HOME CARE FORMS

BUSINESS START-UP CHECKLIST Chose the business idea Research the business idea Is it legal Who will buy it and how often Are you willing to do what it takes to sell the service What will it cost to produce, advertise, sell & deliver With what laws will you have to comply Can you make a profit How long will it take to make a profit Write a business plan and marketing plan Choose a business name Verify right to use the name See if the business name is available as a domain name Register the business name and get a business certificate Register your domain name even if you aren't ready to use it yet Choose a location for the business or make space in the house for it Check zoning laws File partnership or corporate papers Get any required business licenses or permits( usually not required) Reserve your corporate name if you

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will be incorporating Register or reserve state or federal trademark Register copyrights Order any required notices (advertisements you have to place) of your intent to do business in the community Have business phone or extra residential phone lines installed Check into business insurance needs Get adequate business insurance or a business rider to a homeowner's policy Send out publicity releases Apply for sales tax number if needed Get tax information such as record keeping requirements, information on withholding taxes if you will have employees, information on hiring independent contractors, facts about estimating taxes, forms of organization, etc. Call Department of Labor to determine labor laws if you have employees. Apply for employee identification number if you will have employees Find out about workers' compensation if you will have employees Open a bank account for the business Have business cards and stationery printed Purchase equipment or supplies

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Order inventory Order signage Get an email address Find a web hosting company Get your web site set up Have sales literature prepared Call for information about Yellow Pages advertising.

Place advertising in newspapers or other media if yours is the type of business that will benefit from paid advertising Take advantage of free online resources, free marketing on online website such as Craigslist, yahoo local, Google local etc Call everyone you know and let them know you are in business Other

Five Steps to Developing a Mission Statement

Developing a mission statement entails defining the who, what, why, for whom, and how of your institution. Work through the following exercises with your key staff and stakeholders to develop a comprehensive mission statement that clarifies these key questions.

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Arriving at a mission statement that all stakeholders can support may require several iterations.

1. Client statement The client statement is the for whom of your institution; it identifies the target market and the basic strategies you will employ to reach them. In one sentence, articulate whom your institution is intended for, using the following questions as a guideline: a) Whom have you identified as the target market of your institution? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________ b. What activities and sub-sectors are they engaged in? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________ c. Where are they located? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________

d. How will you reach them? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________ 2. Problem statement The problem statement is the why of your program. It defines the problem you are seeking to address. In a few lines summarize the problem, using the following questions as a guideline:

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a. What is the predominant need you identified among your target population? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________ b. What are the constraints the target population faces in maximizing profit in its businesses? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________ Note: If you find that you have identified several problems, be pragmatic about which ones can realistically be tackled. 3. Statement of Purpose The statement of purpose describes what your institution seeks to accomplish. It answers the question, What will the ultimate result of your work be? The statement of purpose uses infinitive verbs such as to eliminate, to increase, to improve, and to prevent, indicating a change in status related to the problems your institution is seeking to alleviate. a. In defining purpose, focus on results rather than methods. Consider questions like How is the situation going to be different because of the products/services offered by your organization? and What is going to change for the target clients? For example, the purpose of a marketing intervention would not be to provide marketing services to poor women entrepreneurs but to increase income of poor women entrepreneurs. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________ b. In one or two sentences, using infinitive verbs, describe the desired result of your institution and the problem or condition that you aim to change.

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________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________ ________________________________________________________________ ________________________________________________________________ ________________ 4. Business statement The business statement describes how your institution will achieve its purpose by depicting the activities you will undertake to this end. In doing so, the business statement characterizes the basic strategy you will use. Most purpose statements yield several potential strategies, each one constituting a different business or intervention. To increase poor women entrepreneurs income, you could provide access to affordable credit, business training, and improved production technology, among other options. Writing a business statement clarifies the means to accomplishing your purpose and gets everyone reading off the same page. a. If the word and appears in either your statement of purpose of your business statement, ask yourself if you are equally committed to both ideas connected by the word and and, if not, acknowledge that one idea is more important. In other words, prioritize your ideas while writing your mission statement. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________ b. Write a business statement for each statement of purpose. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________ 5. Value Statement

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The value statement communicates the who of your institution by embodying the beliefs and principles of your program. Values guide staff, management, and leadership in performing their duties. Often, the values of an institution, such as commitment to economic justice for the poor, integrity, honesty, innovation, cost recoveries are important elements in a staff members decision to work with an organization or are the reason a donor or board member supports a particular program. Ideally, the personal values of stakeholders are aligned with the values of the program of the institution. Through a participatory process of developing a written value statement, program staff and leadership have an opportunity to delineate the values they want the organization to encompass and realign them if necessary. In addition, such a statement holds stakeholders accountable in programming and operations.

a. In a few lines, write a value statement for your institution. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 6. Writing a Mission Statement Synthesize the work completed in Steps 1-5 into a comprehensive statement although length is not specified, a mission statement should be brief, consisting of just a few lines or sentences. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

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________________________________________________________________ ________________________________

SAMPLE JOB APPLICATION FORM

SAMPLE JOB APPLICATION FORM

1. Position applying for:____________________2. Social Security No:________________________

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2. Full Legal Name_______________________________________________________________ __________________ Last Name First Middle 3. Home Phone :(_______) ______________Business Phone :(________) _______________________ 4. Street Address_______________________________City/Town____________________ ___________________ State:_______________________________________________ Zip Code___________________________ 5. Email Address:____________________________________________________________ ______________ 6. Education: 7a. Highest school grade completed: 1 2 3 4 5 6 7 8 9 10 12 7b: Do you have a high school equivalency diploma: Yes 7c: Number of years of post high school education: 7. Name and Location of Educational 8. Institution Degree Received Dates Attended 8a. 8b. 8c. 1 2 11 No 3 4

Major / Specialty

9. If you plan to complete an educational program in the future, then indicate the degree or program to be completed 9a. Completion: 10. Work Experience: Start with the most recent work experience. Describe all traditional, military and voluntary work experience. Describe your knowledge, skills and abilities that demonstrate your qualifications for the position for which you are applying 10a: Job title:

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_______________________________________________________________________ __________ Employer name: _______________________________________________________________________ _ Employer address_______________________________________________________________________ Employment start date: ______________ Employment end date: _______________________ Employer phone number :(_____) __________________ Fax :(_____) ______________________ Supervisor/Manager: _____________________ Title: ______________________________________ Job duties_________________________________________________________________ _______________ __________________________________________________________________ __________________________ Final Salary___________________ Reason for leaving: ____________________________________ 10b: Job title: _______________________________________________________________________ __________ Employer name: _______________________________________________________________________ _ Employer address_______________________________________________________________________ Employment start date: ______________ Employment end date: _______________________ Employer phone number :(_____) __________________ Fax :(_____) ______________________ Supervisor/Manager: _____________________ Title: ______________________________________ Job duties_________________________________________________________________ _______________ __________________________________________________________________ __________________________ Final Salary___________________ Reason for leaving:

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____________________________________

10c: Job title: _______________________________________________________________________ __________ Employer name: _______________________________________________________________________ _ Employer address_______________________________________________________________________ Employment start date: ______________ Employment end date: _______________________ Employer phone number :(_____) __________________ Fax :(_____) ______________________ Supervisor/Manager: _____________________ Title: ______________________________________ Job duties_________________________________________________________________ _______________ __________________________________________________________________ __________________________ Final Salary___________________ Reason for leaving: ____________________________________

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11. Job Skills: Use the following space to provide any additional information that you think would be helpful in our evaluation of your job application. This can include specialized training, seminars, workshops, accreditations, special achievements or valuable skills:

12. Licenses Held: (including drivers) or certifications to practice a trade or profession. License Type Granted by (licensing board) Number

13. References: List the full name, address, phone number and relationships of up to three persons that youd like to use as a reference: Phone Relationsh Full Name Address Number ip

14. Miscellaneous Information: 14a. Which shifts are you willing to accept: Day Evening Night Rotating Weekends Specify shift hours 14b. Which job status are you willing to accept: Full-time Part-time you willing to travel: (specify) 14c. Are No Yes 14d. Please indicate your geographic preferences: 15. Compliance with the Yes No. Immigration Reform and Control Act requires that you are you legally eligible for employment in the United States? Please note that under the Immigration Reform and Control Act of 1986, that you may be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. You may also be will be required to provide documentation that you should you be employed. 16. Veteran Status: Are you a veteran who received an honorable discharge and has: 1. Provided more than 180 consecutive days of full time active duty in the armed forces of the United States or reserve components, including more than the ~ 12 ~ National Guard?, or 2. Have a military service disability rating fixed by the United States Veterans Affairs?

SAMPLE BACKGROUND CHECK RELEASE FORM

Employer Name
I hereby authorize_____________________________ and its designated agents and

representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: Verification of Social Security Number, current and previous residences, employment history including all personnel files, education, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state county jurisdictions, birth records, motor vehicle records to include traffic citations and registration and any other public records. I_______________________________, authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I understand that I must provide my date of birth to adequately complete said screening, and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me, to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. This authorization and consent shall be valid in original, fax, or copy form. I hereby release ___________( Your Agency name), and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization and request to relapse. You may contact me as indicated below; I understand that a copy of this

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authorization may be given to me at any time, provided I request it in writing. Information on this application and results of the background investigation will be maintained in confidence in accordance with company hiring practices.

