* = Required Information

Emergency Contact Form

In case of emergency, please notify:

Telephone Numbers:

Application for Employment

Personal Information

Notify in case of an emergency

Yes No
Yes No

Please note that we are required by Texas law to perform a Criminal Conviction History Check on all unlicensed personnel and are prohibited from permanently employing any person whose check reveals certain past criminal convictions.

Referral Source


High School

1 2 3 4
Yes No


1 2 3 4
Yes No

Trade, Business or Vocational School

1 2 3 4
Yes No
Yes No

Professional Licenses and/or Certifications

Employment Desired and Availability

Yes No
Yes No
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Employment Record

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List Previous Employment Information

Current or Last Employer

Previous Employer

Previous Employer

Yes No

Pre-Employment Medical History And Mobility Evaluation


Before an offer of employment can be made, the section below must be completed.
Envision Home Health Care, is an equal opportunity employer that affirmatively seeks to employ qualified handicapped individuals. The following evaluation will assist us in efforts reasonably accommodate a work environment to your needs.

SECTION 2: Medical History

Back Trouble Heart Trouble
Breathing Problems Hernia
Diabetes Trick Joints
Difficulty Bending Ulcers
Dizziness/Blackouts Cancer
Epilepsy Alchohol Addiction
High Blood Pressure Drug Addiction
Circulatory Problems Any Communicable Disease

Please Review and Sign

In making an application for employment

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or mispresented. I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment and that I am subject to immediate discharge without recourse.

I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I or the facility will have the right to terminate the employment relationship at any time with or without cause and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.

I understand if I am an unlicensed person who has face-to-face patient/client contact that the agency will perform criminal history check per State Regulations as well as a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation or misconduct against residents and consumers are denied employment id DADS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Department of Aging and Disability Services (DADS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there’s a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All DADS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and therefore, unemployable.

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals, I also authorize any appropriate licensing board to release full information concerning my license status and my license history.

Reference Request

Verbal Mail

The individual named below is applying for a position as and has given you as a reference. As we place great importance on the thorough screening of all our applicants, we would appreciate prompt and thoughtful responses.

Thank you in advance:

Applicant Release

I hereby release from all liability of the company or person complaining about this form and authorize them to release all information regarding my employment with them. I understand that this information may be released to clients of the requesting company and other requesting third parties on a need-to-know basis. I also release the requesting company from all liability for any damages from the disclosure of this information.

Excellent Good Fair Poor Not Applicable
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Excellent Good Fair Poor Not Applicable
Excellent Good Fair Poor Not Applicable
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Universal Precautions

Because die infectious status may not be known for every client it is important to prevent exposure to the blood and body Bads of all patella. Ties approach will Emit any potential HIV/HBV exposures.

All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any patient is anticipated.

Gloves must be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all clients and for performing items or surfaces spilled with blood or body fluids. Gloves must also be worn for performing venipuncture and dying vascular access procedures and should be changed after contact with each patient. Hands must be washed immediately upon removal or damage of gloves.

Masks face shields and protective eyewear should be worn during procedures that are likely to generate droplets of mucous membranes of the mouth, nose, and eyes. Long sleeve fluid repellent disposable gowns and/or aprons should be worn and removed immediately if contaminated with bleed or other body fluids.

All sharp items should be considered potentially infectious and handled with extraordinary care. Used needles are not to be recapped, broken, or purposely bent. All needles and sharps shall be placed in puncture-resistant containers.


CATEGORY I: Tasks that involve exposure to blood, body fluids, or tissue.

All procedures or other job-related tasks that involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissue or a potential for spills or splashes of them, are Category 1 Tasks. Use of appropriate protective measures is required.

CATEGORY II: Tasks that involve no exposure to blood, body fluids, or tissue, but -employment may require performing unplanned Category I Tasks.

The normal work routine involves no exposure to blood, body fluids, or tissues but exposure or potential exposure may be required as a condition of employment. Appropriate measures should be readily available to every employee engaged in Category II Tasks.


