* = Required Information

Application Form Waiver

In exchange for the consideration of my job application by CIVILITY HOME CARE (hereinafter called “the Company”),

I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Civility Home Care, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /CEO of the Company. Both the undersigned and Civility Home Care may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I also understand that (1) the Company conducts a thorough background investigation to include but not limited to medical physical, drug/alcohol screening and driving records that may be required by Civility Home Care as a condition of employment. In consideration of Civility Home Care review of this application, I further understand I may be required to successfully pass a random drug/alcohol screen at any time for reasonable suspicion. I release Civility Home Care and all providers of information from liability as a result of furnishing and receiving such information (this does not waive my right to file a charge, testify, assist or participate In an investigation, hearing, or proceeding under Title VII, the Age Discrimination in Employment Act, the Equal Pay Act or the Americans with Disabilities Act. Civility Home Care will perform these background investigations according to non-discriminatory criteria).

I further understand that my employment with the Company shall be “at –will” and this does not create an employment agreement nor guarantee employment for any definite period. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

Civility Home Care is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, marital status, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.


I , understand that CIVILITY HOME CARE LLC (“CIVILITY HOME CARE”) will thoroughly investigate my credit and criminal record, personal background, employment and educational history and verify all available data (“Personnel Screening”) as part of my application for employment. I understand that participation in CIVILITY HOME CARE's Personnel Screening is a condition of hiring. I am, therefore, consenting to said Personnel Screening as a condition of my consideration for employment with CIVILITY HOME CARE. I also understand that any collected information could result in denial of employment.

I also understand that I am not required to disclose the existence of (1) any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes Section 46b-146, 54-76o or 54-142a: (2) criminal records subject to erasure pursuant to Section 46b-146, 54-76o or 54-142a (records pertaining to a finding of delinquency or that a child was a member of a family with service needs), an adjudication as a youthful offender, a criminal charge that has been dismissed or nolle, a criminal charge for which I was found not guilty or a conviction for which I received an absolute pardon, and (3) criminal records have been erased pursuant to Section 46b-146, 54-76o or 54-142a.

  • Any information disclosed by me, or disclosed through the Personnel Screening, shall be confidential and shall not be released to anyone excepts to CIVILITY HOME CARE’s personnel department, personnel in charge of employment, or personnel involved in the interviewing or hiring of applicants. I hereby authorize the release of the Personnel Screening results to those personnels.
  • In the event that I commence any assignment with or through CIVILITY HOME CARE prior to the receipt of the Personnel Screening results, if negative or derogatory information is uncovered,
  • I acknowledge that my employment may be immediately terminated.
  • I have read the foregoing and understand it. I am signing this Consent Form of my own free will without coercion or duress. I also understand that the sole basis for this document and any Personnel Screening is so that I may qualify for an assignment with CIVILITY HOME CARE and CIVILITY HOME CARE’s clients.

I also understand that as part of the employment process, CIVILITY HOME CARE will obtain a consumer report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living.

During the application process and at any time during the tenure of my employment with the Company,I hereby authorize CIVILITY HOME CARE’s designated representative, on behalf of CIVILITY HOME CARE to procure a consumer report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from credit bureaus, courts record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

Dated this day of , 2018.

The EEOC states for the purpose of reemployment inquiries, under the Age Discrimination in Employment Act of 1967, Section 1625.5, “A request on the part of an employer for information such as “Date of Birth” or “State Age” on an employment application form is not, in itself, a violation of the Act.”

To All Applicants
The information requested above is used to assist in the completion of a background investigation. Information will be maintained in a limited access file, detached from your application. The information will be used for the sole purpose of identification when conducting a background investigation.

I have received a copy of my Summary of Rights Under the Fair Credit Reporting Act.

Notice to all Applicant

Personal Information

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Skill Information

How would you rate yourself on your experience with the following aspects of caregiving?