Name (Print) ______________________________________________________________________ First Middle (full name) Last Maiden Print All Former Names Used: (1) ______________________________________________________________________ (2)_____________________________________________________ _______________ Social Security Number: ________-______-_________ SX: ______ Race: _________ D/O/B: ___________________ Current Street Address: _________________________ City: ______________________ State: ___________________________ Zip: _______ Drivers License Number: _____________ State of Issuance: _____________________ May we contact Your Employers: _______________Comments:___________________ ______________________________________________________________________ Signature: _____________________________ Date: ___________________________ Print Residences in the previous 10 years (City & State) City: ________________________________ State: ____________________________ City: ___________________________________ State: _________________________ City: _____________________________________State: ________________________

Using the numbers below, please indicate whether you have been convicted of any crimes listed below: 1. Homicide/Murder 6. Destruction of Property 11. Fraud 2. Rape or Molestation 7. Drug Trafficking/Use or Possession 12. Prostitution 3. Burglary/Robbery/Larceny 8. Child Abuse/Domestic Violence 13. Other 4. Threats of Harassment 9. Public Intoxication/Drunk & Disorderly Conduct 5.Assault or Fighting .10, Theft/Receiving Stolen Goods Number of Violation(s)______________________________________________ Status/Disposition_________________________________________________________ Applicant Signature: ____________________________________________________________

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Date: ________________________________

Sample Time Card

Weekly Work Report Employee ID #:___________Week Ending__________ Name___________________________________ Name of Facility ______________________________ Day Saturday Sunday Monday Tuesday Wednesday Thursday Friday Total Hours Worked: Employee's Signature: _______________________________________ In Time Out Time Daily Total

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I certify that the above hours are correct. Supervisor: _______________________________ Important: Return card to Agency by Monday of the following week

SAMPLE REFERENCE RELEASE FORM

I understand that ___________________ (Name of your agency) will check references, as a part of the hiring process, to learn about my work history. I also understand that I will not have access to them. I release Johnson Medical Staffing and all providers of information from any liability as a result of furnishing and receiving this information. I give permission for the representative of ________ (name of your agency) to contact my current employer for a reference. Please circle - YES NO I give permission for the representative of _______(name of your agency) to contact my past employers as shown on my job application, and those listed below for employment references. Please circle YES NO Failure to authorize contact may exclude you from being considered for employment.
Applicant signature: ___________________________ Date_______________ Other references that you may call: Name, Title: _________________________________ Company: _________________________________

Phone Number: _________________________________ Name, Title: _________________________________

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Company: Phone:

_________________________________ _________________________________

Sample Reference questions: It is usually best to start with simple questions or by asking the reference provider to verify information you already have so he/she becomes more comfortable with you and therefore may be willing to share more information as you ask additional questions. 1. 2. 3. 4. 5. Ask about (or verify) work title and job duties at the organization. Verify dates of employment. Verify reason for leaving. Verify ending salary. Ask the reference provider for his/her relationship to the applicant (direct supervisor, co-worker, Human Resources, friend) 6. What is/are the strengths of the candidate? 7. Knowing what I told you about my job, what area(s) do you think this candidate may need additional training or coaching to be effective? 8. A critical responsibility in this job is ________. Based on your experience with this candidate, will he/she be successful in this area? 9. What type of supervision is this candidate most responsive too? 10. How well did this candidate interact with others (co-workers, supervisors, subordinates)? 11. Did this candidate have any performance issues; or did this candidate have any documented disciplinary actions; or Are there any performance areas I should pay close attention to? 12. Our department processes a high volume of _________ where customer service and attention to detail are very important. Do you think candidate will be successful in an environment like this? 13. How would you describe the quality/quantity of work provided by the candidate? Can you give specific examples? 14. Teamwork is very important to me and my department, will this person be a team player and get along well with co-workers? 15. What motivates this candidate? 16. Is the candidate eligible for rehire? 17. Is there anything I have not asked that you think I should be aware of before making my hiring decision?

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SAMPLE JOB DESCRIPTION Title: Respite Caregiver Reports to: Service Coordinator JOB SUMMARY Responsible for providing relief from daily care giving to primary caregivers of persons at risk for or experiencing a disability. KNOWLEDGE, SKILLS and ABILITIES 1. Ability to implement services as planned in partnership with families and other team members. 2. Has strong communication skills with diverse populations including; families, team members and the public. 3. Contributes to the professional reputation of the agency. OTHER QUALIFICATIONS Must have high school diploma or GED. Must be 18 years or older. All applicants must be able to pass a criminal background check under state regulations. The ability to obtain the First Aid and CPR certification within one month of being hired.

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Performance Standards Respite Caregiver 1. Implements plan in partnership with families and other team members. Function: Implements plan in partnership with families and other team members Standards: a) Is aware of and adheres to all elements of the individual service plan. b) Accesses resources necessary to implement the individual service plan. c) Implements plan in a manner sensitive to the individual, family and community. d) Makes adaptations according to specific developmental, mental health and medical needs.

e) Maintains mutually respectful boundaries with families. f) 2. Interacts with other service providers in a professional manner.

Has strong communication skills with diverse populations including; families, team members and the public Function: Communicates with families in a positive manner. Standards: a) Seeks regular feedback from families regarding the effectiveness of services. b) Adapts to communication styles of individuals from different cultural backgrounds.

c) Is dependable and follows through on commitments. 3. Contributes to the professional reputation of the agency. Function: Adheres to agency policies and procedures. Standards: a) Locates and refers to agency policy manual

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b) Asks for clarification regarding policies/procedures from supervisor. c) Complies with all agency policies and procedures GENERIC JOB DESCRIPTION

Home Health Aides

Provide routine, personal healthcare, such as bathing, dressing, or grooming, to elderly, convalescent, or disabled persons in the home of patients or in a residential care facility. Tasks

Administer prescribed oral medications under written direction of physician or as directed by home care nurse and aide. Change dressings. Check patients' pulse, temperature and respiration. Direct patients in simple prescribed exercises and in the use of braces or artificial limbs. Maintain records of patient care, condition, progress, and problems in order to report and discuss observations with a supervisor or case manager. Massage patients and apply preparations and treatments, such as liniment, alcohol rubs, and heat-lamp stimulation. Provide patients with help moving in and out of beds, baths, wheelchairs or automobiles, and with dressing and grooming. Accompany clients to doctors' offices and on other trips outside the home, providing transportation, assistance and companionship. Care for children who are disabled or who have sick or disabled parents. Change bed linens, wash and iron patients' laundry, and clean patients' quarters. Entertain, converse with, or read aloud to patients to keep them mentally healthy and alert. Perform a variety of duties as requested by client, such as obtaining household supplies and running errands. Plan, purchase, prepare, and serve meals to patients and other family members, according to prescribed diets. Provide patients and families with emotional support and instruction in areas such as infant care, preparing healthy meals, independent living, and adaptation to disability or illness.

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SAMPLE CONTRACT WITH AN INDEPENDENT CONTRACTOR AGREEMENT

This agreement made on _______, 20__, between ______, client of_________________ and__________, Contractor of ____________________________ 1. Services to be performed. Contractor agrees to perform the following services to Client: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ _______________________________________( Description of Services). 2. Time for Performance. Contractor agrees to complete the performance of these services on or before ______, 20__. 3. Payment. In consideration of Contractors performance of these services, Client agrees to pay Contractor as follows: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ____________________________________( Description of how payment will be computed). 4. Invoices. Contractor will submit invoices for all services provided. 5. Independent Contractor. The parties intend Contractor to be an independent Contractor in the performance of these services. Contractor shall have the right to control and determine the method and means of performing the above services; Client shall not have the right to control or determine such methods or means. 6. Other Clients. Contractor retains the right to perform services for other clients 7. Assistants. Contractor, at Contractors expense, may employ such assistants as Contractor deems appropriate to carry out this agreement. Contractor will be responsible for paying such assistants, as well as any expense attributable to such assistants, including income taxes, unemployment insurance, and Social Security taxes, and will maintain workers compensation insurance for such employees. 8. Equipment and Supplies. Contractor, at the Contractors own expense will provide all tools, equipment and supplies necessary to perform the above

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services and will be responsible for all other expenses required for the performance of those services. Contractor______________________________________________________ Client____________________________________________________________

SAMPLE PRE-EMPLOYMENT CHECKLIST

Date:

Applicant:__________________________________________________________

Position:___________________________________________________________

References Requested: Date Received: ____________________ ______________ ____________________ ______________ ____________________ ______________

Interviewed By: Approved By: ____________________ ______________ ____________________ ______________ ____________________ ______________

Education verified:_________________________________________________

Licensure of certification verified:________________________________

Documentation
Education Verified Licensure/certification Verified 1-9 Documentation completed W-9 Completed for Independent Contractor W-4 Completed for Employee Hepatitis Vaccine Form Signed or

Date

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declined Tuberculosis Vaccine Form obtained

Effective starting date: ____________________________________________

Sample Hepatitis B Immunization Consent/Refusal Form

Please check one: Yes, I want to receive the Hepatitis B vaccine. I read the information given to me about Hepatitis B virus and Hepatitis B vaccine and I had the opportunity to ask questions. My questions were answered. I want to participate in the vaccination program. I understand this includes three injections at prescribed intervals over a six month period. I understand that there is no guarantee that I will become immune to Hepatitis B. I understand that I might experience an adverse side effect as the result of the vaccination. Date Given Lot # Administered By Next Date Due 1st Dose 2nd Dose 3rd Dose No, I dont want to receive the Hepatitis B Vaccine. I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring Hepatitis B Virus (HBV). I was given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to me. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at an increased risk of acquiring Hepatitis B, a serious disease. If in the future, I want to be vaccinated with the Hepatitis B vaccine, I understand that I can receive the vaccine series at no charge to me. __________________________ Employee Name City, State, Zip Social Security Number Signature

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PRIVACY ACT INFORMATION Agency: ________________________________ Address ________________________________ Telephone Number _____________ Date The collection and use of this information are consistent with the provisions of 5 U.S.C. 552a (Privacy Act of 1974). This information is sensitive and protected by the Privacy Act. It is only available to staff on a need to know basis. Electronic material must be password protected and must not be used except in accordance with routine uses identified in OPM/GOVT-10, Employee Medical File System Records. Paper records must be similarly used and protected in a locked file or room that is available only to staff who have a need to know this information and in accordance with OPM/TGOVT

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SAMPLE INTERVIEW CHECK LIST The interview Checklist: An interview checklist is a tool that helps you organize your formulated questions. It helps to ensure the interview is properly conducted and also serve as a reminder to ask key questions during the interview. Also after the candidate has left, you will need to evaluate the person to consider for hiring. The interview checklist is a vital tool for post interview evaluation. When evaluating the candidate post interview make sure to consider how the person interacted with others, energy level, genuine interest in your agency and the position and also evaluate personal qualities, organizational fit, common sense and good judgment. Name of Candidate__________________________________ Date__________ Time of Interview_________________ Position applying for_________________ Salary_________________________ Start Date____________________ Other_______________________________ Appearance/Demeanour_____________________________________________ Technical Questions: (List specific questions to be asked of all candidates in relation to specific skills Q1._____________________________________________________________ A1.______________________________________________________________ Q2._____________________________________________________________ A2.______________________________________________________________ Q3._____________________________________________________________ A3.______________________________________________________________ Accomplishments: (List the questions, to be asked of all candidates, related to a candidates effectiveness of performance.) Q1._____________________________________________________________ A1.______________________________________________________________