I have read the above and have been instructed in the techniques of universal precautions and the Envision Home Health Care, exposure control plan for blood-borne pathogens. If I choose to disregard the above standards, I realize l am doing so against Envision Home Health Care policy and OSHA standards.

I understand the potential dangers of recapping needles and of the failure to take adequate precautions to prevent or decrease the risk of exposure to blood and body fluids.

I also understand infractions of this policy will result in disciplinary action against me ranging from verbal counseling to termination.


Envision Home Health Care maintains confidentiality of operations, activities, and business affairs of Envision Home Health Care and the clients according to 1996. Health Information Portability and Accountability Act (HIPAA). Due to the nature of the work, etch employee wig gain, directly or indirectly, sensitive and confidential information on clients/patients and staff members. The health care professional safeguard the dent's right to privacy by judiciously protecting the information of a confidential nature including medical treatment information, diagnosis, medical records, personal patient information, etc. This information should be snared only Web those persons who, due to their position, have a need-to-know, Sensitive or confidential information must never be used as the basis for social conversation or gossip. If an employee is in doubt as to whether or not certain information may be shared, he/she should consult with his/her supervisor.


Envision Horne Health Care conduct "random/for cause" drug testing on its employees. Envision Home Health Care maintains a drug-free workplace policy with regard to the possession, use, distribution, and sale of drugs and alcohol, All employees are prohibited from the unlawful or unauthorized manufacture, distribution, dispensing, possession, or use of a controlled substance or any alcoholic beverage while in the workplace or on Company-paid time Violation of this policy can result in disciplinary action up to and including termination of employment. I acknowledge I have received a copy of Envision Home Health Care policy on drug testing.


Envision Home Health Care is committed to providing a work environment, that is free from all forms of discrimination and unlawful harassment including sexual harassment. This policy applies to all employees inducting management personnel. Sexual harassment is any unwelcome sexual advances either explicit or implicit as a term or condition of employment, improper behavior may be verbal, visual, or physical in nature and/or the creation of a hostile environment. Management will investigate complaints of sexual harassment promptly, impartially, and without fear of retaliation to the employee. An employee should report the alleged incident immediately and confidentially to the appropriate manager of Human Resources.


Envision Home Health Care does not reimburse or provide incentives to employees, physicians, durable equipment providers, family, or another health professional for patient referrals for home health services. Employees found in violation of this policy will be subject to discipline up to termination of employment.


Envision Home Health Care does not discriminate against clients or employees based on race, color, religion, age, sex, national origin, marital, or disability.


Envision Horne Health Care employees will report suspected abuse, neglect, and/or exploitation to the slate departments of both the Texas Department of Family and Protective Services the Department of Aging and Disability Services, and Envision Home Health Care management. Envision Home Health Care employees suspected of abuse, neglect, or exploitation will be suspended immediately, an investigation will be conducted, and if the investigation validates the claim, the employee will be terminated.


Envision Home Health Care is a non-subscriber to workers' compensation insurance. An employee who incurs an injury on the job that requires emergency medical treatment or is lite threatening should proceed to the nearest emergency room. Emergency medical treatment (non-tie threatening) or non-emergency treatment should be referred to Envision Home Health Care designated clinic. Notify Envision Home Health Care of an injury within 24 hours to complete paperwork. Medical expenses for injuries are covered with the exception of the following: employee's willful intent to hurt self or others, intoxication or drug use, horseplay, acts of God, and/or acts of a third party.


Envision Home Health Care utilizes a progressive discipline process in cases of misconduct or unacceptable performance. This includes the verbal warning, written warning, and final warning. Disciplinary action may begin at an advanced stage of the processor may result in immediate termination based upon the nature and severity of the offense, the employee's record, and other circumstances.


I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. I understand that copies of the policy and procedure manuals are available and that it is my responsibility to read, understand and confirm all applicable agency Policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions.


