.

Each employee must complete all new hire trainings as required by The Department of Health to meet licensure competency requirements.

Homecare services include: Assistance with self-administration of medications, personal care such as assistance with personal hygiene, dressing, and feeding, homemaking such as assistance with household tasks housekeeping, shopping, meal planning and preparation, and transportation, companionship, respite care such as assistance and support provided to the family; and other non-skilled services.

Peaceful Home Care provides non-skilled services to individuals in their homes or other independent living environments. We conduct criminal background checks, child abuse clearance and finger printing on all staff. We also conduct Tuberculosis screenings for all direct care workers and office staff with direct consumer contact upon hiring and on a yearly basis. We ensure the competency of individuals that provide care by making sure they: Possess a valid nurses license; or demonstrate competency by passing a competency examination developed by the Pennsylvania Homecare Association and approved by The Pennsylvania Department of Health; or have successfully completed at least one of the following: The nurse aide certification and training program sponsored by the Department of Education, a home health aide training program meeting the requirements of 42 C.F.R 484.36, a training program developed by a Peaceful Home Care , or other entity that meets the requirements, a training program meeting the training standards imposed on Peaceful Home Care by virtue of their participation as a provider in a Medicaid Waiver or other publicly funded program providing home and community based services, a program approved by the department and published in the Pennsylvania Bulletin or posted on the Department's website. We review direct care competency at least annually, more frequently if warranted, to ensure direct care workers have the proper skills to provide the care required for consumers.

NAME OF APPLICANT (PRINT)

DATE

SIGNATURE OF APPLICANT

DATE

CONSUMER RIGHTS

(Defined in the PA Department of Health Regulations Chapter 611.57 Consumer Protections)

(a) Consumer rights. The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights:

(1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk.

(2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

(b) Prohibitions. No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

(c) Information to be provided. Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood:

(1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services.

(2) The hours when those service will be provided.

(3) Fees and total costs for those services on an hourly or weekly basis.

(4) Who to contact at the department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or registry.

(5) The Department's complaint Hot Line (1-866-826-3644) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).

(6) The hiring and competency requirements applicable to the direct care workers employed by the home care agency or referred by the home care registry.

(7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

NAME OF APPLICANT (PRINT)

DATE

SIGNATURE OF APPLICANT

DATE

Your application will be considered for any vacancies for up to 90 days after it is received.

Peaceful Home Care is an Equal Opportunity Employer

_____________

OLDER ADULTS PROTECTIVE SERVICES ACT May 2011

Prohibitive Offenses Contained in Act 169 of 1996 as Amended by Act 13 Dept. of Aging

Following Offenses as Contained in PA Crimes Code (18 Pa. C.S.)

Offense Code Prohibitive Offense Description Type/Grading of Conviction

CC2500 Criminal Homicide Any

CC2502A Murder I Any

CC2502B Murder II Any

CC2502C Murder III Any

CC2503 Voluntary Manslaughter Any

CC2504 Involuntary Manslaughter Any

CC2505 Causing or Aiding Suicide Any

CC2506 Drug Delivery Resulting in Death Any

CC2702 Aggravated Assault Any

CC2901 Kidnapping Any

CC2902 Unlawful Restraint Any

CC3121 Rape Any

CC3122.1 Statutory Sexual Assault Any

CC3123 Involuntary Deviate Sexual Intercourse Any

CC3124.1 Sexual Assault Any

CC3125 Aggravated Indecent Assault Any

CC3126 Indecent Assault Any

CC3127 Indecent Exposure Any

CC3301 Arson and Related Offenses Any

CC3502 Burglary Any

CC3701 Robbery Any

CC3901 Theft

CC3921 Theft By Unlawful Taking

CC3922 Theft By Deception

CC3923 Theft By Extortion

CC3924 Theft By Property Lost Any

CC3925 Receiving Stolen Property ONE (1) FELONY

CC3926 Theft of Services or

CC3927 Theft By Failure to Deposit TWO (2)

