Healthcare Support Worker Form

HEALTHCARE SUPPORT WORKER FORM

Worker Identification

Date of birth:    Gender:

Emergency Contact

Agency / Employment Details

Employment type: Employee Contractor Per diem

Qualifications & Certifications

CPR/First Aid certified: Yes No    Expiration:

Background Checks & Medical Clearance

I authorize the employer/agency to obtain criminal background checks, employment verification, and reference checks as required for my role.

Consent to background check: I consent I do not consent

Drug screening required: Yes No

TB test / screening status: Negative Positive Not done    Date of last test:

Skills, Competencies & Assigned Tasks

Please indicate tasks you are trained and authorized to perform:

Personal care (bathing, dressing)
Mobility assistance / transfers
Medication assistance (non-administering)
Medication administration (requires training)
Wound care/dressing changes
Vital signs monitoring
Meal preparation / feeding
Light housekeeping
Transportation / errands
Companionship / social support

Assigned Client / Patient Information

Client DOB:    Client primary diagnosis:

Health, Medical & Safety Information

Availability & Schedule

Privacy, Confidentiality & Acknowledgments

I acknowledge that in the performance of my duties I will have access to protected health information and other confidential personal information. I agree to maintain the confidentiality of all such information and to use and disclose that information only as permitted by law and by the employer/agency policies.

I understand that unauthorized disclosure may result in disciplinary action, termination, and civil or criminal penalties. I agree to immediately report any privacy or security incident to my supervisor.

Authorization to share limited client information with supervising clinicians and necessary care team members: Yes No

Legal Certifications & Worker Acknowledgment

By signing below I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification, omission, or failure to disclose relevant information may result in denial of assignment, termination of employment, or other corrective action.

I further acknowledge that I have received, read, and understand applicable safety procedures, infection control policies, and emergency response protocols required for my assigned duties. I accept responsibility to seek clarification or supervision when encountering tasks or situations beyond my training or scope.

I authorize the release of information contained in this form to the employer/agency and to those individuals or entities involved in client care and compliance verification. This authorization is valid until the authorization expiration date listed above unless earlier revoked in writing.

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