By the execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior employment at 1 cast every 12 months if hired. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from my employment with this Agency. I understand that I am umemployable in the NAR or EMR per TAC $93.3 and TxH&SC Chapter 253; or if listed as unemployable in the Office of the Inspector General's List of Excluded Individuals and Entities (LEIE) pursuant to sections 1128 and 1156 of the Social Security Act.
Criminal History Check

I have informed this agency of all names (i.e, maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and I may not have face-to-face patient contact or have access to patient records until results are returned. I will be notified of results.

Convictions Barring Employment

(A) a person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:

  • An offense under Chapter 19, Penal Code (criminal homicide)
  • An offense under Chapter 20, Penal Code (kidnapping and unlawful restraint)
  • An offense under Chapter 21.02, Penal Code (continuous sexual abuse of a young child or children)
  • An offense under Chapter 21.08, Penal Code (indecent exposure)
  • An offense under Chapter 21.11, Penal Code (indecency with a child)
  • An offense under Chapter 21.12, Penal Code (improper relationship between educator and student)
  • An offense under Chapter 21.15, Penal Code (improper photography or visual recording)
  • An offense under Chapter 22.011, Penal Code (sexual assault)
  • An offense under Chapter 22.02, Penal Code (aggravated assault)
  • An offense under Chapter 22.021, Penal Code (aggravated sex assault)
  • An offense under Chapter 22.04, Penal Code (injury to a child, elderly individual, or a disabled individual)
  • An offense under Chapter 22.041, Penal Code (abandoning or endangering a child)
  • An offense under Chapter 22.05, Penal Code (deadly conduct)
  • An offense under Chapter 22.07, Penal Code (terroristic threat)
  • An offense under Chapter 22.08, Penal Code (aiding suicide)
  • An offense under Chapter 25.031, Penal Code (agreement to abduct from custoday)
  • An offense under Chapter 25.08, Penal Code (sale or purchase of child)
  • An offense under Chapter 28.02, Penal Code (arson)
  • An offense under Chapter 29.02, Penal Code (robbery)
  • An offense under Chapter 29.03, Penal Code (aggravated robbery)
  • An offense under Chapter 32.53, Penal Code (exploitation of a child, elderly individual, or disabled individual)
  • An offense under Chapter 33.021, Penal Code (online solicitation of a minor)
  • An offense under Chapter 34.02, Penal Code (money laundering)
  • An offense under Chapter 35A.02, Penal Code (Medicaid Fraud)
  • An offense under Chapter 36.06, Penal Code (obstruction or retaliation)
  • An offense under Chapter 42.09, Penal Code (cruelty to livestock animals)
  • An offense under Chapter 42.092, Penal Code (cruelty to nonlivestock animals); or
  • A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.
  • An offense the Agency determines to be contraindicated to employment with the consumers the Agency serves

(B) a person may also be bared from employment the duties of which involve direct contact with a client in a facility if convicted of any of the following crimes within the past 5 years:

  • An offense under Section 22.01, Penal Code (assault punishable as a Class A misdemeanor or as a felony)
  • An offense under Section 30.02, Penal Code (burglary)
  • An offense under Chapter 31, Penal Code (theft that is punishable as a felony)
  • An offense under Section 32.45, Penal Code (theft that is punishable as a felony)
  • An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or a felony)
  • An offense under Section 37.12, Penal Code (false identification as a peace officer); or
  • An offense under Section 42.01, (a) (7),(8),(9), Penal Code (disorderly conduct)

(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 and 247 is entitled to obtain criminal history record information may not be employed in facility licensed under Chapter 242 or 247 if the person has been convicted

  • Of an offense under Section 30.02, Penal Code (burglary) or
  • Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code.

For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receive a dismissal and discharge in accordance with Section 5 (c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential.

