CCA · Employee Packet

T01 · Employee Information & Background Check

First Name *

Last Name *

Street Address *

City *

State *

ZIP *

Phone *

Email *

Date of Birth *

SSN *

Driver's License

License #

State

Expiration

Citizenship & Tax

Citizenship Status

Tax Filing Status

Withholdings / Dependents

Emergency Contact

Name

Relationship

Phone

Background Check Authorization

No felony convictions

Has felony conviction(s)

If yes, list convictions in last 10 years

Employee Signature *

T02 · Address History

Previous Address (last 7 years)

Dates at Previous Address

References

List 3 references (Name, Relationship, Phone)

Direct Deposit Authorization

Bank Name

Account Type

Routing Number

Account Number

I-9 Identification Documents

Upload one of the following: Passport (List A), OR Driver's License + Social Security Card (List B + C).

Passport

Driver's License

Social Security Card

Employee Signature *

T03 · Personal Care Worker Employment Agreement

View full agreement PDF →

PCW Name *

Agreement Date *

Pay Rate *

Employment Type *

I acknowledge the confidentiality clause

I acknowledge the non-solicitation clause

I acknowledge the client abandonment policy

Employee Signature *

Agency Representative Signature *

T04 · Employment Agreement Addendum — Sick Leave & CO SecureSavings

View full addendum PDF →

By initialing below, the employee acknowledges receipt and understanding of Colorado's Paid Sick Leave entitlement and the Colorado SecureSavings program notice.

I have read and understand the Paid Sick Leave and SecureSavings notices

Employee Initials *

T05 · Work-Related Injuries Provider Acknowledgement

View full notice PDF →

I have read and understand the designated provider notice for work-related injuries

Employee Signature *

T06 · Job Description Acknowledgement

View full job description PDF →

I have read and understand the Personal Care Worker job description

Employee Signature *

T07 · Personal Care Worker Limitations Acknowledgement

View full limitations PDF →

I have read and understand the PCW scope of practice limitations

Employee Signature *

T08 · Employee Orientation Acknowledgement

View full orientation packet PDF →

Check each topic the employee has been oriented on:

Company overview and mission

Personnel policies and procedures

Payroll, timekeeping, and benefits

Safety procedures and infection control

HIPAA and client confidentiality

Abuse, neglect, exploitation reporting

Emergency procedures and on-call

Grievance and disciplinary policies

Employee Signature *

Agency Representative Signature *

T09 · Written Notice of Home Care Consumer Rights — Delivery Record

View full Consumer Rights notice PDF →

This is signed by the CLIENT (or client's agent) acknowledging receipt of the Consumer Rights notice, and by the Agency Representative delivering it.

Client or Client's Agent Name *

Agency Representative Name *

Client (or Agent) Signature *

Agency Representative Signature *

T10 · Initial Training Packet Acknowledgement

View full 16-page training packet PDF →

I have read and understand the Initial Training Packet

Training Completion Date *

Employee Initials *

CCA Employee Packet