Apply Online with Visiting Angels - Waco / Temple

Applicant Information
Driver License State

Organization Telephone Contact Person Dates Worked May We Contact Ver
Contact Person Telephone Position/Title Dates Known Ver

Criminal History

Name Location Major Graduate? End Date
Name Location Graduate? End Date

Live-Ins - Being a Live-In means several consecutive days of care where the caregiver stays at the care recipient's home for the entire number of days.

Skills and Preferences

Specialized Training

Additional Questions

I do hereby authorize a review and full disclosure of all records, or any part thereof, to any duly authorized agent of Visiting Angels, whether the said records are public or private, and including those which may be deemed to be of a privileged or confidential nature, and I release all persons from liability on account of such disclosure. The intention of this authorization is to provide information which will be considered in determining my suitability for employment with Visiting Angels. On your part, by your signature subscribed below, you hereby authorize this company, or anyone authorized by it for such purpose, to make either oral or written inquiry of the nature described above, and authorize any company or person of whom such inquiry is made to respond to such inquiry either orally or in writing, or in any manner. Further, to facilitate and expedite such inquiries, the undersigned hereby authorizes the reproduction of this paper and its submission to any employer or other person of whom the inquiries are made.

At my own discretion i will be using my automobile as part of the duties in the care of clients.
I agree that I have the primary responsibility for my automobile insurance. I agree to release the agency from responsibility for any accident in which there is damage to my automobile or injury to its occupants.

Your Service to Our Clients:
You agree that you will exert every reasonable effort to have our client(s) constantly attended to, without interruption of service, during the hours on the predetermined weekly schedule.
Non Disclosure Agreement and Restrictive Covenant:
All information which we provide to you shall be considered strictly confidential and you agree that you will not, directly or indirectly, during your association with us, make available to any person any of our confidential information without our specific written consent. You further agree not to circumvent or bypass our rights by doing business directly with any individual (client) or business entity (client) whom we have introduced to you (or by entering into employment with such individuals or business entities) without our advance written consent, both during the period in which you provide services to any such client and for a period of 2 years after.
You agree to release Visiting Angels from any and all responsibility for any incidents which may occur which are personally harmful to you while you are performing services to clients (or in traveling to and from the client's residence), including all injuries, or potential loss of revenue.
You hereby authorize Visiting Angels to run federal, state, and county criminal checks, social security number trace checks, driving record checks, previous employment reference checks and credit checks to determine your qualifications for referrals to our clients.
I have read, understand, and will comply with the Caregiver Restirctive Covenant Agreement

If you so choose, Visiting Angels will provide you with a Hepatitis B Vaccination before you begin employment with Visiting Angels.
I understand that I have the right to a Hepatitis B Vaccination before employment at Visiting Angels.
I would like to begin employment with Visiting Angels without providing proof of Hepatitis B Vaccination.

The following criteria are utilized to identify an employee with potential TB. This criterion is also utilized to determine if an employee needs a chest x-ray.
Detection of employees who may have active TB is based on the following criteria:
Potential active symptoms:
1. Persistent cough greater than 2 weeks duration
2. Bloody sputum
3. Night sweats
4. Weight loss
5. Anorexia
6. Fever
Groups with a higher prevalence of TB infection:
1. Medically under served populations
2. Homeless individuals
3. Current or past prison inmates
4. Alcoholics
5. Injecting drug users
6. Elderly
7. Foreign-born persons from Asia, Africa, the Caribbean, and Latin America
8. Contacts to individuals with TB
9. Groups with a greater risk to progress from latent TB infection to active disease
10. Individuals with HIV infection, silicosis, S/P gastrectomy or jejuno-ileal by pass surgery, greater than 10 pound below normal body weight, chronic renal failure, diabetes mellitus, immunosuppressed due to medication, and those with some malignancies
11. Individuals who have been infected within the past 2 years and individuals with fibrotic lung disease on chest x-ray
I have reviewed the signs and symptoms of TB. I am not experiencing symptoms of TB. I understand that if I experience any of the above symptoms I am to report to management immediately.

