Employment Application

Please list at least two professional references.

Note: Shaded areas are for back office staff only. Just enter the Employee Name and SSN here.

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview.

, acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority 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 record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.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 $25.00 to the fingerprinting services company.

Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

have read and understand the list of offenses listed below and I have not been convicted of any of these criminal offenses. I further understand that this agency will request a criminal history check from the Texas Department of Public Safety and will conduct a search of the Nurse Aide Registry and the Employee Misconduct Registry. I have also been informed this information is privileged information and will not be disclosed by the agency. I also understand that the agency reserves the right to hire applicants at their own discretion. Applying for the agency does not guarantee employment, and does not have to disclose the reason for not offering employment.

Offenses that constitute a bar to employment:

1. an offense under Chapter 19, Penal Code (criminal homicide);
2. an offense under Chapter 20, Penal Code (kidnapping and unlawful restraint);
3. an offense under Section 21.11, Penal Code(indecency with a child)
4. an offense under Section 22.011, Penal Code (sexual assault)
5. an offense under Section 22.02, Penal Code (aggravated assault)
6. an offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
7. an offense under Section 22.041, Penal Code (abandoning or endangering child);
8. an offense under Section 22.08, Penal Code (aiding suicide);
9. an offense under Section 25.031, Penal Code (agreement to abduct from custody);
10. an offense under Section 25.08, Penal Code (sale or purchase of a child);
11. an offense under Section 28.02, Penal Code (arson);
12. an offense under Section 29.02, Penal Code (robbery);
13. an offense under Section 29.03, Penal Code (aggravated robbery);
14. or a conviction under the laws of another state, federal law, of the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed under Subdivision(1)-(13)

A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date the person is Convicted of:

1. an offense under Section 22.01 Penal Code (assault), that is punishable as a class. A misdemeanor or as a felony;
2. an offense under Section 30.02, Penal Code (burglary);
3. an offense under Section 31, Penal Code (theft), that is punishable as a felony;
4. an offense under section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or
5. an offense under Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony

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

1. an offense under Section 30.02, Penal Code (burglary); or
2. 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.

1. Section 250.006 (a) (23), an offense under Section 36.06, Penal Code (obstruction or retaliation); and
2. Section 250.006 (a) (24), clarification regarding offenses under Sections 42.09 (cruelty to livestock animals) and 42.092 (cruelty to non-livestock animals), Penal Code.

Effective September 1, 2011, convictions for the offenses added by house bill 2609 prohibit employment by any provider or agency subject to Health and Safety Code Chapter 250. Home and Community-based Services (HCS) and Texas Home Living (TxHmL) providers are subject to Health and Safety Code Chapter 250 as outlined in Title 40 of the Texas Administrative Code, Section 9.177(n). Consumer Directed Service Agencies (CDSAs) and CDS employers are subject to Health and Safety Code Chapter 250, effective September 1, 2011 (see Information Letter No. 11-112). Providers, including a CDSA, must ensure all service providers are employable under Health and Safety Code Section 250.006.

House Bill 8 and Senate Bill 199 (80th Regular Session), which were signed into law by the governor on June 15, 2007 contained provisions adding new convictions to Section 250.006 of the Health and Safety Code. Senate Bill 199 also added new Subsection 250.006 (d), which clarifies that a person who is placed on deferred adjudication community supervision for an offense listed in Section 250.006 is not considered convicted of the offense.

Section 1.17 of House bill 8 amended Chapter 21 of the Penal Code, creating an offense at Section 21.02, continuous sexual abuse of your child or children.

Section 3.44 of House Bill 8 amended Section 250.006 (a) of the Health and Safety Code, adding the new, above described offense to Section 250.006 (a) (3).

Per Section .01 (a) of House Bill 8, the provision of 250.006 (a) regarding prohibition of employment will apply to offenses under Section 21,02 of the Penal Code committed on or after September 1, 2007. Offenses under Section 21.02 of the Penal Code that result in conviction prohibit employment of the offender.