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Q2._____________________________________________________________ A2.______________________________________________________________ Q3._____________________________________________________________ A3.______________________________________________________________ Patient/Customer Service Questions: (List the questions to be asked of all candidates related to service quality desired of all candidates hired to work for your agency Q1._____________________________________________________________ A1.______________________________________________________________ Q2._____________________________________________________________ A2.______________________________________________________________ Q3._____________________________________________________________ A3.______________________________________________________________ Other: (List other questions which are important for this position) Q1._____________________________________________________________ A1.______________________________________________________________ Q2._____________________________________________________________ A2.______________________________________________________________ Q3._____________________________________________________________ A3.______________________________________________________________ Additional Notes____________________________________________________________ ________________________________________________________________ Follow-up: _______________Schedule Second Interview with candidate ________________Sent Rejection letter ________________Acceptance letter to be sent, Send date_________________

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SAMPLE BACKGROUND CHECK RELEASE FORM

Employer Name____________________________________
I hereby authorize_____________________________ and its designated agents and

representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: Verification of Social Security Number, current and previous residences, employment history including all personnel files, education, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state county jurisdictions, birth records, motor vehicle records to include traffic citations and registration and any other public records. I_______________________________, authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I understand that I must provide my date of birth to adequately complete said screening, and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me, to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. This authorization and consent shall be valid in original, fax, or copy form. I hereby release _______( Your Agency name), and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization and

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request to relapse. You may contact me as indicated below; I understand that a copy of this authorization may be given to me at any time, provided I request it in writing. Information on this application and results of the background investigation will be maintained in confidence in accordance with company hiring practices.

Name (Print) ______________________________________________________________________ First Middle (full name) Last Maiden Print All Former Names Used: (1) _____________________________________________________________________ (2)_____________________________________________________ _______________ Social Security Number: ________-______-_________ SX: ______ Race: ________ D/O/B: ___________________ Current Street Address: __________________________ City: _____________________ State: ______ Zip: _______ Drivers License Number: ____________________________________ State of Issuance: _______________________ May we contact Your Employers: ___________________ May We contact Your Supervisors: ___________________ Comments: ______________________________________________________________________ Signature: _________________________________________________ Date: ____________________________________ Print Residences in the previous 10 years (City & State) City: ____________________________________ State: _______________________ City: ____________________________________ State: _______________________ City: _____________________________________ State: _______________________ Using the numbers below, please indicate whether you have been convicted of any crimes listed below: 1. Homicide/Murder 6. Destruction of Property 11. Fraud 2. Rape or Molestation 7. Drug Trafficking/Use or Possession 12. Prostitution 3. Burglary/Robbery/Larceny 8. Child Abuse/Domestic Violence 13. Other 4. Threats of Harassment 9. Public Intoxication/Drunk &

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Disorderly Conduct 5. Assault or Fighting 10. Theft/Receiving Stolen Goods Number of Violation (s)______________________________________________ Status/Disposition_________________________________________ Applicant Signature: __________________________________ Date: _____________________

SAMPLE EMPLOYMENT SCREENING FORM Authorization for Release of Information Background Verification Disclosure As part of the employment process, ________ (Your agency name here) hereby known as "The Company", may obtain a consumer report and/or Investigative Consumer Report. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for the purposes of employment only, a Consumer Report may be made which may include information about your credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided, in the event the Report contains information regarding your character, general reputation, personal characteristics or mode of living. Authorization and Release During the application process and at any time during any subsequent employment, I hereby authorize _________________________, on behalf of The Company 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, court 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. I authorize without reservation, any

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party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original, fax, or copy form. _________________________________________________________ Applicant's Signature and Date

Sample Drug Testing Consent Form

I have applied for employment with [Your Business] in a position that requires me to operate an automobile. As a condition for my application being considered, I understand and agree to undergo substance screening. I understand that if my test results are positive, I shall not be considered further by [Your Business] for a driver position. I hereby authorize any physician, laboratory, hospital or medical professional retained by [Your Business] for screening purposes to conduct such screening and to provide the results to [Your Business], and I release [Your Business] and any person affiliated with [Your Business] and any such institution or person conducting the screening, from liability therefore. Applicant's signature: _________________________________________________ Applicant's name: ____________________________________________________ Date: ______________________________________________________________

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Sample Notice To Employee of Suspension W/O Pay (Example) FORM C To: From: Date Subject: Notice of Suspension Without Pay Employee Name Employee SSN Supervisor Name Supervisor Title

Summarize the purpose of the memorandum, and state the beginning and ending dates and times of the suspension without pay. This is official notice that you are suspended without pay beginning at 8:00 a.m. on November 28, 2010 and ending at 5:00 p.m. on November 30, 2010. Summarize the reasons for the suspension and list previous attempts to correct the behavior, providing dates and actions as much as possible. This suspension is disciplinary action for the reasons set forth below: 1. You continue to fail to report to work on time, despite previous attempts to correct this behavior through counseling and formal disciplinary action. 2. You were counseled about the importance of arriving at work on time and reporting to the proper place on (date). You and your supervisor signed documentation of this counseling, stating your agreement to work at correcting this behavior.

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3. You received a written reprimand on (date) for continuing to report to work late after oral counseling by your supervisor. That letter of reprimand warned of the possible consequences if you continued to be late to work. You have reported to work late on two (2) additional occasions after receiving the written reprimand. On the first occasion, (date), you were twenty (20) minutes late to work. On the second occasion, (date), you were thirty-five (35) minutes late. The reasons you gave for being late (overslept; could not find matching socks to wear) were not sufficiently compelling to excuse your lateness, and you failed to call the office to warn that you would be late on either occasion. State the results of the employees failure to return to work as expected at the end of the suspension If you fail to return to work at the end of the suspension period without notifying me promptly of an acceptable reason for not returning as scheduled, I will assume that you have resigned your position with the agency voluntarily.

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SAMPLE JOB OFFER LETTER Ms. (Offeree's Name) (Address) (City, State, Zip Code) Dear Ms. (Name): XYZ Company, Inc. is pleased to offer you the position of Nurse for our organization. We are all excited about the potential that you bring to our company. As we discussed during your interviews, you will be working in our north [city] regional office. You will report directly to the Vice-President of Operations and be a member of our Executive Management Team. After finishing orientation for new executives, your initial task will be to help recruit and train new personal care aides focused on developing our company's non medical care services, but there will be many other projects associated with our overall management that will need your attention. You will be classified as an exempt executive-level employee. Your initial compensation package includes a weekly salary of $1600 (payable biweekly), full medical and dental coverage through our company's employee benefit plan, and fringe benefits as covered in the enclosed pamphlet. In accepting our offer of employment, you certify your understanding that your employment will be on an at-will basis, and that neither you nor the Company has entered into a contract regarding the terms or the duration of your employment. As an at-will employee, you will be free to terminate your employment with the Company at any time, with or without cause or advance notice. Likewise, the Company will have the right to reassign you, to change your compensation, or to terminate your employment at any time, with or without cause or advance notice.

~ 33 ~

We look forward to your arrival at our company and are confident that you will play a key role in our company's expansion into national and international markets. Please let me know if you have any questions or if I can do anything to make your arrival easier. Sincerely, [Name] Senior Vice-President XYZ Company, Inc.

SAMPL EMPLOYMENT ERMINATION CONTRACT Usually for salaried employees Employer [name of company] and Employee [employee's name] hereby agree to this Termination Contract. Employee and Employer had an employment agreement from [start date] to [termination date], in which they agreed that they would resolve any employment dispute as follows [method of dispute resolution, such as arbitration, and/or choice of law]. Employee hereby agrees and obligates [himself/herself] to the following: 1. Employee will not engage in any competition with Employer for the period of [duration of noncompetition agreement, such as one year], which includes employment with another company in the same or similar business as Employer, establishment of a new company in the same or similar business as Employer, or any contractual arrangement under which Employee consults, advises, or assists another company in the same or similar business. 2. Employee will not engage in conduct or make statements relating to [his/her] employment or this Termination Contract that can be construed as critical or derogatory of Employer its employees, agents, partners, shareholders, officers, directors, and affiliated companies. 3. Employee releases and discharges all claims, complaints, charges, disputes, and demands against Employer and its employees, agents, partners,

~ 34 ~

shareholders, officers, directors, and affiliated companies, except for claims, complaints, charges, disputes, or demands that could arise from a breach of this Termination Contract, such as claims for back pay, front pay, damages, and fees such as attorneys' fees, that could arise from federal or state employment laws or from any conduct by Employer. Employee has had the opportunity to consult with [his/her] attorney and is aware of [his/her] legal rights, but knowingly and voluntarily waives those rights to the extent possible under law. 4. Employee will not share, divulge or disclose any information about Employer or its employees, agents, partners, shareholders, officers, directors, and affiliated companies that Employee knows is confidential or is considered a trade secret, trademark, service mark, trade name, patent, or copyright, including information or a product invented or developed by Employee during [his/her] employment with Employer. 5. Employee has surrendered to Employer paper and electronic copies of all letters, memoranda, documents, records, and other material that is the property of Employer. Employee has also surrendered to Employer all other tangible property of Employer, including keys, products, charge cards, telephones, pagers, computer and other equipment, and vehicles. 6. Employee will not share, divulge, or disclose the provisions of this Termination Agreement except to Employee's family, agents, representatives, or advisors, or to the extent required by law. Employer and Employee further agree that in consideration for the above agreements and promises, Employer will pay Employee as follows: [terms of severance payment, such as lump-sum amount or payment schedule]. Such severance payment constitutes the entire obligation of Employer to Employee. Employer and Employee further agree that in the event of any breach of this Termination Contract or default hereunder; the injured party has the right to pursue any legal action available to enjoin the breaching party from further

~ 35 ~

injurious conduct and/or to recover from the breaching party damages for such breach or default. Dated: Signed:

SAMPLE TERMINATION OF CONTRACT

Date____________________ The undersigned have entered into a contract dated____________________(the contact) for the purpose of___________________________________________________________ ____________________________________________________________ ____________________________________________________________ _______________________________(List the purpose of the contract). The undersigned acknowledges that, by their mutual agreement, the Contract is hereby terminated without further recourse by either party. The termination of the Contract shall be effective on date__________________ Name______________________ Signature__________________________ Name______________________ Signature_________________________

~ 36 ~

RESPITE CAREGIVER CHECKLIST

Patient _____________________ Social _____________ Birth date_________ Doctor______________________________ Phone __________ Location___________________

Hospital___________________ Phone ______________ Medical Insurance______________ Home/ Health/Hospice Patient?_______ Agency Phone_____________ Nurse_______________ Diagnoses________________________________________ How Long_________________ Characteristics of diagnoses affecting care ___________________________________________ Current Symptoms ____________________________________________________________ Allergies ____________________________________History of seizures??_____ Patient's general emotional state (shy, sense of humor, weepy, sudden outbursts, etc)_______________________________________________________________ _____ Generally understand instructions ____ May not understand instructions _____ Vision Limitations Favorite distractions/Likes___________________________________________________ Dislikes___________________________________________________________ Universal Precautions instructions can be found __________________________ MEDICATIONS DOSE TIME TAKEN SPECIALS

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INSTRUCTIONS

1. _________________________________________________________________ _ 2. _________________________________________________________________ _ 3. _________________________________________________________________ _

Special Instructions

A. Taken on Empty Stomach B. Wake up patients to TAKE Medications C. With food/liquid (circle) D. Take (time) before eating E. Taken on patient Request F. Avoid ______________ G. Document when given H. Other _____________

Medical Equipment When Needs Assistance Need to Know 1. _________________________________________________________________ _ 2. _________________________________________________________________ _ Appointments (doctor's office, physical therapy, beauty/barber, visit friends, ball game, etc.) To (Name) Location phone Date Time 1. _________________________________________________________________ _ 2. _________________________________________________________________ _ PERSONAL CARE AND COMFORT Personal Care needs (attach instructions to this sheet) Catheter Care Hearing aid Shaving Peri-Care Mouth/Oral care

~ 38 ~

Bed Sores Foley Bag Dressings Changed Hair/skin/nail care Dentures Moving Patient Moves around Transfers from bed to chair Bedbound Reposition Requires Special unassisted with assistance life Special Instructions Walking/transporting patients Unassisted Cane Walker Wheelchair Physical Therapies 1. Unassisted 2. Needs Assistance 3. Range of Motion__________________________ Frequency ___________________ 4. Special Exercises ________________________________________ Toileting Unassisted Bedpan Urinal Catheter Colostomy Bedside Commode Incontinent pads other Bathing Bed bath Shower Tub Needs assistance __times per week Equipment needed 1. None 2. Transfer bench 3. Shower bench 4. Wheelchair Bedroom Comfort Bedtime Wake time Nap time(s) Room temperature Closed windows Prefers room dark Change Bed Pull sheet Blankets(s) Day__ or night__ Special bed items (sheepskin, egg crate mattress, extra pillows- attach sheet) Food- for meals/snacks or special instructions, see attached list Needs Assistance Needs to be fed Has difficulty Takes nothing by Tube feeding swallowing mouth feeding Soft foods Record Liquid Intake Meal times___ Breakfast____Luch_____ Dinner_______Snack Entertainment Options/preferences TV Radio Reading or being read to cards Other Avoid_________________________________________________________ HOUSE RULES AND INSTRUCTIONS

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1. Locking Doors 2. Don't Smoke 3. Working Stove 4. Fireplace 5. Gas shut off valve 6. Fire Extinguishers 7. Guests 8. Pet Care guidelines 9. Neighbors Other information________________________________________________________ _________________________________________________________________ ____________ _________________________________________________________________ _______ EMERGENCY PREPAREDNESS Discuss 911 preferences_____________________________________________________ DNR Order or Advanced Directives can be found______________________________ I'll return home on____________________ I will be away from ________________________to________________________ Location___________________________________________Phone__________ ______ Friends and Relatives you can contact in an emergency Name/address_____________________________________________ Phone____________ Name/address_____________________________________________ Phone____________

SAMPLE HOME SAFETY CHECK LIST

~ 40 ~

Home Exterior Yes Are step surfaces non-slip? Are step edges visually marked to avoid tripping? Are steps even and in good repair? Are stairway handrails present? Are handrails securely fastened to fittings? Are walking paths covered with a non-slip surface and free of objects that might be tripped over? Are walking paths clear, safe and even with no holes in the concrete? Is sufficient lighting available to provide safe ambulation at night? Are leaves and snow cleared away? Are tools and yard equipment safely and securely stored? Helpful tips: Poor lighting may contribute to trips and falls. Install light switches at the top and bottom of stairways to avoid climbing and descending in the dark. Install lights or colored tape on each step to provide a visual distinction between one step and the next. Paint doorsills a different color than the floor. No

Interior (Entry and Main Living Area) Is the entryway clear of clutter with at least 36 wide access? Do the door locks operate smoothly? Does the porch light adequately light the porch and door? Are the light switches located near room entrances? Are the lights bright enough to compensate for limited vision? Are the lights glare free? Are stairways well lit? ` Are handrails present on both sides of stairway? Are the handrails securely fastened? Are the stairways free of objects? Are there light switches at top and bottom of stairs? Are the stairs marked for visibility with contrasting tape or step lights?

Yes

No

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Are steps slip resistant? Are steps even and uniform in size and height? Are there smoke and carbon monoxide detectors present with fresh batteries? Are all electrical outlets cool to the touch? Are electric cords properly plugged in and safely tucked away? Are there nightlights in halls and stairwells? If present are electric heaters placed well away from rugs curtains and furnishings? Is the fireplace chimney clear of accumulation and inspected annually? Are carpets in good repair with edges tacked or taped down? Are linoleum and plastic stair treads secure? Are throw rugs secured with non-slip backing and taped down? Are floors finished in a non-slip way? Has high polish been avoided? Are rooms uncluttered to permit unobstructed mobility? Is water temperature reduced to prevent scalding? Are water faucets clearly marked hot and cold? Is the furnace checked yearly? Are there house smoking rules established? Do the room furniture patterns allow easy access to doors and windows? Do the doors drawers and windows open and shut easily? Is the furniture strong enough to provide support during transfers? Are telephones easily accessible? Are flashlights available in every room? Is glow tape stuck on important items to identify them in dark? Are cleaners and poisons clearly marked? Are window and door locks sturdy and operational? Are medications properly stored and usage instructions written down? Is a first aid kit available with up-to-date supplies?

Helpful tips: Improve the lighting in your home by using brighter bulbs, at least 60 watts. Use lampshades or frosted bulbs to reduce glare. Use uncut, low pile carpeting instead of thick pile to reduce tripping potential. Replace old windows with polarized glass or apply tinted material to eliminate glare without reducing light. Use chairs that have seating at least 14 16 inches from the floor and sturdy

~ 42 ~

armrests to provide leverage during sitting or rising for safer transfers.

Kitchen Are dishes and food stored on lower shelves for easy access? Is step stool sturdy and have a high handle for support? Are step stool treads slip resistant and in good repair? Is lighting sufficient especially over the stove sink and countertops? Are towels and curtains kept away from the stove? Are electric appliances and their cords kept well away from the sink? Is flooring nonslip? Are the Off indicators on stove and appliances clearly marked with brightly colored tape? Is there a telephone in the kitchen? Are emergency telephone numbers displayed including family contacts? Is there a fire extinguisher within easy reach and in good order? Are whistling teakettles and food timers in use? If the pilot light on the stove goes out is the gas odor strong enough to alert the homeowner? Is food properly stored? Are refrigerator and cupboards free of spoiled or expired food? Are pots and pans of a lightweight type? Are pot holders and oven mitts available?

Yes

No

~ 43 ~

Are the appliances including refrigerator and stove in good working order? Are pet dishes set out of walking area? Are table and chairs strong and secure enough to provide support when leaning standing or sitting?

Helpful tip: A well-organized kitchen will make cooking and cleaning easier and prevent falls. Rearrange frequently used items to avoid excessive bending and reaching. Use a hand held reaching tool for hard to reach objects.

Bedroom Are lamp and light switches within reach of the bed? Is the electric blanket in good working order? Is the telephone accessible from the bed? Is there an emergency telephone list near the telephone? Is there a flashlight and a whistle near the bed? Are medications stored away from the nightstand? Is the bed an appropriate height for easy transfer?

Yes

No

Helpful tips: It can be challenging not to mention expensive to keep fresh batteries in flashlights. Try purchasing flashlights that plug into the wall and remain constantly charged. Some rechargeable flashlights even have built in nightlights to make them easy to locate in the dark. Stand slowly when getting out of bed. Give your body time to adjust to an upright position. Wear well-fitting slippers and avoid night wear that drags on the ground. Tie the belt on your robe. Keep pathways between the bed and bathroom and the bedroom door unobstructed by clutter or furniture. The bed should be at least 18 high (from the top of the mattress to the floor) to allow more comfortable and safe transfers.

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 The edge of the mattress should be firm enough to support a seated person without sagging.

Bathroom Is the door wide enough for unobstructed access with or without an assistive device like a cane, walker, or wheelchair? Is the threshold low enough to avoid being a tripping hazard? Does the floor have a non slip surface? Are floor rugs secured with non slip backing and carpet tape? Are grab bars securely fastened next to the toilet and in the tub and shower areas? Are there non skid strips, decals or rubber mats in the tub or shower? Is there a tub or shower seat available? Is the toilet seat elevated for easy transfers? Is there sufficient, accessible, glare free light available? Is there telephone access available in the bathroom?

Yes

No

Helpful tips: If you are on strong medication or in a frail or delicate condition, do not bathe by yourself. Have someone assist you in and out of the bath and check on you periodically. Use a bath-chair, grab bars and hand held shower to provide stability when bathing. Do not use towel bars for support.

~ 45 ~

 Check water temperature with your hand before entering the tub or shower.