1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience

1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
Bathing/ Showering/ Grooming/ Dressing
Incontinent Care/ Diapers/ Toileting Assistance Feeding
Cooking/ Cleaning/ Housekeeping
Transfers (from bed to wheelchair)
Hoyer Lift patients
Turning/ Positioning/ Body Audit
Documenting Care (following care plan)
Range of Motion
Medication Reminders
Drive patient to (doctor/ pharmacy/ groceries)
Yes No
Alzheimer’s & Dementia
Congested Heart failure Patient
MS Patients
ALS Patients
Stroke Patient
Diabetes Patient
Parkinson’s Patient
Wheelchair Bound
Bed bound patients
Joint Replacement (knee/hip/shoulder)
Hospice Patient
Combative patients
Insulin Non-Insulin
Non Personal Experience Caregiving
PCA or Similar Expires
CNA Expires
Home Health Aide
Adult CPR - Expires
Pediatric CPR - Expires
No Dogs
No Cats
No Smokers
No family/children in household
No Driving

Education Information

High School
Business or Trade School
Professional School

Reference Information

Please list two references OTHER THAN relatives or previous employers (i.e. people you’ve helped in past, friends, co- workers, etc.)

Military Information

Yes No
Yes No

Work Experience

Please list your work experience for the past five years beginning with your most recent job held. If you were self -employed, give company name. Attach additional sheets if necessary.
Employment Dates
Pay or Salary
Yes No

Employment Dates
Pay or Salary

Employee Emergency Contact

Employee Name




I hereby, authorize the below addressed individual, whom I have listed in my questionnaire form, to forward my references to CIVILITY HOME CARE. In addition, I release the addressed individuals and CIVILITY HOME CARE from all liability for any damage whatsoever incurred in furnishing such information. I understand that falsification of date or derogatory information discovered as a result of this investigation may prevent me from being accepted, or if accepted, may subject my contract to termination.

The above individual is interested in contracting their services with CIVILITY HOME CARE and has given your name as a reference. The individual has given us written authorization to verify their work history. Would you kindly complete this form and return to us at your earliest convenience

Above Average Average Below Average
Above Average Average Below Average
Above Average Average Below Average
Above Average Average Below Average
Above Average Average Below Average
Above Average Average Below Average
Yes No

Standard Rules for CIVILITY HOME CARE Employees

1. Always be on time. For new cases or as a fill-in worker, plan to be 30 minutes earlier. Find, review and sign in on the Care Plan Book. Call the office if you cannot locate the Care Plan Book or if you have questions about the contents of the book or the care plan.

2. Wear your name tag.

3. All calls need to come through the office. Do not give out your home/ personal phone number. Remember that the client, the clients’ family members, and your family members should call the main office number for a change in their service, to request more service, to inquire about new business or to reach you on another job. We will contact you if an emergency should occur. Do not contact the client when you are not on duty. The office staff will contact the client and/ or their family; if necessary. Any concerns regarding the client’s health or condition should be directed to the care planner, who will then take any necessary action.

4. Your family members and friends are not allowed on your work site.

5. Do not discuss personal/business problems with the client.

6. Do not discuss company issues with the client; such as, your pay rate, evaluations, etc.

7. Dress neatly and be clean. Wear uniform-like clothing unless the client asks you to wear something else. Never wear jeans, shorts, or sweat pants. Always wear closed toed shoes. Scrubs are recommended; unless, you are working in an assisted living facility or other senior living community.

8. Always maintain a professional attitude. Be kind and courteous; remember, you are in the client's private home.

9. Call the office once a day when assigned a new job to report on the condition and status of the job, and once a week after that to report on your client’s condition and status of a job.

10. Always call in schedule and mileage changes no later than the day of service.

11. Call the office staff twenty-four (24) hours in advance to cancel a daily job. Call the office staff forty-eight (48) hours in advance to cancel a live-in job. The office phone is always answered. The office will notify the client.

12. Call the office weekly to let them know when you are available, if you are not scheduled for work, or want more hours.

13. Leave the client's home cleaner than you found it.

14. Always get permission to smoke and ask where the best place would be for you to smoke. NEVER SMOKE INSIDE YOUR CLIENTS’ HOME. Empty and clean all ashtrays, as they are used. 1

15. Whenever transporting a client in a car; wear a seat belt and insist that the client wear his/ her seat belt as well. Call the office if the client refuses to do so. (Only employees with approved insurance coverage and written authorization can transport clients.) NEVER USE YOUR CELL PHONE FOR CALLS, TEXTING, OR EMAILS WHILE DRIVING YOUR CLIENT.