Section 1 of Senate Bill 199 amended Section 250.006 (a) of the Health and Safety Code, adding the following offenses:

1. Section 21.08, Penal Code (indecent exposure)
2. Section 21.12, Penal Code (improper relationship between educator and student)
3. Section 21.15, Penal Code (improper photography or visual recording)
4. Section 22.05, Penal Code(deadly conduct)
5. Section 22.021, Penal Code (aggravated sexual assault)
6. Section 22.01, Penal Code (Terroristic Threat)
7. Section 33.021, Penal Code (online solicitation of a minor)
8. Section 34.02, Penal Code (money laundering)
9. Section 35A.02, Penal Code (Medicaid Fraud), and
10. Section 42.09 Penal Code (cruelty to animals),

Section 1 of Senate Bill 199 amended 250.006 (b) of the Health and Safety Code, adding the following offenses:

• Section 37.12, Penal Code(false identification as a peace office) and
• Section 42.01 (a)(7), (8), or (9), Penal Code(disorderly conduct)

Effective September 1, 2007, existing convictions and new convictions for the offenses added by Senate Bill constitute barriers of employment in facilities and agencies subject to Health and Safety Code Chapter 250.

Additional to Bars to Employment

Bars pursuant to Texas Administrative Code, Title 40, Part 1, Chapter 3 § 3.201 Texas Health and Safety Code

Chapter 481 -- Texas Controlled Substances Act: a conviction that is punishable as a felony (involving manufacture, delivery, intent to distribute, conspiracy to possess or produce with intent to distribute, distribution to a minor, illegal expenditure or investment, or transfer or receipt of chemical laboratory apparatus).

Section 15.01, Penal Code (Criminal Attempt of any offense listed as a bar)
Section 43.03, Penal Code (Promotion of Prostitution)
Section 43.04, Penal Code (Aggravated Promotion of Prostitution)
Section 43.05, Penal Code (Compelling Prostitution)
Section 43.25, Penal Code (Sexual Performance by a Child)
Section 43.26, Penal Code (Possession or Promotion of Child Pornography)

I acknowledge that if i am found to have been convicted of any other offense(s) that the agency detemines to be a contraindication to my employment, these offense(s) may also bar my employment

RE: Request for Reference:

We are requesting and employee/personal reference on the below named person. A complete and prompt response would be appreciated as employment is pending. All information will be held in strict confidentiality.

RE: Request for Reference:

We are requesting and employee/personal reference on the below named person. A complete and prompt response would be appreciated as employment is pending. All information will be held in strict confidentiality.

The PHC Program includes the following tasks:

(1) personal care tasks related to the care of the individual's physical well being, including:

(A) bathing, which is:

(i) drawing water in sink, basin, or tub;

(ii) hauling or heating water;

(iii) laying our supplies;

(iv) assisting in or out of tub or shower;

(v) sponge bathing and drying;

(vi) bed bathing and drying;

(vii) tub bathing and drying: and

(viii) providing standby assistance for safety;

(B) dressing, which is:

(i) dressing the individual;

(ii) undressing the individual; and

(iii) laying out clothes;

(C) meal preparation, whoch is:

(i) cooking a full meal;

(ii) warming up prepared food;

(iii) planning meals;

(iv) helping prepare meals; and

(v) cutting clients food for eating;

(D) feeding/eating, which is:

(i) spoon-feeding;

(ii) bottle-feeding;

(iii) assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and

(iv) providing standby assistance or encouragement;

(E) exercise, which is walking with the individual;

(F) grooming, shaving, or oral care, which is;

(i) shaving;

(ii) brushing teeth;

(iii) shaving underarms and legs, when requested;

(iv) caring for nails; and

(v) laying out supplies;

(G) routine hairs or skin care, which is:

(i) washing hair;