~ 46 ~

Service plan is used to determine monthly or bi-weekly service fees. A base fee is charged and added fees are determined by extra duties which are in capital letters below. SERVICE PROVISION CHECKLIST Household Cleaning Kitchen Area Sweeping and mopping floors? Washing dishes? Drying dishes? Cleaning counter tops? Cleaning the outside of stove? Cleaning the oven? Gathering and taking out trash? Note day trash is picked up. Cleaning inside/outside of refrigerator? Cleaning counter tops? Living Room Area Vacuum the floor Dusting the furniture? Cleaning the Bedroom Make the bed? Vacuum the floor? Dusting the furniture? Change the sheets? Cleaning the Bathroom Cleaning bathroom floors and walls? Cleaning sink, tub, toilet? Remember, home maintenance tasks are NOT covered by Medicaid or OPI. Always check with your case manager if the activity does not appear on your Task List. Consider alternate ways of getting these tasks done by volunteers, friends, family, etc.

Yes

No

Yes

No

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Home Maintenance Cleaning windows? Cleaning ceiling fans? Do you need someone to mow the yard? Do you need help raking your leaves? Do you need help shoveling your walk or driveway? Do you need help with flower gardens? Do you need help with potted plants? Do you need help maintaining your water softener? Do you need help to replace the batteries in smoke detectors? Do you need help to replace light bulbs? Do you need help to clean/replace A/C or furnace filters? Do you have an emergency generator? Will you need help to operate it if necessary?

Yes

No

SHOPPING, ERRANDS, and TRANSPORTATION

Do you need help grocery shopping? Do you want your caregiver to do your grocery shopping for you? Do you need your caregiver to write the grocery list? Do you need your caregiver to keep an inventory list of food and supplies you need Do you need your caregiver to go with you to the grocery store? Do you need help putting groceries away? Do you need help carrying bags? Do you need your caregiver to clip coupons? Do you need help to pay at the register? Yes No

Errands and appointments: Will you need transportation for medical appointment? Will you need transportation for social and community events? Will you need someone to drive your vehicle to appointments? Do you need help scheduling or canceling appointments?

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Do you need help transferring in and out of the car? Do you need physical help getting into a building? Do you need help once you are inside a building? Do you use a service dog? Do you need your caregiver to give you verbal cues?

Laundry
Do you need help doing laundry? Do you need your caregiver to do the laundry for you? Do you need help sorting your laundry? Do you need help washing/drying your laundry? Do you need help cleaning your lint filter? Do you need help folding your laundry? Do you need help putting your laundry away? Do you need help with ironing? Do you need any items hand washed? Do you need any clothes taken to the dry cleaner? Do you need help having clothes sewn or mended? Yes No

MEAL PREPARATION and EATING

Do you need help preparing meals? Will you plan your meals? Do you want help planning your meals? Do you need your caregiver to prepare all your meals for you? Do you want your caregiver to prepare meals and put them in the refrigerator or freezer for later use? Where do you want to eat your meals (kitchen, living room): Do you need help planning your meals? Do you need help eating? Do you need help cutting your food? Do you need your homecare worker to feed you? Do you need your caregiver to position your glass, plate and utensils? Yes No

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Do you need stand-by assistance in case of choking? Are you on a special diet?

BATHING
Do you need help bathing? Do you bathe every day? Do you use the shower? Do you use the bathtub? Do you prefer a bed bath? Do you need help washing your body? Do you wash any parts of your body by yourself? Do you need help with skin care treatments? Do you need help transferring? Do you need help washing your hair? Do you need help drying your body? Do you need help drying your hair? Do you need help combing your hair? Do you wear a robe when leaving the bathroom? Do you need help with deodorant or cologne? Yes No

GROOMING PERSONAL HYGIENE and DRESSING

ORAL HYGIENE Do you need help brushing your teeth? Do you brush you teeth 1x, 2x or 3x a day Do you use an electric toothbrush? Do you need help with your electric toothbrush? Do you use a water pick Do you need help with your water pick? Do you floss your teeth? Do you need help with flossing? Do you use mouthwash? Do you need help with mouthwash? Do you have removable dentures or other removable dental Yes No

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device? Do you need help removing dentures or other dental device? Do you need help cleaning dentures or other dental device? SHAVING Do you need help shaving? Do you shave every day? Do you use an electric razor? Do you use a safety razor? Do you shave under your arms? Do you shave your legs? Do you shave your face? Do you need help with aftershave or lotion? Do you need help trimming a beard or mustache? Do you need help trimming your toe nails? Do you need help trimming your finger nails? DRESSING Do you need help getting dressed? Do you need help getting undressed? Do you need help picking out your clothes? Do you need help putting on/off undergarments? Do you need help putting on/off pants/skirts? Do you need help putting on/off shirts? Do you need help putting on/off a necktie or scarf? Do you need help putting on/off socks? Do you need help putting on make-up? Do you need help combing your hair? Yes No

Yes

No

MOBILITY Transfer
Do you need help with transferring? Do you use any special equipment to transfer? (Transfer board, Hydraulic or electric lift) Please mark the areas you need help in transferring to or from:

Yes No

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Bed Toilet Chair Car Bath/Shower

NIGHT SERVICES

Will you need a live-in caregiver?

Do you need help with any part of your bedtime routine? Do you use an alarm clock? Do you need help using the alarm clock? Do you need help transferring in and out of bed? Do you need to be turned during the night? Do you use any devices, or pillows for positioning? Do you need help using the restroom during the night? Will you need your caregiver to stay overnight? Do you use an oxygen machine while sleeping?

Yes No

MEDICATION MANAGEMENT
Do you need help with your medicines? Do you take medicine every day? Do you use oxygen during the day? Do you need help taking your medicine? For example, put your medicine in your hand or have help with a drink. Do you need help organizing your medicine in a pillbox? Do you need help remembering when to take them? Do you need someone to pick up your medicine from the Pharmacy? If yes, do you need help programming or filling your medication device? Yes No

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BOWEL/ CONTINENCE SERVICES

Do you need help removing clothing? Do you need help cleaning after toileting? Do you need help transferring to or from the toilet? Do you use adult incontinence products? Please explain help needed: (for example, removing briefs, cleaning, replacing briefs) Do you use the toilet? Do you use grab bars Do you need help to get up or down from the toilet or Commode? Do you use a bedside commode? Do you empty the bedside commode? Do you use a bedpan? Yes No

Communication
Are you able to express yourself verbally and be clearly understood by others? Do you understand what people are saying to you? Do you use sign language? Do you read sign language? Do you use gestures with some speech? Do you need things explained to you with extra detail? Do you use a communication device? Do you need a communication device? Do you need help maintaining and programming a Communication device? Do you use hearing aids? Do you need someone to clean and check the batteries of your hearing aids? Yes No

~ 53 ~

Do you use an adapted telephone? Do you need someone to reprogram your adapted telephone periodically?

PET CARE
Do you have any pets? Do you need help to feed or water your pet? Do you need help to walk your pet? Do you need help to clean birdcage or fish tank? Do you need help to clean the kitty litter box or dog pen? Do you need help to bathe your pet? Do you need help to take your pet to be groomed? Do you need help to give your pet medicine? Do you need help to take you pet to vet appointments? Yes No

HOME CARE EQUIPMENT CHECKLIST

1. Disinfectants for soaking clothing and utensils used by the sick. Not all disinfectants are equally effective for every purpose. For clothing and food utensils, corrosive or poisonous disinfectants are to be avoided. Antiseptics do not kill bacteria; they only retard their growth. Among the common disinfectants that can be used in the home are: 1. Alcohol, 75 percent by weight, used for disinfecting instruments and cleaning the skin

~ 54 ~

2. Lysol, for decontaminating clothing and utensils 3. Soap with an antibacterial agent for scrubbing the hands 4. Carbolic acid (phenol) for disinfecting instruments and utensils (it is corrosive, poisonous, and very effective if used in 5 percent solution) 5. Cresol in 2.5 percent solution for disinfecting sputum and feces (less poisonous than phenol and can be obtained as an alkali solution in soap) 6. Boric acid, a weak antiseptic eyewash 7. Detergent creams, used to reduce skin bacteria 2. Disposable rubber gloves, to be used when handling patients with open wounds or contagious diseases, as well as for cleaning feces. 3. Paper napkins and tissues for cleaning nasal and oral discharges. 4. Rectal and oral thermometers. The former is used primarily for infants, while the latter is used for adults and older children. Thermometers should always be thoroughly disinfected after use by soaking in isopropyl alcohol, and they should be washed prior to reuse. 5. Eating and drinking utensils to be used only by the patient. Disposable utensils are preferable. 6. Urinal, bedpan, and sputum cup for patients who cannot go to the toilet. After use, they should be thoroughly disinfected with cresol and washed with liquid soap containing an antibacterial agent. 7. Personal toilet requisites: face cloths and towels, toilet soap, washbasin, toothbrush and toothpaste, comb, hairbrush, razor, and a water pitcher (if running water is not accessible to the patient). 8. Measuring glass graduated in teaspoon and tablespoon levels for liquid medication.

~ 55 ~

9. Plastic waste-disposal bags that can be closed and tied.

SAMPLE SERVICE PLAN AGREEMENT FORM Name of Client_____________________ Phone Number (_____)_________________ Street Address______________________________(Apt)_________City_________________ Zip Code_____________ Service Begin Date:_________________ Name Of Agency:_______________________ Detail Services to be provided: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

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_______________________________________________________________________ _________________________________________________ How often will Services be provided: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___________________________________ Service Review Date (Services must be reviewed every six month):______________________ Changes to Current Service Plan( A new service plan must be developed every six month):_________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ____ Agency Representative Signature_________________________ Date_______________ Client/ Legal Representative Signature___________________________Date_______________

Checklist for Home Health Care Medical Devices

Name of Client______________________________ Checklist Completion Date____________________ Please use this checklist to maintain your medical device safely and effectively in your home. As a homecare medical device user, you should know how your device works. Read your patient education information. Ask your doctor or supplier questions about your device and take notes. Ask what you need to operate your device. Do you need electricity, running water, telephone or computer connections to operate your device? Check to see that your home is suited for your device. Do the stairs, doorways, bathrooms or house wiring present any problems? Keep Instructions for Use close to your device.

