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Home
About Us
Services
Chronic & Specialized Care
Adult & Child Disability Care
Cancer Care
Diabetes & Dialysis Care
Memory Care (Alzheimer’s & Dementia)
Parkinsons Care
Stroke Recovery Care
Post-Surgical & Mobility Recovery
Orthopedic & Surgical Recovery
Hospice & Palliative Care
Essential Home Care
Child Care Services
Respite Care
24/7 Home Care
Companion & Travel Assistance
Areas We Service
Pricing
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Bioharzadous Waste Management Acknowledgement
Step
1
of
2
50%
APPLICANT ACKNOWLEDGEMENT OF RECEIPT ON: RECOMMENDED METHOD OF HANDLING BIOMEDICAL WASTE
Applicant Name
Date
MM slash DD slash YYYY
Please check all that are true
I have been verbally informed of the recommended method of handling biomedical Waste generated in the home care setting
I have been given written material on “Safe Sharps Disposal at Home”
I have been given written material on “Cleaning up after Injury or Accident in Your Home”
FLORIDA CONCIERGE HOME CARE has given me the chance to discuss my concern regarding biomedical waste management in my home.
Applicant Signature
Date
MM slash DD slash YYYY
Witness Signature
Date
MM slash DD slash YYYY
NON-DISCRIMINATION POLICY
In accordance with Title VI of the Civil Rights Act of 1964 and itsimplementing regulation, FLORIDA CONCIERGE HOME CARE is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRIMINATE AGAINST RACE, COLOR, CREED, RELIGION, SEX, AGE, GENDER PREFERENCE, NATIONAL ORIGIN HANDICAP (MENTALOR PHYSICAL), ETHICAL/POLITICAL BELIEFS, DECISION REGARDING ADVANCE DIRECTIVES OR COMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI.
In accordance with Section 504 of Rehabilitation Act of 1973 and it’simplementing regulation, FLORIDIA CONCIERGE HOME CARE WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP.
In accordance with the Age Discrimination Act of 1975 and it’s implementing regulation, FLORIDA CONCIERGE HOME CARE WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision ofservices, unless age is a factor necessary to normal operation or the achievement of any statutory objective.
In accordance with the Americans with Disabilities Act of 1992 (42 USC & 12101) and it’simplementing regulations, (private employers with more than 25 Registry personnel), FLORIDA CONCIERGE HOME CARE WILL NOT, DIRECTLY OR THROUGHT CONTRACTUAL OR OTHER ARRANGEMENTS
DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment thatsubstantially limits a major life activity, or for which there is a record if impairment or which causesthe individual to be regarded asimpaired.
I hereby verify that have had all my questions answered by my satisfaction and that I understand all of the material covered.
Applicant Name
Applicant Signature
Date
MM slash DD slash YYYY
Print Name
Address
Phone
Position
Schedule Availability
Monday
From (Time)
Hours
:
Minutes
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PM
AM/PM
To (Time):
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:
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AM
PM
AM/PM
Overnight?
Yes
No
Tuesday
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To (Time):
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PM
AM/PM
Overnight?
Yes
No
Wednesday
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To (Time):
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Yes
No
From (Time)
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To (Time):
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:
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AM/PM
Overnight?
Yes
No
Friday
From (Time)
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To (Time):
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AM
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AM/PM
Overnight?
Yes
No
Saturday
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To (Time):
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AM/PM
Overnight?
Yes
No
Sunday
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To (Time):
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PM
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Overnight?
Yes
No
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