Acknowledgement. Employee Signature. Printed Name. Job Title

Transcription

1 Acknowledgement I have read this job description and fully understand the requirements set forth therein. I understand that this is to be used as a guide and that I will be responsible for performing other duties as assigned. I further understand that this job description does not constitute an employment contract with Premier Therapy. Employee Signature Date Printed Name Job Title 11/7/2013

2 RESIDENTS RIGHTS POLICY Policy: Each of the residents at this facility has a right to a dignified existence, self-determination and communication with and access to individuals and services inside and outside of facility. We promote and protect THE RIGHT OF EACH INDIVIDUAL RESIDENT TO: 1. Safe, clean living environment. 2. Be free from physical, verbal, mental and emotional abuse and to be treated with courtesy, respect and full recognition of dignity and individuality. 3. Adequate and appropriate medical treatment, nursing care and other services that comprise necessary and appropriate care consistent with the program for which the resident contracted. This care shall be provided without regard to race, color, religion, national origin, age or source of payment. 4. Have all reasonable requests and inquiries responded to promptly. 5. Have clothes and bed sheets changed as the need arises to insure comfort and sanitation. 6. Obtain a specialty of any physician or other person responsible for resident s care or for the coordination of care. 7. Select a staff physician of choice or obtain own physician outside the home. 8. Participate in decisions that affect your life; to participate in plan of care meetings; and participate in planning care in treatment and in changes in care and treatment, have access to information on medical record; give or withhold informed consent; refuse treatment. 9. Withhold payment to physician if physician did not visit. 10. Confidential treatment of personal and medical records: refuse release of medical record to any individual outside the home except as required by law we transfer to another facility, or as required by a third-party payment contract. 11. Privacy during medical examination or treatment and personal care. 12. Refuse to serve as medical research subject. 13. Be free from any physical or chemical restraints or prolonged isolation imposed for the purpose of discipline or convenience and not required to protect residents or others from injury unless ordered by the physician. (Chemical restraint is defined as that which alters the functioning of the central nervous system in a manner that limits physical and cognitive functioning to the degree that the resident cannot attain his or her highest practical physical, mental and psychological well being.) 14. Obtain pharmacist of choice and pay fair market price for drugs. 15. Exercise all civil rights unless adjudicated incompetent: Right to Vote. 16. Have access to opportunities that enable resident, at his/her expense or at the expense of a third-party payer, to achieve fullest potential in education, vocation, social, recreation and rehabilitation. 17. Consume a reasonable amount of alcoholic beverage, at his/her expense, unless contraindicated by attended physician. 18. To be informed, prior to admission, that this is a non-smoking facility. I, have read and understand the above (printed name) noted Resident s Rights and will adhere and abide by them accordingly. Signature Date

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12 EMPLOYEE HANDBOOK ACKNOWLEDGMENT PAGE I ACKNOWLEDGE THAT I HAVE (please check one): received a printed copy viewed an electronic version* of the Premier Therapy Employee Handbook dated April 1, I understand that I am expected to read and comply with the Handbook. I ALSO UNDERSTAND THE FOLLOWING: The Employee Handbook outlines certain standards, policies, procedures, programs and benefits, but they are not all-inclusive and I am responsible for consulting with my supervisor, the next level of management or the Corporate Office regarding questions not addressed in the Handbook. The Employee Handbook is not intended to be, nor should I construe it as an express or implied contract of employment or a guarantee of employment for any specific period of time. It also is not intended to guarantee to me any specific terms or benefits of employment. The Employee Handbook is subject to change at the sole discretion of the Company and without prior notice. The Company may deviate from its standards, policies, procedures, programs and benefits, including those discussed in the Handbook, when it deems necessary in its sole discretion. This Employee Handbook supersedes and replaces all prior employee handbooks, manuals, or policies issued by the Company or any predecessor owner or operator. My employment with the Company is at-will, meaning that either the Company or I can terminate my employment at any time and for any reason and with or without cause or notice. No written materials may be distributed or oral representations made to me, which contradict the employment at-will standard. Please sign, date and fax this form to or mail to Premier Therapy, 701 Sharon Road, Beaver, PA Printed Name Employee s Signature Date *An electronic version is available via the company's intranet "Resources" link accessible from your therapy department.