CC3928 Unauthorized Use of a Motor Vehicle MISDEMEANORS

CC3929 Retail Theft within the 3900 Series

CC3929.1 Library Theft (CC3901-CC3934)

CC3929.2 Unlawful Possession of Retail or Library Theft Instruments

CC3929.3 Organized Retail Theft

CC3930 Theft of Trade Secrets

CC3931 Theft of Unpublished Dramas or Musicals

CC3932 Theft of Leased Properties

CC3933 Unlawful Use of a Computer

CC3934 Theft From a Motor Vehicle

CC4101 Forgery Any

CC4114 Securing Execution of Documents by Deception Any

CC4302 Incest Any

CC4303 Concealing Death of a Child Any

CC4304 Endangering Welfare of a Child Any

CC4305 Dealing in Infant Children Any

CC4952 Intimidation of Witnesses or Victims Any

CC4953 Retaliation Against Witness or Victim Any

CC5902B Promoting Prostitution Felony

CC5903C Obscene or Other Sexual Materials to Minors Any

CC5903D Obscene or Other Sexual Materials Any

CC6301 Corruption of Minors Any

CC6312 Sexual Abuse of Children Any

Offenses as Contained in PA Controlled Substance, Drug, Device & Cosmetic Act (P.L. 233, No. 64)-- PARTIAL LISTING*

Offense Code Prohibitive Offense Description Type/Grading of Conviction

CS13A12 Acquisition of Controlled Substance by Fraud Felony

CS13A14 Delivery by Practitioner Felony

CS13A30 Possession with Intent to Deliver Felony

CS13A35 (i), (ii), (iii) Illegal Sale of Non-Controlled Substance Felony

CS13A36 Designer Drugs Felony

CS13Axx* ANY OTHER FELONY DRUG CONVICTION APPEARING ON PA RAP SHEET

Effective February 4, 2004, facilities will not be sanctioned for hiring or continuing to employee individuals who demonstrate rehabilitation by evidence for a minimum five-year aggregate work history in care-dependent services, without incident, from either the date of conviction or release from incarceration, whichever is later. Applicants are responsible for providing official verification of such dates. Care-dependent services include healthcare, eldercare, childcare, mental health, mental retardation, or care of the disabled. Facilities must reasonably investigate the character of an individual with a previously disqualifying criminal offense by means of interviews, references and evidence of work history. Facilities that hire such as individual are required to obtain specific employer-provided documentation of that individual's personnel file. (This provision applies to the Older Adults Protective Services Act (OAPSA) only).

I understand that I must be dismissed from employment if I have been convicted of any of the crimes listed above within the past five years.

I hereby swear / affirm that the information as set forth above is true and correct. I understand that the penalty for false swearing is a misdemeanor of the third degree pursuant to Section 4903(b) of the Crimes Code.

FOR ADDITIONAL EMPLOYEE STATEMENT, IF APPLICABLE.

(If ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH A SEPARATE SHEET OF PAPER)

Employee (Please Print)

DATE

Employee Signature

DATE

Witness (Please Print)

DATE

Witness Signature

DATE

(DPW, CY&F) June 8, 2005, (Dept of Aging) December 23, 2003 and (PA Dept. of Aging Interim Guidance) February 6, 2004, Peaceful Home Care Revision September 2013.

P EACEFUL HOME CARE

HOME HEALTH AIDE

AGREEMENT OF HOURS TO WORK

If offered a position as a direct care professional, I have agree to be available for scheduling of cases, the following days and times. I understand that I must work at least 8 hours a week to maintain my status at Peaceful Home Care as a Direct Care Professional.

I understand that by committing to and signing this agreement, I will be given a schedule that is suitable to what I have indicated below as my starting availability as a new Home Health Aide with Peaceful Home Care.

I also understand that if I refuse to accept a schedule that I have stated I am available for, I will risk not being assigned any cases / hours to work for an unspecified period of time as it may also lead to being terminated as a Peaceful Home Care employee if there are no available hours.