~ 57 ~

Pay attention to alarms and error messages. Be familiar with what the alarms and error messages mean. Follow Instructions as given. Call supplier for help if you don't understand how your device works. Report to your doctor or device supplier any new problems you have with the device. Take care of your device and operate it according to the manufacturer's directions. Read your instructions for taking care of your device and follow them for: o Cleaning o Replacing batteries, filters o Protecting your device (e.g. keep food and drinks away from your device)

Can you safely take your device from home to school, work, and church and vacation spots? Check ahead to see if these other places are suited for your device. Dispose of your medical device according to the manufacturer's instructions. Always have a back-up plan and supplies. Make sure you know what to do if your device fails. Have emergency phone numbers for suppliers, homecare agency, doctor and manufacturer. Be sure that you have the after-hour phone numbers. If appropriate, keep extra batteries for your device. Know how to replace them. Educate your family and caregivers about your devices. Include them in hospital planning meetings or any device demonstrations. Ask them to do a hands-on demonstration to show they can effectively use the device. Keep children and pets away from your medical device. Don't let children play with dials, settings, on/off switches, tubings, machine vents or electrical cords. Don't allow pets to chew or play with electrical cords. Check with your supplier to see if you can turn off your device when not using it. Contact your doctor and home health care team often to review your health condition. Check to see if there are new conditions that may change the way you or your caregiver use the device. o Are there changes in vision, hearing or ability to move? o Have you had an illness, new medicines or loss of feeling? Report any serious injuries, deaths or close calls. Report these events to the FDA at 800-332-1088. The FDA will take action when needed to protect the public's health. Report these events to your supplier.

~ 58 ~

Home Care Tasks Checklist

Directions: This checklist is to help identify the tasks required to be completed by a home care worker. For each question, answer if help is needed and indicate how often. This will help in determining who to hire to work in the home. Bedroom Assist with getting in/out of bed Yes No Frequency and Comments

~ 59 ~

Make bed

Change bed linen

Bathroom

Yes No

Help with bathing

Help with toileting

Help with grooming

Clean sink, tub, toilet, and surfaces Personal Care Yes No

Help with dressing

Help with transferring

~ 60 ~

Help with walking

Health

Yes No

Manage medications

Nursing care

Occupational therapy

Physical therapy

Speech therapy

Meals

Yes No

Plan menus

Prepare and serve meals

~ 61 ~

Help with feeding

Wash, dry and store dishes and utensils

Clean sink, stove, counters, refrigerators Household Wash, dry and fold clothing and linens Yes No

Empty and take out trash

Clear, dust and organize surfaces throughout home

Vacuum carpets

Sweep floors

~ 62 ~

Wet or dry mop in rooms you use

Complete yard work

Shopping

Yes No

Prepare list

Run errands

Buy food and supplies

Store items as requested

Transportation

Yes No

Take to social activities

Take to doctors appointments

~ 63 ~

Take to other activities (religious, etc.) Social activities Yes No

Reading to your loved one

Playing games with your loved one

Visit with your loved one (conversation) Other tasks Yes No

~ 64 ~

Personal care checklist

(Discuss with Client before initiating Service)

Considerations to be discussed Medical advice Manual handling Discussion with Client Training Required for staff Risk Assessment Update job descriptions Staff identified and appointed. Action in case of an emergency.

Tick if required

Actions

Home Supplies Needed(such as

cleaning supplies for bathroom, kitchen, Yard)

Supplies Who will provide if needed? Pads Wipes Spare clothes Gloves Disposable aprons Yellow bags Hand wash Diapers

~ 65 ~

Additional information

Checklist completed by Date

SAMPLE CLIENT DAILY RECORD SHEET

Name of Caregiver:_____________________________________________________ Title/Name of Agency:___________________________________________________ Phone: (______)________________________________________________________ Date:__________________________________________________________________ Shift Start Time:_________________________________________________________ Shift End Time:__________________________________________________________

Name of Client:___________________________________________________________ Address:________________________________________________________________ _

Food:

Amount:

Time:

Comment:

Activities:

Duration:

Time:

Comment:

Medication:

Dose:

Time :

Comment:

~ 66 ~

Rate the following from 1 to 10 with 1 being the lowest and 10 being the highest Pain and Discomfort: 1 2 3 4 5 6 7 8 9 10 Energy Level: 1 2 3 4 5 6 7 8 9 10 Sleep Pattern 1 2 3 4 5 6 7 8 9 10 Nausea/Constipation: 1 2 3 4 5 6 7 8 9 10 Document additional changes noted _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ______________________________________________________________________

~ 67 ~

SAMPLE AUTHORIZATION FOR RELEASE OF INFORMATION

CLIENT INFORMATION:
FULL NAME ADDRESS CITY BIRTHDATE SS# ZIP

STATE

PERSON RESPONSIBLE - PARENT/LEGAL GUARDIAN

INFORMATION TO BE DISCLOSED:

TO WHOM THE INFORMATION SHALL BE DISCLOSED:

NAME ADDRESS INSTITUTION (If Applicable) CITY STATE ZIP

PURPOSE OF THE REQUEST:

SIGNATURE TO RELEASE INFORMATION:

~ 68 ~

CLIENT/LEGAL GUARDIAN WITNESS/NOTARY ( if necessary)

DATE DATE

REVOCATION/EXPIRATION: The client has the right to revoke (take back)

this authorization at any time if done so in writing. Signed authorizations shall expire in 90 days from the date of signing.

COPIES: The client/Legal Guardian will be provided with a copy of this signed
authorization.

SAMPLE CERTIFIED NURSING ASSISTANT SKILLS CHECKLIST

Print Name
Self-Rating Key: 0-No experience (please print) 1-Minimal experience/works with supervision 2-Independent/works without supervision in most cases 3-Senior/works at a supervisory or teaching level

Has knowledge of and can provide care and assist patients with the following tasks: 0 1 2 AMBULATION 1. Crutches 2. Walker 3. Cane 4. Gait belt PERSONAL CARE x 1. Bath: a. Bed b. Tub c. Shower

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2. Skin Care: a. Back rub b. Decubitus prevention/care 3. Dress: a. Assist as needed b. Use of assistive devices 4. Hair Care 5. Nail Care (fingers & toes) a. Clean/file/trim with clippers 6. Oral Hygiene: a. Mouth care b. Brush teeth c. Denture care 7. Shaving: Safety razor/electric razor NUTRITION / HYDRATION x 1. Feeding techniques 0 2. Assist with eating 3. Use of feeding assistive devices 4. Measure & record intake 5. Encourage fluids BASIC INFECTION CONTROL PROCEDURESx 1. Hand washing 2. Universal precautions 3. Use of warm & cool applications ASSISTING OR CARE OF PATIENT WITH BOWEL & BLADDER ELIMINATIONx 1. Bedpan / urinal 2. Bedside commode 3. Care of incontinent patient 4. Stoma care 5. Bowel / bladder training 6. Measure & record output URINARY CATHETER CARE 1. Perineal hygiene 2. Foley catheter 3. Supra pubic catheter TRANSFER TECHNIQUES x 1. Use of transfer gait belt 2. Weight bearing 3. Non-weight bearing 4. Mechanical lift 5. Wheelchair 1 2 3

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TURNING / POSITION PATIENT 1. Supine 2. Side-lying 3. In chair 4. In bed 5. Use of lift sheet COMMUNICATION x 1. Verbal 2. Non-verbal with cognitively impaired patients RANGE OF MOTION EXERCISES x 1. Active 2. Passive 3. Combination TAKE & RECORD VITAL SIGNS 1. Temperature a. Oral b. Rectal c. Ear canal 2. Pulse: a. Apical b. Radial c. Pedal 0 3. Respirations 4. Blood Pressure 5. Height 6. Weight a. Standing b. Bed scale c. Chair scale SAFETY DEVICES 1. Vest restraint 2. (Soft) wrist / ankle restraint 3. Padded side rail 4. Side rails MENTAL HEALTH & SOCIAL SERVICE NEEDS x 1. Demonstrates principles of behavior management 2. Provides emotional support to patient 3. Encourages family support 4. Encourages patients to make personal choices 5. Respects patients rights & dignity, including privacy & confidentiality 1 2 3

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6. Encourages self-care as ability allows 7. Knowledge of adult, child and elder abuse reporting statutes 8. Knowledge of domestic violence and violent injury reporting statues SAFETY / EMERGENCIES 1. Recognizes & reports safety hazards 2. Recognizes & reports emergencies and responds appropriately 3. Handles 02 safely 4. Observes, reports & documents changes in body functions, behavior CARE OF PROSTHETIC DEVICES x 1. Limbs 2. Eye glasses 3. Hearing aids SPECIMEN COLLECTION x 1. Urine 2. Stool 3. Sputum UNDERSTAND AND CAN PERFORM x 1. Binders & Bandages a. ACE bandages b. Support stockings 2. Care of the deceased 0 ASSIST THE CARE OF PATIENT WITH x 1. Diabetes 2. Cancer 3. Heart Disease 4. 02 therapy 5. Respiratory disease 6. Terminal 7. Infectious diseases 1 2 3

To the best of my knowledge, information provided on this CNA Skills Checklist is true and accurate. My signature indicates that I have read this document in its entirety and understand its contents.

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Print Name: Signature: Date:

SAMPLE MEDICATION ADMINISTRATION RECORD Name of Client_________________________________

MONTH_________________ 20________
***SINGLE ORDER AND PRE-OPERATIVE***

MEDICATION-DOSAGE ROUTE OF ADMINISTRATION

GIVEN DATE TIME INIT

MEDICATION-DOSAGE ROUTE OF ADMINISTRATION

GIVEN DATE TIME INIT

INI TIA L

FULL SIGNATURE / TITLE

INITIAL

FULL SIGNATURE / TITLE

INITIAL

FULL SIGNATURE / TITLE

ALLERGIES

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DATE

TIME

DESTINATION

DISTANCE

SAMPLE MILEAGE REIMBURSEMENT SHEET

Employee Name___________________________________________ Supervisor Signature____________________________ Date___________

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Petty Cash Sheet

Name of Client_________________________ Address__________________________ Date Amount Spent Item purchased Balance Caregiver initials

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Sample Projecting Cash Flow Form

Name of Business Owner Type of Business Prepared by Date .. 1. Cash on hand (beginning month) 2. Cash receipts (a) Cash sales (b) Collections from credit accounts (c) Loan or other cash injections (specify) .. .. .. ..