Light Housekeeping Defined:
You are not required to provide a general housekeeping service. Typical light housekeeping tasks to be provided by you would include: tidying up of rooms in which the care recipient spends his/her time (bedroom, living room, kitchen), washing dishes after meals (wiping spills on sink or floor, "spot mopping"), sweeping kitchen floor when needed, passing the vacuum in rooms used by care recipient, occasional light dusting, tidying bathrooms after use by care recipient (rinsing tub or shower after use, wiping spills on sink or floor). No caregiver is permitted to spend more than 20% of his/her overall work time performing housekeeping duties.
Visiting Angels, as a non-nursing agency, falls under the Fair Labor Standards Act (FLSA).
"Under the Fair Labor Standards Act (FLSA), 'Companionship Services' means services for the care, fellowship, and protection of persons who become of advanced age or physical or mental infirmity and cannot care for themselves. Such services include meal preparation, bed making, clothes washing and other similar personal services. General household work is also included, as long as it does not exceed twenty percent (20%) of the total weekly hours worked by the companion. The term 'Companionship Services' does not include service performed by trained personnel such as registered or practical Nurses."
Therefore, Visiting Angels is exempt from the hourly wage laws involving paying and/or charging overtime for time invoiced or worked as well as the limitations of an 8 hour day or a 40 hour work week.
It is our policy to educate caregivers and ensure that all Visiting Angels caregivers have a clear understanding of this law and agree not to spend more than 20% of their time each week performing "housekeeping".
By signing below, you agree to spend a minimum of 80% of your time while working at Visiting Angels as a companion/caregiver to your assigned patient(s).
I have read and understand the overtime exemption:

Assistance with all matters of Living Assistance including personal hygiene and grooming, planning and preparing meals, light housekeeping, laundry, and helping in coping with the routines of everyday life, including providing basic companionship and moral support.
I understand the Caregiver job description:

1. Infections Control
Any infection that is acquired while the client is receiving services from the agency must be documented in the communication log, and the caregiver must report it immediately to the office so that it may be documented in the infections control log at the office. This documentation must include the date that the infection was detected, the client's name, primary diagnosis, signs/symptoms, type of infection, pathogens identified, and treatment.
The Administrator will be responsible for assuring compliance with the communicable disease reporting rules and to assure that communicable diseases are reported as required. Documentation will include the date the infection was detected, the client's name, primary diagnosis, signs/symptoms, type of infection, pathogens identified and treatment.
The type of infections that will be reported to the Administrator for all care recipients identified after services begin, will include, but are not limited to the following:
- Urinary tract infections requiring physician intervention.
- Upper and/or lower respiratory tract infections requiring physician intervention.
- Wound infections identified following admission.
- Infections acquired within the first thirty days after hospital discharge or one year after implantable devise (e.g. hop prosthesis) may be considered nosocomial.
- Fever of unknown origin.
- Signs and symptoms of two or more of the following:
* Fever greater than 100.4, elevated pulse rate, chills, sore throat, cough, malaise, nausea or vomiting, acute diarrhea (liquid stools over a 12 hour period of time), headache, dyspnea, rash, ulcer, pustule, drowsiness, confusion, or coma; or
* Localized tenderness, redness, erythema, heat; or
* Urgency, frequency, dysuria; or
* Change in odor, color, and consistency of drainage;
- Physician diagnosis of an infection; and/or
- Disease(s) from state's list of reportable diseases.
Staff members with signs or symptoms of an infectious or communicable disease or a temperature over 101 degrees Fahrenheit will be directed not to work unless authorized by a physician. Anyone with a fever, draining lesions, or any other symptoms of an infectious disease must be cleared by the Administrator prior to resuming direct patient care.
All staff members directly exposed to pathogens during patient care will be directed to a physician for evaluation and follow-up.
2. Prevention
To prevent contamination of other family members when a patient has a skin wound or ophthalmic infections, etc., and special linen care is indicated:
* Instruct family members in the necessary steps only if there is a chance of contamination through common linen use.
- Instruct family to keep necessary linen items separated (towels, sheets, pillow cases) from the rest of the family's. encourage separate sleeping arrangements if indicated.
- Wash hands thoroughly with soap and water before and after used linen handling.
- Infected linen should be placed in a separate laundry bag and tied. If no laundry bag is available, a clean pillowcase can be used.
- Infected linen should be washed separately using:
* Hot water and soap detergent
* One cup of bleach should be added to the wash cycle
* Run through wash cycle twice
* Complete cycle and place in the dryer
- Dish and Utensil Precaution at Home
To prevent contamination of other family members when a patient has hepatitis, amebiasis, shiegella, salmonella, staph, enterocolitis, active tuberculosis, etc., special care may be indicated.
- Instruct family members in dish and utensil precautions only if there is a chance of contamination through common dish and utensil use.
- Instruct family members that food preparation is the same for the patient and family and that the same pots and pans may be used, unless a patient is placed on a special diet.
- Encourage the use of disposable paper plates and cups as well as plastic utensils if family economics allow.
* Place used dishes and utensils in a bag.
* Tie the open end of the bag securely and dispose.
* Wash hands thoroughly.
- Separate dishes and utensils that are to be used by the patient. These are to be cleaned separately and stored separately from other family members'.
* After all dishes used by other family members are washed, the contaminated dishes may be washed.
* Place leftover food and waste into a bag, tie and dispose.
* Gloves should be worn when washing these articles. A dishwasher is preferred in order to attain adequate degree of heat.
* Soak in very hot soapy water in a separate plastic basin.
* Do not place directly in sink.
* Scrub items with a detergent powder and hot water. Water should be as hot as possible and still allow handling.
* Rinse in hot, running water.
* Rewash using a disinfectant; rinse in cold water.
* Scour sink and basin; wipe basin with alcohol.
Expectorant Precautions (Non-Tuberculosis Patient)
- Instruct patient to use only disposable tissues for nose and throat secretions to prevent spread of droplet infections.
- Place a bag within easy reach of the patient.
- Instruct patient to place each used tissue into a bag.
- When a bag is 1/2 to 3/4 full, a family member should gather up the open ends of the bag and tie it securely.
- Wash hands thoroughly with soap and running water.
- Discard tied bag.
- Wash hands again.
- Precautions to Prevent Acquisition of Blood Borne Infections, Hepatitis B and HIV
To prevent the exposure to blood borne pathogens, the following barrier precautions should be adhered to:
- Sharp items (needles, scalpel blades, and other sharp instruments) should be considered as potentially infectious and be handled with extraordinary care to prevent accidental injuries. These items are not to be handled by Visiting Angels caregivers.
- Hand washing should occur before and after contact with the patient.
- Gloves should be worn, if in direct contact with blood, blood specimens, tissue body fluids, excretions, or articles whose surfaces are potentially contaminated by the body fluids (bed linens, towels, dressing, tissues).
Care of Waste
Blood and other body fluids can be flushed down the toilet. Disposable items that are contaminated with blood and body fluids should be wrapped in a plastic bag that is impervious and sturdy, and placed in a second bag before being discarded.
Spills of blood or other body fluids should be cleaned with soap and water or household detergent, followed by a solution of 5.25% hypochlorite (dilution 1:10 of household bleach with water.)
Care of Dishes/Utensils:
Routine washing of dishes int he dishwasher is felt to be adequate. If no dishwasher is available, use hot water and soap with a small amount of bleach added.
- Care of Linens:
Wash separately in hot water with standard detergent and bleach.
Care of Sharp Objects:
Visiting Angel's caregivers are not to handle sharp objects. If a client needs assistance in shaving, it is only permissible to use an electric razor.
- Persons receiving large doses of steroids.
- Persons with known immune deficiency diseases.
- Persons receiving or have recently received chemotherapy and/or radiation therapy.
- Persons receiving immunosuppressive medications.
- Persons who are pregnant.
Safe Handling and Disposal of Biohazardous Waste
Visiting Angels is a non-medical personal assistance service; therefore, no medical or special waste should ever be handled by a Visiting Angels employee. Visiting Angels' caregivers/employees are instructed to leave all handling and disposal of medical waste to a professional, medical staff.
All caregivers must either submit to a Hepatitis B vaccination, or sign a waiver refusing the vaccination before beginning employment with Visiting Angels.
I have read and understand the policies on infectious control and disease prevention:

My initials below indicates that I understand that I have the right to receive a copy of the handbook prior to beginning work at Visiting Angels. I also understand and will comply with the guidelines set forth in this handbook. I understand I am not guaranteed a full schedule or a certain number of hours each week while working for Visiting Angels.
Management reserves the rights, at its sole discretion, to modify the terms and conditions of this policy and procedure handbook.
I have read and understand the Visiting Angels Policies and Procedures Handbook, Policies on Safety and OSHA Compliance & Emergency Preparedness Plan.

I have been notified that a Computerized Criminal History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on the name and date of birth identifiers I supply.
Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization conducting the criminal history check for background screening is not allowed to discuss any criminal history record information obtained using the 'Name and DOB' method. Therefore, the agency may request that I have a fingerprint search performed to clean any mis-identification based on the result of the 'Name and DOB' search.
For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (automated Fingerprint Identification System). I have been made aware that in order to complete this process, I must make an appointment with L1 Enrollment Services, submit a full and complete set of my fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company, L1 Enrollment Services.
Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.

Applicant/Caregiver Certification of Authenticity
The information I have provided on this online application is true and accurate.
Caregiver/Applicant Signature:____________________________________________
Applicant - Do not complete information below this line. For internal use only.
(This copy must remain on file by your agency. Required for future DPS Audits)
Agency Name: Visiting Angels
Please: Check and initial each applicable space

1. Criminal Background Check Verified
2. Nurses Aide Registry Search
3. Employee Misconduct Registry Phone Search