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 Test YES NO TB Test Date MM slash DD slash YYYY Flu Shot YES NO Flu Shot Date MM slash DD slash YYYY COVID-19 Shot YES NO COVID-19 Shot Date MM slash DD slash YYYY COVID-19 Booster Dose YES NO COVID-19 Booster Dose Date MM slash DD slash YYYY LICENSESDo you have HCA license? YES NO HCA License Expiry Date MM slash DD slash YYYY HCA License ID # State Issued HCA License Do you have CNA license? YES NO CNA License Expiry Date MM slash DD slash YYYY CNA License ID # State Issued CNA License Do you have HHA license? YES NO HHA License Expiry Date MM slash DD slash YYYY HHA License ID # State Issued HHA License Do you have LVN license? YES NO LVN License Expiry Date MM slash DD slash YYYY LVN License ID # State Issued LVN License Do you have RN license? YES NO RN License Expiry Date MM slash DD slash YYYY RN License ID # State Issued RN License BENEFITSPlease note you are entitled to benefits.Health Benefits YES NO Dental Benefits YES NO Vision Benefits YES NO 401-K Benefits YES NO EASE Benefits Package YES NO URL for EASE Benefits Package TRAININGS10-Hour Training & HIPAA Training should be completed before hire.10-Hour Training YES NO 10-Hour Training Due / Renewal Date MM slash DD slash YYYY 10 Hour Training Course Link HIPAA Training YES NO HIPAA Training Due / Renewal Date MM slash DD slash YYYY HIPAA Training Course Link Yearly Training YES NO HIPAA Training Due / Renewal Date MM slash DD slash YYYY Yearly Training Course Link CPR Training (Every 2 yrs) YES NO CPR Training Due / Renewal Date MM slash DD slash YYYY CPR Training Course Link Sexual Harassment Course (Every 2 yrs) YES NO Sexual Harassment Course Due / Renewal Date MM slash DD slash YYYY Sexual Harassment Course Link Set up on ADP Payroll YES NO URL for ADP Payroll OFFICE SUPPLIESADL Forms YES NO PPE Gear YES NO Uniform SizeXSSMLXLXXLSignatureTime Off Request MM slash DD slash YYYY EmailThis 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