If in the future, as a Home Health Aide, my schedule availability were to change after starting (i.e., for reasons such as school scheduling, another job, etc.) I will work with my direct supervisor on my schedule. However, I would continue to remain committed to work the schedule that I would be given initially until such changes would be able to be made.

Number of hours per week maximum that I am willing to work:

M	T	W	T	F	S	S

Face to Face Interview

(To be filled out during interview process by the interviewee)

A Face to Face Interview will be conducted on all potential employees prior to being hired. Additional interviews maybe required before a position may be offered to an applicant.

Please provide a copy of the following;

Social Security Card

Driver's License/Photo Id

Auto Insurance cards

Any training certificates/Competency trainings

Prior work related experiences

Dementia and Alzheimer’s experience

Signature of Interviewee

Signature of personnel coordinator / interviewer

DISCLAIMER FOR PEACEFUL HOME CARE JOB DESCRIPTION

The attached job description is to provide you with information about the position you are applying/ interviewing for. The attachment of this job description in no way implies an offer of employment.

Please sign the attached job description and return it along with your application.

JOB DESCRIPTION

Employee Name

Job Title: Home Health Aide Job Number: N/A

Business Title: N/A Job Family: Direct Care Union Title: N/A Exemption Status: Non-Exempt

Supervisor Name: Supervisor's Title:

Effective Date: Date Revised:

POSITION SUMMARY:

1. Job Activities:

Activities may include but are not limited to

- Basic housekeeping and home management necessary to ensure safe and sanitary conditions.

- Shopping assistance with or without the consumer.

- Laundry including washing, drying, putting away.

- Transportation of a consumer to complete chores or keep appointments when alternative transportation services are inappropriate or unavailable

- Meal planning, preparation, clean-up

- Escort to medical appointments

- Assisting consumer with ambulation and transfers

- Assisting with routine bodily functions, including eating, feeding, toileting, bathing, dressing, personal hygiene, grooming

- Providing health maintenance activities including activities such as skin care, mouth care, and medication assistance.

- Companion-type services including, but not limited to, assistance with transportation, letter writing, reading mail, and escorting

- Supervision of consumers for clients and safety

2. General Responsibilities:

- Become familiar with policies and procedures that are associated with Peaceful Home Care.

- Establish an effective working relationship with co-workers, management, families, consumers, and payor sources.

- Attend staff meetings, and mandatory in-service trainings as instructed

- Carry out all duties in a responsible, professional, and ethical manner upholding the mission of Peaceful Home Care .

-Perform other duties and job activities as are assigned

EDUCATION:

Less than high school diploma

High School diploma or equivalent

High School plus some college, business or technical

2-Year / Associate Degree

MENTAL AND EMOTIONAL REQUIREMENTS:

X Manage stress appropriately

X Make decisions under pressure

X Manage anger/ fear/ hostility/ violence of others appropriately

X Handel Multiple priorities

X Work Alone

Work in areas that are confined and/ or crowded

WORKING CONDITIONS (Please check one of the following):

X INSIDE

Spends approximately 75% or more of the time inside. Inside work has good ventilation, comfortable, temperature.

OUTSIDE

Spends approximately 75% of time outside.

BOTH

The activities occur inside or outside in approximately equal amounts.

HAZARDS (Please check all that apply to the position):

Exposure to toxic/caustic/chemical detergents

Exposure to extreme conditions, hot/cold

X Exposure to dust/fumes/gasses

Exposure to mechanical parts

Exposure to potential electric shock

Exposure to x-ray/electromagnetic energy

X Exposure to cigarette smoke

X Exposure to cellular telephones

Exposure to high pitched noises

X Exposure to communicable diseases

X Exposure to blood and/ or body fluids

Unprotected heights

CRT (computer) monitor

X Exposure to strong odors

Operating heavy equipment

Other (Specify)

PHYSICAL REQUIREMENTS / ACTIVITY:

SEDENTARY WORK: Prolonged periods of sitting and exert 10lbs of force occasionally.