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

For Agency Use Only: Criminal History, Employee Misconduct Registry (EMR), Nurse Aide Registry (NAR), and LEIE checks completed:
Criminal History Check completed on-line Other convictions identified on Criminal History (Document reason hiring in Comments below) NAR EMR checked online at https://emr.dads.state.tx.us/DadsEMRWeb
LEIE Applicant Employable Applicant not employable

DPS Computerized Criminal History (CCH) Verification

I , acknowledge that a Computerized Criminal History (CCH) check will be performed by accessing the Texas Department of Public Safety Security Website and will be based on name and date of birth identifiers supply. (This is not a consent form) Authorization for this agency to access an individual's criminal history data may be found in Texas Government Code 411 Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, therefore the organization conducting the criminal history check i am not allowed to discuss with me any criminal history record information obtained using this method. This agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and date of birth search. Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

In order to complete the process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.dfps.state.tx.us/Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprint services company.

(This copy must remain on file by your agency. Required for future DPS Audits)

Check and Initial each Applicable Space

Yes No

Job Description: Personal Attendant

Title of Immediate Supervisor: Administrator

Position Summary:

Primary function is to provide personal assistance services to the client in their place of residence; to assist in providing a safe and clean environment; work cooperatively with client and family and share observations and problems with the supervisor.


  1. If under 18 years age, must either be a high school graduate or be enrolled in a vocational education program. High School or GED preferred if over 18 years of age.
  2. Must have current drivers license or reliable transportation to trace to assignments.
  3. If at least 18 years of age, must provide proof of education and/or experience to perform tasks as assigned. If under age 18, must successfully demonstrate competency to perform tasks assigned.
  4. Must be able to read and write in English and follow written and verbal instructions in English effectively.
  5. Competent to perform tasks assigned by supervisor.
  6. Must agree to and pass a criminal history check and Employee Misconduct Registry Check.

Work in patient's homes in various conditions, possible exposure to blood and body fluids and infectious diseases; ability to work a flexible schedule, ability to travel locally some exposure to unpleasant weather. Prolonged standing and walking required. Ability to lift up to 50 pounds. Requires working under some stressful conditions to meet deadlines, to identify client needs; to make quick decisions and meet patient/family psycho social needs. Requires hand-eye coordination and manual dexterity.

I have read the above job description and essential functions. I understand and agree to carry out these responsibilities as assigned. I understand and acknowledge that nothing contained in this job description may be constructed as limiting the employer's right to discipline or terminale my employment at any time for failure to perform satisfactorily. I have not been employed as Administrator with an agency that was cited with violations that resulted in enforcement in enforcement action, or convicted of a felony or misdemeanor as listed in 97.601(b)(2).

Salary Acceptance Form

Administrator All Administrator

at Envision Home Health Care I have been provided with a copy of the job description for the above position.

In accordance with my position, my rate of pay will be:

I have accepted the above stated position with Envision Home Health Care I agree with and accept the salary stated above.

Attendant Base Wages Acknowledgement

To: Employee

From: DADS/Community Based Alternatives Providers

Subject: Information letter 13-50 REVISED/Required Base Wages of Personal Attendants Effective September 1,2015

The purpose of t he letter is to inform providers that effective September 1, 2015, (Title 40 Texas Administrative Code $49.71 - $49.73) persons providing attendant services in the following programs and services must be paid at least $8.00 per hour.

  • Primary Home Care Services, including Community Attendant Services and Family Care
  • Personal Assistance Services in the Community Based Alternatives Program
  • Respite and Flexible Family Support Services in the Medically Dependent Children Program
  • Title XIX and Title XX - attendants only in Day Activity and Health services


Bobby Koshy, Administrator

Authorization for Direct Deposit - Employee Form

This authorize (the 'Company') to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commrcially accepted method to my (our) accout(s) indicated below and to other accounts I (we) identify in the future (the 'Account'). This authorizes the financial institution holding the account to post all such entries.

Note: Enter your company name in the blank space above.

Account Nuumber 1:

Checking Saving

This authorization will be effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it.

IMPORTANT: This document must be signed by employees requesting automatic deposit of paychecks and retained on file by the employer. Do not send this form to insult. Employees must attach a voided check for each of their accounts to help verify their account numbers and bank routing numbers.