13 EMPLOYMENT APPLICATION Today s Date: Premier Therapy and its affiliate, Atlas Rehab and Wellness, (the "Company") is an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, or ph ysical or mental disability. Rev. 5/1/13 Have you previously worked for Premier Therapy or Atlas Rehab & Wellness? PERSONAL If so, when and in what capacity? Last Name First Initial Social Security # Street Address Home Telephone # ( ) City State Zip Business Telephone # ( ) address Cell Telephone # ( ) Position Applied For Referred By Hourly Rate Desired EDUCATION Circle Highest Grade Completed: High School College, Trade or Business Graduate Studies School Name of School City and State Degree, Diploma, License/Certificate Date Graduated High School College/University Vocational, Business, Other List Any Professional Designations EMPLOYMENT HISTORY LIST ALL EMPLOYMENTS FOR THE PAST 10 YEARS, STARTING WITH THE MOST RECENT POSITION.ALL INFORMATION MUST BE COMPLETED.YOU MAY ATTACH A RESUME, BUT NOT IN PLACE OF COMPLETING THE REQUIRED INFORMATION. Employed From / / Employed Until / / Job Title Duties & Responsibilities Employer Name Supervisor Name Starting Salary Employer Address Supervisor Phone # Ending Salary Reason for Leaving Employed From / / Employed Until / / Job Title Employer Name Supervisor Name Starting Salary Employer Address Supervisor Phone # Ending Salary Reason for Leaving Duties & Responsibilities 1

14 REFERENCES (LIST THREE BUSINESS ASSOCIATED REFERENCES) Name Name Name Business Relationship/Years Acquainted Business Relationship/Years Acquainted Business Relationship/Years Acquainted Phone Phone Phone GENERAL Yes No If hired, will you be able to work rotating weekend and holiday coverage and overtime in accordance with Premier Therapy policy? Can you perform the essential functions of the position for which you are applying, with or without reasonable accommodation? If no, please explain. (If you have any question as to what functions are applicable to the position for which you are applying, please ask the interviewer before you answer the question.) Have you ever been convicted of a crime, including a sex abuse or child abuse-related crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court? (A yes response does not automatically disqualify your application.) If yes, please explain. Have you ever had your professional license suspended, revoked, and/or are you currently under a disciplinary action status with the state licensing board? (A "yes" response does not automatically disqualify your application.) If yes, please explain. CERTIFICATION &AUTHORIZATION The above information is true and correct. I understand that, in the event of my employment by the Company, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary, I understand and agree that, if hired, my employment will be terminable at will and may be terminated by the Company or me at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents, which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of The document(s) provided will be used for completion of Form I-9. Resignation Without Notice Policy While we hope both you and Premier Therapy will mutually benefit from continued employment, we realize it may become necessary for you to leave your job with Premier. If you anticipate having to resign your position, you are expected to submit your written notice at least three (3) weeks in advance of the date you must leave and work all of your final schedule. In this regard, failure by an employee to comply with our Resignation Without Notice Policy will result in the employee being paid minimum wage for hours worked in any unissued paycheck and forfeiting any accrued paid time off. This policy helps Premier Therapy maintain the best quality care for our residents while avoiding interruptions. If an application for employment is going to be processed, the applicant must sign accordingly, signifying they understand this policy. For further information, ask your interviewer to show you the Resignation Without Notice Policy in the Premier Therapy Employee Handbook. I hereby acknowledge that I have read and agree to the above statements. Printed Name Signature Date 2 Please fax both pages to: or mail to: Premier Therapy 701 Sharon Rd. Beaver, PA 15009

15 Electronic Signature Form Signature will be uploaded to therapy software for use on electronic patient documentation and therapy records. PLEASE PRINT First Name: Middle Initial: Last Name: Discipline: * Date of Birth: / / OTs and OTAs: If you are NBCOT certified, your credentials will be OTR/L or COTA/L after your signature below. If you are not NBCOT certified, your credentials would be OTA/L or OT/L. PTs and PTAs: Please include PT or PTA after your signature below. Speech Therapists: Please include "CCC/SLP" or "CFY/SLP" following your signature below. Please keep entire signature AND CREDENTIALS within the box and DO NOT TOUCH THE LINES. Sign Here: Today's Date: Please sign, date, and fax this form to or mail to: Premier Therapy 701 Sharon Road Beaver, PA /16/13

16 Form W-4 (2014) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2014 expires February 17, See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,000 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Is age 65 or older, Is blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity iincome, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A You are single and have only one job; or B Enter 1 if: { You are married, have only one job, and your spouse does not work; or... B Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more than one job. (Entering -0- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above).. E F Enter 1 if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit... F (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $65,000 ($95,000 if married), enter 2 for each eligible child; then less 1 if you have three to six eligible children or less 2 if you have seven or more eligible children. If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter 1 for each eligible child... G H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to that apply. avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Form W-4 Department of the Treasury Internal Revenue Service Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Your first name and middle initial Last name OMB No Your social security number Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box. City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2014, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2014)