.. ..

3. Total cash receipts (2a+2b+2c=3) 4. Total cash available (before cash out) (1+3) 5. Cash paid out (a) purchases (merchandise) (b) Gross wages

.. ..

..

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(excludes withdrawals) (c) Payroll expenses (taxes, etc.) (d) Outside services (e) Supplies (office and operating) (f) Repairs and maintenance (g) Advertising (h) Car, delivery and travel (i) Accounting and legal (j) Rent (k) Telephone (l) Utilities (m) Insurance (n) Taxes (real estate, etc.) (o) Interest (p) Other expenses (specify each) (q) Miscellaneous

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(unspecified) (r) Subtotal (s) Loan principal payment (t) Capital purchases (specify) (u) Other start-up costs (v) Reserve and/or escrow (specify) (w) Owner's withdrawal

6. Total cash paid out (5a through 5w) 7. Cash position (end of month) (4 minus 6) Essential operating data (non-cash flow information) A. Sales volume (dollars) B. Accounts receivable (end on month) C. Bad debt (end of month) D. Inventory on hand

..

..

..

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(end of month) E. Accounts payable (end of month)

PROJECTED PROFIT AND LOSS STATEMENT Name of Business_____________________________________________ Owner_______________________________________________________ Type of Business______________________________________________ Prepared by Date______________________________________________ *

Income
Total Sales (1 year after loan funding):____________________________ Cost of Sales: $___________________________________________

Gross Profit: $ ____________________________________________

Expenses

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Fixed Expenses

Controllable Expenses

Rent $:__________________ $:________________ Utilities $:_______________ _ $:______________ Equipment Leases $: _______ $:_____________________ Depreciation $:____________ $:__________________ Insurance $:______________ $:________ License/Permits $:_________ $:_____________ Loan Payment $:__________ $:___________ Miscellaneous $:__________ $:_________________ Other $:________________ $:_______________________ TOTAL Total Expenses $:_______________________________ Net Profit (Loss) Before Taxes $:___________________ Taxes $:______________________________________ Net Profit (Loss) After Taxes $:____________________

Salary/ Wages Payroll Expenses Supplies Advertising Dues/ Subscription Fees Legal & Accounting Repairs/Maintenance Miscellaneous Other

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PAYROLL DEDUCTION AUTHORIZATION

I______________(Name of Employee) hereby authorizes _________________________________ to Deduct an amount of $___________ from my gross earnings each payroll period beginning_______________ Item(s) checked below: In payment for: ____ Credit Union ____ Employee Savings Plan ____ 401 K Plan ____ Union Dues ____Other Total $ Amount ___________ ___________ ___________ ___________ ___________ ___________

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Signature of Employee_________________________________ Date________________________ Print Name_______________________________

STANDARD (sample) SERVICES AGREEMENT THIS AGREEMENT is made on BETWEEN 1. 2. [the Buyer] of (the "Buyer"); and [the Service Provider] of (the "Service Provider"), [Month, day, year]

Collectively referred to as the "Parties". RECITALS The Buyer wishes to be provided with the Services (defined below) by the Service Provider and the Service Provider agrees to provide the Services to the Buyer on the terms and conditions of this Agreement. 1. Key Terms

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1.1 Services The Service Provider shall provide the following services ("Services") to the Buyer in accordance with the terms and conditions of this Agreement: [Insert a description of the Services here] 1.2 Delivery of the Services a. Start date: The Service Provider shall commence the provision of the Services on [insert date here]. b. Completion date: The Service Provider shall complete/cease to provide (delete as appropriate) the Services by/on (delete as appropriate) [insert date here] ("Completion Date"). c. Key Dates: The Service Provider agrees to provide the following parts of the Services at the specific dates set out below: [insert dates here] 1.3 Site The Service Provider shall provide the Services at the following site(s): [insert details here if applicable] 1.4 Price d. As consideration for the provision of the Services by the Service Provider, the price for the provision of the Services is [insert price here] ("Price"). e. The Buyer shall/shall not (delete as appropriate) pay for the Service Providers out-of-pocket expenses [comprising [please insert examples here, if agreed]). 1.5 Payment

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f. The Buyer agrees to pay the Price to the Service Provider on the following dates [if appropriate]: [Specify whether the price will be paid in one payment, in installments or upon completion of specific milestones. These details should be specified here.] g. The Service Provider shall invoice the Buyer through _______ for the Services that it has provided to the Buyer weekly/monthly/after the Completion Date] (delete as appropriate). h. The Buyer shall pay such invoices within 21 days of their receipt from the Service Provider. i. The method of payment of the Price by the Buyer to the Service Provider shall be by: i. ii. iii. [check][cheque] sent to the following address: [insert details wire transfer through _______to the following account: credit card payment through ______ (delete as appropriate) j. Any charges payable under this Agreement are exclusive of any applicable taxes, tariff surcharges or other like amounts assessed by any governmental entity arising as a result of the provision of the Services by the Service Provider to the Buyer under this Agreement and such shall be payable by the Buyer to the Service Provider in addition to all other charges payable hereunder. 2. General terms

here]

2.1 Intellectual Property Rights

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The Service Provider agrees to grant to the Buyer a non-exclusive, irrevocable, royalty free license to use copy and modify any elements of the Material not specifically created for the Buyer as part of the Services. In respect of the Material specifically created for the Buyer as part of the Services, the Service Provider assigns the full title guarantee to the Buyer and any all of the copyright, other intellectual property rights and any other data or material used or subsisting in the Material whether finished or unfinished. If any third party intellectual property rights are used in the Material the Service Provider shall ensure that it has secured all necessary consents and approvals to use such third party intellectual property rights for the Service Provider and the Buyer. For the purposes of this Clause 2.1, "Material" shall mean the materials, in whatever form, used by the Service Provider to provide the Services and the products, systems, programs or processes, in whatever form, produced by the Service Provider pursuant to this Agreement. . 2.4 Term and Termination a. This Agreement shall be effective on the date hereof and shall continue, unless terminated sooner in accordance with Clause 2.4(b), until the Completion Date. b. Either Party may terminate this Agreement upon notice in writing if: i. the other is in breach of any material obligation contained in

this Agreement, which is not remedied (if the same is capable of being remedied) within 30 days of written notice from the other Party so to do; or ii. a voluntary arrangement is approved, a bankruptcy or an administration order is made or a receiver or administrative

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receiver is appointed over any of the other Party's assets or an undertaking or a resolution or petition to wind up the other Party is passed or presented (other than for the purposes of amalgamation or reconstruction) or any analogous procedure in the country of incorporation of either party or if any circumstances arise which entitle the Court or a creditor to appoint a receiver, administrative receiver or administrator or to present a winding-up petition or make a winding-up order in respect of the other Party. c. Any termination of this Agreement (howsoever occasioned) shall not affect any accrued rights or liabilities of either Party nor shall it affect the coming into force or the continuance in force of any provision hereof which is expressly or by implication intended to come into or continue in force on or after such termination. 2.5 Relationship of the Parties The Parties acknowledge and agree that the Services performed by the Service Provider, its employees, agents or sub-contractors shall be as an independent contractor and that nothing in this Agreement shall be deemed to constitute a partnership, joint venture, agency relationship or otherwise between the parties. 2.6 Confidentiality Neither Party will use, copy, adapt, alter or part with possession of any information of the other which is disclosed or otherwise comes into its possession under or in relation to this Agreement and which is of a confidential nature. This obligation will not apply to information which the recipient can prove was in its possession at the date it was received or obtained or which the recipient obtains from some other person with good

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legal title to it or which is in or comes into the public domain otherwise than through the default or negligence of the recipient or which is independently developed by or for the recipient. 2.7 Notices Any notice which may be given by a Party under this Agreement shall be deemed to have been duly delivered if delivered by hand, first class post, facsimile transmission or electronic mail to the address of the other Party as specified in this Agreement or any other address notified in writing to the other Party. Subject to any applicable local law provisions to the contrary, any such communication shall be deemed to have been made to the other Party, if delivered by: i. first class post, 2 days from the date of posting; ii. iii. hand or by facsimile transmission, on the date of such delivery or transmission; and Electronic mail, when the Party sending such communication receives confirmation of such delivery by electronic mail. 2.8 Miscellaneous a. The failure of either party to enforce its rights under this Agreement at any time for any period shall not be construed as a waiver of such rights. b. If any part, term or provision of this Agreement is held to be illegal or unenforceable neither the validity nor enforceability of the remainder of this Agreement shall be affected. c. Neither Party shall assign or transfer all or any part of its rights under this Agreement without the consent of the other Party.

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d. This Agreement may not be amended for any other reason without the prior written agreement of both Parties. e. This Agreement constitutes the entire understanding between the Parties relating to the subject matter hereof unless any representation or warranty made about this Agreement was made fraudulently and, save as may be expressly referred to or referenced herein, supersedes all prior representations, writings, negotiations or understandings with respect hereto. f. Neither Party shall be liable for failure to perform or delay in performing any obligation under this Agreement if the failure or delay is caused by any circumstances beyond its reasonable control, including but not limited to acts of god, war, civil commotion or industrial dispute. If such delay or failure continues for at least 7 days, the Party not affected by such delay or failure shall be entitled to terminate this Agreement by notice in writing to the other. g. This Clause 2.8(g) and Clauses 2.3, 2.5, 2.6, 2.7 and 2.8 of this Agreement shall survive any termination or expiration. h. This Agreement shall be governed by the laws of the jurisdiction in which the Buyer is located (or if the Buyer is based in more than one country, the country in which its headquarters are located) (the "Territory") and the parties agree to submit disputes arising out of or in connection with this Agreement to the non-exclusive of the courts in the Territory. 2 Amendments to existing clauses

Clause(s) [insert amended clause reference(s) here] shall be amended to read as follows: 3 Additional clauses

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AS WITNESS the hands of the Parties hereto or their duly authorized representatives the day and year first above written. SIGNED by for and on behalf of [the client]

SIGNED by for and on behalf of [the Service Provider]

DURABLE POWER OF ATTORNEY

FOR HEALTH CARE

I, ___________________________________, am of sound mind and I

(Print or type your full name)

voluntarily make this designation.