16. Do not ride as a passenger, if your client is the driver.

17. You will not be sent alone to cases requiring total lifting. Do not attempt to lift a client who requires total lifting. If there is a significant change in the amount of lifting required on your job, notify the office so that we can take immediate action. If you are assigned to a client who requires lifting or transfer assistance and you are not willing or capable of SAFELY performing the lift or transfer, DO NOT ATTEMPT THE LIFT OR TRANSFER, call the office immediately for instructions.

18. Only use an electric shaver to shave a client and never clip or cut a client’s finger nails or toe nails.

19. Report any gifts to the office immediately. Never accept a gift unless you have cleared the matter with the office. NEVER accept cash or checks made out to you from a client.

20. Check with the office when shopping for a client. Never accept cash or have a check made out in your name for shopping. Use the expense record in the Care Plan Book. Never buy alcohol for a client. As a rule, caregivers do not pour alcohol for the client. If the client’s family or the care planner asks for this service, we will consider it on a case by case basis.

21. Do not report to work while under the influence of drugs or alcohol. Do not consume drugs or alcohol while on duty with your client. These are grounds for immediate termination of employment with CIVILITY HOME CARE.

22. Do not use your client’s telephone for personal calls.

23. Ask client before changing the television or radio station. Do not order pay per view television without permission from the client. Report to the office any client requested pay per view orders including the event to be ordered.

24. Do not rearrange client’s furniture, kitchen items, or personal belongings.

25. Report any personal injury while on duty to the office immediately 845-278-1727 but no later than twenty-four (24) hours after the injury occurs.

By signing you agree that you have read and understand the above rules set by CIVILITY HOME CARE.


In consideration of my employment or the continuation of my employment by CIVILITY HOME CARE. I hereby agree as follows:

I understand that CIVILITY HOME CARE. Hereafter known as the “Company” attains confidential information which includes matters not generally known outside the Company, such as procedures, policies, forms, methods, and processes relating to the operations of a home care company, methodologies, and techniques of the company such as information concerning sales, costs, profits, organizations, customer lists, personnel, Patient Health Information and pricing methods. I further understand that while I am employed by CIVILITY HOME CARE, I may obtain or hear of confidential information of the Company and of other parties which have been provided to the Company in confidence, except as the Company and of other parties which have been provided to the Company in confidence. I agree not to disclose, use or copy any confidential information of CIVILITY HOME CARE (whether or not produced by me) or of other parties which have been provided to the Company in confidence, except as the Company may authorize or direct. I further agree that during my employment and/or upon termination, I am responsible for the care and usage of all Company equipment (i.e. - cell phones, vehicles) issued to me during my employment. Upon termination, all Company issued equipment will be returned in its original condition/ packages (allowing for normal wear). I understand I am financially responsible for the addition phones charges I incur, that exceed the Company phone plan. These charges will be settled with CIVILITY HOME CARE. No later than thirty days from termination dates.

During the period of my employment by CIVILITY HOME CARE and for the period of one year after the termination thereof, the employee shall not directly or indirectly, either for themselves or for any other person, company or business organization, call upon, solicit, accept, divert, or take away or attempt to call upon solicit, accept, divert, or take away any customers, business or prospective customers of CIVILITY HOME CARE. The employee during his/ her employment with CIVILITY HOME CARE. And for the period of one year thereafter, is not to solicit or discuss any employee of CIVILITY HOME CARE, the employment of such CIVILITY HOME CARE employee by any person, company, or business organization other than CIVILITY HOME CARE.

I acknowledge that I have carefully read and considered all the terms and conditions of this agreement. I agree that these terms and conditions are necessary for the reasonable and proper protection of the Company and its affiliates, and I further agree, were I to breach any of the convents described above the damage to the Company would be irreparable. I therefore agree that the Company, in addition to any other remedies available to it, shall be entitled to preliminary and permanent injunctive relief against any breach or threatened breach by me of any said convents, without having to post bond.

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