Health Care Security Ordinance Employee Voluntary Waiver Form HR HUB PERSONAL DETAILSYour Full Name First Last Your PhoneYour Email Address Date of Birth MM slash DD slash YYYY Hire Date MM slash DD slash YYYY Leave Date MM slash DD slash YYYY Driver's License / ID Driver's License Expiration Date MM slash DD slash YYYY U.S. Passport / Greencard # Passport / Greencard Expiration Date MM slash DD slash YYYY EMERGENCY CONTACTNext of Kin Full Name Next of Kin Phone NumberVACCINATIONSTB TestYesNoTB Test Date MM slash DD slash YYYY Flu ShotYesNoFlu Shot Date MM slash DD slash YYYY COVID-19 ShotYesNoCOVID-19 Shot Date MM slash DD slash YYYY COVID-19 Booster ShotYesNoCOVID-19 Booster Date MM slash DD slash YYYY LICENSESDo you have HCA license?YesNoHCA License ID # State Issued HCA License HCA License Expiry Date MM slash DD slash YYYY Do you have CNA license?YesNoCNA License ID # State Issued CNA License CNA License Expiry Date MM slash DD slash YYYY Do you have HHA license?YesNoHHA License ID # State Issued HHA License HHA License Expiry Date MM slash DD slash YYYY Do you have LVN license?YesNoLVN License ID # State Issued LVN License LVN License Expiry Date MM slash DD slash YYYY Do you have RN license?YesNoRN License ID # State Issued RN License RN License Expiry Date MM slash DD slash YYYY BENEFITSPlease note you are entitled to benefits.Health BenefitsYesNoDental BenefitsYesNoVision BenefitsYesNo401-K BenefitsYesNoEASE Benefits PackageYesNoURL for EASE Benefits Package TRAININGS10-Hour Training & HIPAA Training should be completed before hire.10-Hour TrainingYesNo10-Hour Training Due Date MM slash DD slash YYYY 10 Hour Training Course Link HIPAA TrainingYesNoHIPAA Training Due Date MM slash DD slash YYYY HIPAA Training Course Link Yearly TrainingYesNoYearly Training Due Date MM slash DD slash YYYY Yearly Training Course Link CPR TrainingYesNoEvery 2 yearsCPR Training Due Date MM slash DD slash YYYY CPR Training Course Link Sexual Harassment CourseYesNoEvery 2 yearsSH Course Due Date MM slash DD slash YYYY Sexual Harassment Course Link Setup on ADP PayrollYesNoURL for ADP Payroll OFFICE SUPPLIESADL FormsYesNoPPE GearYesNoUniform SizeXSSMLXLXXLSignatureTime Off Request MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Subscribe To Our NewsletterReceive Senior Care news and articles. Success! Name Email About You About You I'm a Senior / Family Member of a senior. I'm a Professional who works with seniors and their family members. Subscribe