APPOINTMENT OF PATIENT ADVOCATE I designate _____________________________, my _________________

(Insert name of patient advocate) (Spouse, child, friend )

Living at __________________________________________________________

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(Address of patient advocate)

as my patient advocate. If my first choice cannot serve, I designate ________________________________, my ______________________, living at
(Name of successor patient advocate) (Spouse, child, friend ... )

_______________________________________________________________________ _ (Address of successor patient advocate)

to serve as patient advocate. My patient advocate or successor patient advocate must sign an acceptance before he or she can act. I have discussed this appointment with the individuals I have designated as patient advocate and successor patient advocate.

GENERAL POWERS My patient advocate or successor patient advocate shall have power to make care, custody and medical treatment decisions for me if my attending physician and another physician or licensed psychologist determine I am unable to participate in medical treatment decisions. In making decisions, my patient advocate shall try to follow my previously expressed wishes, whether I have stated them orally, in a living will, or in this designation. My patient advocate has authority to consent to or refuse treatment on my behalf, to arrange medical and personal services for me, including admission to a hospital or nursing care facility, and to pay for such services with my funds. My patient advocate shall have access to any of my medical records to which I have a right, immediately upon signing an Acceptance. This shall serve as a release under the Health Insurance Portability and Accountability Act.

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Immediately upon signing an Acceptance, my patient advocate shall have access to my birth certificate and other legal documents needed to apply for Medicare, Medicaid, and other government programs. . POWER REGARDING LIFE-SUSTAINING TREATMENT (OPTIONAL) I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment which would allow me to die, and I acknowledge such decisions could or would allow my death. My patient advocate can sign a do-notresuscitate declaration for me. My patient advocate can refuse food and water administered to me through tubes.
___________________________________________________________ (Sign your name if you wish to give your patient advocate this authority)

POWER REGARDING MENTAL HEALTH TREATMENT (OPTIONAL) I expressly authorize my patient advocate to make decisions concerning the following treatments if a physician and a mental health professional determine I cannot give informed consent for mental health care:
(check one or more consistent with your wishes)

outpatient therapy

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 my admission as a formal voluntary patient to a hospital to receive

inpatient mental health services. I have the right to give three days notice of my intent to leave the hospital.

my admission to a hospital to receive inpatient mental health services psychotropic medication electro-convulsive therapy (ECT) I give up my right to have a revocation effective immediately. If I
revoke my designation, the revocation is effective 30 days from the date I communicate my intent to revoke. Even if I choose this option, I still have the right to give three days notice of my intent to leave a hospital if I am a formal voluntary patient.
___________________________________________________________ (Sign your name if you wish to give your patient advocate this authority)

POWER REGARDING ORGAN DONATION (OPTIONAL) I expressly authorize my patient advocate to make a gift of the following (check any that reflect your wishes)

any needed organs or body parts for the purposes of transplantation,

therapy, medical research or education

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 only the following listed organs or body parts for the purposes of
transplantation, therapy, medical research or _________________________________________________ education:

my entire body for anatomical study (optional) I wish my gift to go to _________________________________________________

(Insert name of doctor, hospital, school, organ bank or individual)

The gift is effective upon my death. Unlike other powers I give to my patient advocate, this power remains after my death.
_________________________________________________ (Sign your name if you wish to give your patient advocate this authority)

STATEMENT OF WISHES My patient advocate has authority to make decisions in a wide variety of circumstances. In this document, I can express general wishes regarding conditions such as terminal illness, permanent unconsciousness, or other disability; specify particular types of treatment I do or not want in such circumstances; or I may state no wishes at all. If you have chosen to give your patient advocate power concerning mental health treatment, you can also include specific wishes about mental health treatment such as a preferred mental health professional, hospital or medication. A. My wishes are as follows (you may attach more sheets of paper):
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _____

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_______________________________________________________________________ _____________________________________________________________________

or B. I choose not to express any wishes in this document. This choice shall not be interpreted as limiting the power of my patient advocate to make any particular decision in any particular circumstance. I may change my mind at any time by communicating in any manner that this designation does not reflect my wishes. It is my intent no one involved in my care shall be liable for honoring my wishes as expressed in this designation or for following the directions of my patient advocate. Photocopies of this document can be relied upon as though they were originals. SIGNATURE I sign this document voluntarily, and I understand its purpose. Dated: ______________ Signed: __________________________________________
(Your signature)

_________________________________________________________________
(Address)

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STATEMENT REGARDING WITNESSES

I have chosen two adult witnesses who are not named in my will; who are not my spouse, parent, child, grandchild, brother or sister; who are not my physician or my patient advocate; who are not an employee of my life or health insurance company, an employee of a home for the aged where I reside, an employee of community mental health program providing me services or an employee at the health care facility where I am now.

STATEMENT AND SIGNATURE OF WITNESSES We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, without duress, fraud or undue influence. ____________________
(Print name) (Address) _____________________ __________________________________________________ (Print name) (Signature of witness)

___________________________________________
(Signature of witness)

_________________________________________________________________

_________________________________________________________________
(Address)

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ACCEPTANCE BY PATIENT ADVOCATE

(1) This designation shall not become effective unless the patient is unable to participate in decisions regarding the patients medical or mental health, as applicable. If this patient advocate designation includes the authority to make an anatomical gift as described in section 5506, the authority remains exercisable after the patients death. (2) A patient advocate shall not exercise powers concerning the patient's care, custody and medical or mental health treatment that the patient, if the patient were able to participate in the decision, could not have exercised in his or her own behalf. (3) This designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant patient's death. (4) A patient advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the patient has expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient's death. (5) A patient advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities. (6) A patient advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and shall act consistent with the patients best interests. The known desires of the patient expressed or evidenced while the patient is able to participate in medical or mental heath treatment decisions are presumed to be in the patient's best interests. (7) A patient may revoke his or her designation at any time or in any manner sufficient to communicate intent to revoke.

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(8) A patient may waive his or her right to revoke the patient advocate designation as to the power to make mental health treatment decisions, and if such waiver is made, his or her ability to revoke as to certain treatment will be delayed for 30 days after the patient communicates his or her intent to revoke. (9) A patient advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate intent to revoke. (10) A patient admitted to a health facility or agency has the rights I, ______________________________________, understand the above
(Name of patient advocate)

conditions and I accept the designation as patient advocate or successor patient advocate for ___________________________________________, who signed a
(Name of patient)

durable power of attorney for health care on the following date: ______________________.

Dated:

________________

Signed: _________________________________________________
(Signature of patient advocate or successor patient advocate)

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LIVING WILL

I, ___________________________________ am of sound mind, and I voluntarily make this declaration. If I become terminally ill or permanently unconscious as determined by my doctor and at least one other doctor, and if I am unable to participate in decisions regarding my medical care, I intend this declaration to be honored as the expression of my legal right to authorize or refuse medical treatment. My desires concerning medical treatment are _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___________

My family, the medical facility, and any doctors, nurses and other medical personnel involved in my care shall have no civil or criminal liability for following my wishes as expressed in this declaration. I may change my mind at any time by communicating in any manner that this declaration does not reflect my wishes.

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Photostatic copies of this document, after it is signed and witnessed, shall have the same legal force as the original document. I sign this document after careful consideration. I understand its meaning and I accept its consequences.

Dated: _________________

Signed: _______________________________
(Your signature)

_______________________________________________ _______________________________________________ (Address)

STATEMENT OF WITNESSES

We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, without duress, fraud or undue influence.
________________________ ____________________________________ (Print Name) (Signature of Witness) _______________________________________________ _______________________________________________ (Address) _____________________________ ____________________________________ (Print Name) (Signature of Witness)
_______________________________________________________________ _______________________________________________________________

(Address)

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~ 100 ~

DO-NOT-RESUSCITATE ORDER
I have discussed my health status with my physician, _________________. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order is effective until it is revoked by me. Being of sound mind, I voluntarily execute this order, and I understand its full import.
_______________________________________
(Declarants signature)

__________________
(Date)

_______________________________________
(Type or print declarants full name)

_______________________________________
(Signature of person who signed for declarant, if applicable)

__________________
(Date)

_______________________________________
(Type or print full name)

_______________________________________
(Physicians signature)

__________________
(Date)

_______________________________________
(Type or print physicians full name)

ATTESTATION OF WITNESSES
The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the individual has (has not) received an identification bracelet.
_____________________________________
(Witness signature) (Date)

________________________________
(Witness signature) (Date)

_____________________________________
(Type or print witnesss name)

________________________________
(Type or print witnesss name)

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DO-NOT-RESUSCITATE ORDER
I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order is effective until it is revoked by me. Being of sound mind, I voluntarily execute this order, and I understand its full import.

_______________________________________
(Declarants signature)

__________________
(Date)

_______________________________________
(Type or print declarants full name)

_______________________________________
(Signature of person who signed for declarant, if applicable)

__________________
(Date)

_______________________________________
(Type or print full name)

ATTESTATION OF WITNESSES
The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the individual has (has not) received an identification bracelet.
_____________________________________
(Witness signature) (Date)

________________________________
(Witness signature) (Date)

_____________________________________
(Type or print witnesss name)

________________________________
(Type or print witnesss name)

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Declaration of Anatomical Gift

I, __________________________________, am of sound mind, and I voluntarily make this declaration. In the hope I may help others, I make the following anatomical gift to take effect upon my death: (You may check any one box or both boxes A and C)

A. Any needed organs or body parts for the purposes of transplantation,

therapy, medical research or education. Only the following listed organs or body parts for the purposes of transplantation, therapy, medical research or education: _____________, _____________, _____________.

B.

C. My entire body for anatomical study.

Dated: _____________
(Address)

Signed: ____________________________________
(Your Signature)

_________________________________________________________________

OPTIONAL I wish my gift to go to __________________________________________.

(Insert name of doctor, hospital, school, organ bank or individual)

I wish to have my body at my funeral: STATEMENT OF WITNESSES

yes

no

This declaration was signed in our presence by the declarant or at his or her direction. We sign below as witnesses in the presence of the declarant. ________________________________
(Print Name) (Address)

______________________________
(Signature of Witness)

_________________________________________________________________ ________________________________
(Print Name)

______________________________
(Signature of Witness)

_________________________________________________________________

~ 103 ~

(Address)

~ 104 ~