Is this a New Hire or Terminated Employee Is this a New Hire or Terminated Employee New Hire Resignation Termination

Department Information Department Information Home Health Hospice Office Staff

Supervisor

Hire Date (MM/DD/YYYY)

Start Date (MM/DD/YYYY)

Date of Notice Given (MM/DD/YYYY)

Last Day of Work (MM/DD/YYYY)

Position/Title

Employee Information Employee Information Male Female

First Name

Last Name

Middle Name (IF NONE, TYPE "NA")

Other Names (Alias, Maiden, Married)

DOB (MM/DD/YYYY)

Social Security Number

Address, City, State, Zip Code

Personal Phone #

Personal Email Address

Covid-19 Information - Required per CMS Guidelines Covid-19 Information - Required per CMS Guidelines

Covid-19 Vaccination Status (MUST BE COMPLETE PRIOR TO SEEING ANY PATIENTS) Covid-19 Vaccination Status (MUST BE COMPLETE PRIOR TO SEEING ANY PATIENTS) Copy of Vaccine Card (Deliver to Blake) Exemption Letter (Form Emailed to Mandie)

Covid Test Date - New Employee Form Filled Out?

Test Result Test Result Positive Negative

Race (Optional) Race (Optional)American Indian or AlaskanAsianBlack or African AmericanHawaiin or Other Pacific IslanderWhiteOther

Ethnicity (Optional) Ethnicity (Optional)Hispanic or LatinoNot Hispanic or Latino

Employee IT Needs (Check all that apply. Note: Devices May Need to be Ordered) Employee IT Needs (Check all that apply. Note: Devices May Need to be Ordered) Company Email Phone Laptop None

Comments/Notes (Not Required)