(ii) drying hair;

(iii) assisting with setting, rolling, or braiding hair, not including stying, cutting, or chemical processing of hair;

(iv) combing or brushing hair;

(v) applying nonprescription lotion to skin;

(vi) washing hands and face;

(vii) applying makeup; and

(viii) laying out supplies;

(H) assistance with self-administered medications, which is assistance with medication as defined in §97.2(11) of this title (relaxing of Definitions);

(I) toileting, which is;

(i) changing diapers;

(ii) changing colostomy bag or emptying catheter bag;

(iii) assisting on or off bedpan;

(iv) assisting with the use of a urinal;

(v) assisting with feminine hygiene needs;

(vi) assisting with clothing during toileting;

(vii) assisting with toilet hygiene, including the use of toilet paper and washing hands;

(viii) changing external catheter;

(ix) preparing toileting supplies and equipment, not including preparing catheter equipment; and

(x) providing standby assistance; and

(J) transfer, which is:

(i) non-ambulatory movement from one stationary position to another, not including carrying;

(ii) adjusting or changing the individual's position in a bed or chair (positioning); and

(iii) assisting in rising from a sitting to a standing position;

(K) ambulation, which is

(i) assisting in positioning for use of a walking apparatus;

(ii) assisting with putting on and removing leg braces and prostheses for ambulation;

(iii) assisting with ambulation or using steps;

(iv) assisting with wheelchair ambulation; and

(v) providing standby assistance:

(2) home management tasks that support the individual’s health and safety, including:

(A) cleaning, which is:

(i) cleaning up after the individual's personel care tasks;

(ii) emptying and cleaning the individual's bedside commode;

(iii) cleaning the individual's bathroom;

(iv) changing the individual's bed linens and making the individual's bed;

(v) cleaning floor of living areas used by the individual;

(vi) dusting areas used by the individual;

(vii) carrying out the trash and setting out garbage for pick up;

(viii) cleaning stovetop and counters;

(ix) washing the individual's dishes; and

(x) cleaning refrigerator and stove:

(B) laundry, which is:

(i) doing hand wash;

(ii) gathering and sorting;

(iii) loading and unloading machines in residence;

(iv) using laundromat machines;

(v) hanging clothes to dry;

(vi) folding and putting away clothes; and

(C) shopping, which is:

(i) preparing a shopping list;

(ii) going to the store and purchasing or picking up items;

(iii) picking up medications; and

(iv) storing the individual's purchased items; and

(3) escorting, including:

(A) Accompanying the individual outside the home to support the individual in living in the community;

(B) Arranging for transportation, not including direct individual transportation;

(C) Accompanying the individual to a clinic, doctor's office, or location for medical diagnosis or treatment; and

(D) Waiting in the doctor's office or clinic with an individual if necessary due to client's condition or distance from home.

Source Note: The provisions of this §47.41 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802

La Estrella Home Care requires all attendants to Clock-in and Clock-out by telephone. Attendants will use a cell or landline phone to call a toll free number and enter a client ID, employee ID and if no landline, enter a 6-digit code displayed on the token at the start and end of the work schedule.

I have read the above statement and understand that this use of telephony determines me being paid for the correct number of authorized hours and the failure to follow the above steps will lead to my employment termination.

La Estrella Home Care requiere que todo los atenientes marquen su hora de entrada y hora de salidad por teléfono. Atenientes van an usar un teléfono celular o un teléfono fijo para hable a un número gratuito e ingresar el número de indentificación de cliente, el número del identificación del empleado y si el cliente no tiene teléfono fijo, ingresar un código de 6 dígitos que aparace en la ficha o token a la entrada y salida del horario de trabajo.

He lecído la declaración anterior y entiendo que el uso de la telefonía determina si voy a ser pagado(a) el número correcto de horas autorizadas y que el fracaso de seguir los pasos ya mencionados es cause para la terminación de mi empleo.