LIGHT WORK

Exert up to 20 lbs of force occasionally, and / or up to 10lbs of force frequently.

X MEDIUM WORK

Exert up to 50lbs occasionally, and/ or up to 20lbs frequently, and/ or up to 10lbs continuously.

X MEDIUM WORK

Exert up to 50lbs occasionally, and/ or up to 20lbs frequently, and/ or up to 10lbs continuously.

HEAVY WORK

Exert up to 100lbs occasionally, and/or 50 lbs frequently, and/ or over 20 lbs continuously

VERY HEAVY WORK

Exert over 100 lbs force occasionally, and/ or over 50 lbs frequently, and /or over 20lbs continuously.

EVALUATE THE REQUIREMENTS AND ACTIVITY PERCENTAGE IN TIME FOR THIS POSITION BASED ON THE FOLLOWING: (Please see definitions on the next page)

1-Not at all (0%) 2-Occasionally (1-33%) 3-Frequently (34-66%) 4-Continuously (67-100%)

1	2	3	4		1	2	3	4
	X			Climbing			X		Lifting
	X			Balancing			X		Fingering
		X		Stooping			X		Grasping
		X		Kneeling			X		Feeling
		X		Crouching			X		Talking
	X			Crawling			X		Hearing
			X	Reaching		X			Repetitive Motions
			X	Standing		X			Reading
			X	Walking		X			Writing
		X		Pushing		X			Driving
		X		Pulling		X			Sitting
			X	Seeing		X			Distinguishing Colors

DEFINITION OF PHYSICAL ACTIVITY

CLIMBING	Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like. Using feet and legs, and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.
BALANCING	Maintaining body equilibrium to prevent falling, when walking, standing, or crouching on narrow, slippery or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
STOOPING	Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to be a considerable degree and requires full use of the lower extremities and back muscles.
KNEELING	Bending legs at knee to come to rest on knee or knees.
CROUCHING	Bending the body downward and forward by bending leg at spine.
CRAWLING	Moving about on hands and knees or hands and feet.
REACHING	Extending hand(s) and arm(s) in any direction.
STANDING	Particularly for sustained periods of time.
WALKING	Moving about on foot to accomplish tasks, particularly for long distances.
PUSHING	Using upper extremities to exert force in order to draw, drag, haul, or tug objects in a sustained motion.
PULLING	Using upper extremities to exert force in order to draw, drag, haul, or tug objects in a sustained motion.
LIFTING	Raising objects from a lower to higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires the substantial use of the upper extremities and back muscles.
FINGERING	Picking, pinching, typing, or otherwise working, primarily with fingers rather than the whole hand or arm as in handling.
GRASPING	Applying pressure to an object with fingers and palm.
FEELING	Perceiving attributes of objectives, such as shape, size, temperature, or texture by touching with skin, particularly that of the fingertips.
TALKING	Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, of quickly.
HEARING	Perceiving the nature of sounds with no less than a 40 dB loss at 500 Hz, 1,000 Hz and 2,000 Hz with or without correction. Ability to receive detailed information through oral communication, and make fine discrimination in sound, such as when making adjustments on machined parts.
READING	Looking at carefully so as to understand the meaning of something written, printed, etc.
WRITING	Expressing or communicating in written form; giving a written account of.
DRIVING	Operating a vehicle; may include transporting others.
SITTING	Being seated with the body supported by the buttocks or thighs.
SEEING	Perceiving with the eyes; looking at.
DISTINGUISHING COLORS	Having non-defective color perception
REPETITIVE MOTIONS	Substantial movements (motions) Including, but not limited to, the wrists, hands and/or fingers.

Peaceful Home Care

Acknowledgement of Job Description

I, (Please Print Name) acknowledge that I have read, and received the attached job description for the position of , which I am interviewing for today. I can complete the essential job functions with or without reasonable accommodation(s).

Applicant's Signature

DATE

Employer's Signature

DATE

EQUAL EMPLOYMENT POLICY

Peaceful Home Care does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.