17 Form W-4 (2014) Page 2 Deductions and Adjustments Worksheet Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. 1 Enter an estimate of your 2014 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1950) of your income, and miscellaneous deductions. For 2014, you may have to reduce your itemized deductions if your income is over $305,050 and you are married filing jointly or are a qualifying widow(er); $279,650 if you are head of household; $254,200 if you are single and not head of household or a qualifying widow(er); or $152,525 if you are married filing separately. See Pub. 505 for details $ $12,400 if married filing jointly or qualifying widow(er) 2 Enter: { $9,100 if head of household } $ $6,200 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter $ 4 Enter an estimate of your 2014 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 2014 Form W-4 worksheet in Pub. 505.) $ 6 Enter an estimate of your 2014 nonwage income (such as dividends or interest) $ 7 Subtract line 6 from line 5. If zero or less, enter $ 8 Divide the amount on line 7 by $3,950 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H, page Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10 Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note. Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter -0- ) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet Note. If line 1 is less than line 2, enter -0- on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed.. 8 $ 9 Divide line 8 by the number of pay periods remaining in For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $ Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are Enter on line 2 above $0 - $6, ,001-13, ,001-24, ,001-26, ,001-33, ,001-43, ,001-49, ,001-60, ,001-75, ,001-80, , , , , , , , , , , ,001 and over 15 If wages from LOWEST paying job are Enter on line 2 above $0 - $6, ,001-16, ,001-25, ,001-34, ,001-43, ,001-70, ,001-85, , , , , , , ,001 and over 10 Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. If wages from HIGHEST paying job are Enter on line 7 above $0 - $74,000 $590 74, , , ,000 1, , ,000 1, , ,000 1, ,001 and over 1,560 If wages from HIGHEST paying job are Enter on line 7 above $0 - $37,000 $590 37,001-80, , ,000 1, , ,000 1, ,001 and over 1,560 You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

18 IT 4 Rev. 5/07 Notice to Employee 1. For state purposes, an individual may claim only natural dependency exemptions. This includes the taxpayer, spouse and each dependent. Dependents are the same as defined in the Internal Revenue Code and as claimed in the taxpayer s federal income tax return for the taxable year for which the taxpayer would have been permitted to claim had the taxpayer filed such a return. 2. You may file a new certificate at any time if the number of your exemptions increases. You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases because: (a) Your spouse for whom you have been claiming exemption is divorced or legally separated, or claims her (or his) own exemption on a separate certificate. (b) The support of a dependent for whom you claimed exemption is taken over by someone else. (c) You find that a dependent for whom you claimed exemption must be dropped for federal purposes. The death of a spouse or a dependent does not affect your withholding until the next year but requires the filing of a new certificate. If possible, file a new certificate by Dec. 1st of the year in which the death occurs. For further information, consult the Ohio Department of Taxation, Personal and School District Income Tax Division, or your employer. 3. If you expect to owe more Ohio income tax than will be withheld, you may claim a smaller number of exemptions; or under an agreement with your employer, you may have an additional amount withheld each pay period. 4. A married couple with both spouses working and filing a joint return will, in many cases, be required to file an individual estimated income tax form IT 1040ES even though Ohio income tax is being withheld from their wages. This result may occur because the tax on their combined income will be greater than the sum of the taxes withheld from the husband s wages and the wife s wages. This requirement to file an individual estimated income tax form IT 1040ES may also apply to an individual who has two jobs, both of which are subject to withholding. In lieu of filing the individual estimated income tax form IT 1040ES, the individual may provide for additional withholding with his employer by using line 5. please detach here Employee s Withholding Exemption Certificate IT 4 Rev. 5/07 Print full name Social Security number Home address and ZIP code Public school district of residence (See The Finder at tax.ohio.gov.) School district no. 1. Personal exemption for yourself, enter 1 if claimed If married, personal exemption for your spouse if not separately claimed (enter 1 if claimed) Exemptions for dependents Add the exemptions that you have claimed above and enter total Additional withholding per pay period under agreement with employer... $ Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled. Signature Date

19 IT 4 NR! please detach here Employee s Statement of Residency in a Reciprocity State IT 4NR Rev. 12/00 Print full name Social security number Home address and ZIP code Ohio Employers: You are required to have a copy of this form on file for each employee who is a resident of Indiana, Kentucky, West Virginia, Michigan or Pennsylvania receiving compensation paid in Ohio and who claims exemption from withholding of Ohio income tax under the reciprocal agreements between Ohio and these other states. Employees residing outside Ohio and in a state with whom Ohio has reciprocity: If you are a resident of a state with whom Ohio has reciprocity, you may claim exemption from withholding of Ohio income tax by completing this form and filing it with your employer, under the reciprocal withholding agreements between Ohio and these states. Note: If you change your residence from the state specified herein to any other state, you must notify your employer within10 days. I hereby declare, under penalties of perjury, that I am a resident of the state of and that, pursuant to an agreement existing between that state and the state of Ohio, I claim exemption from withholding of Ohio income tax on compensation paid to me in the state of Ohio. Signature Date

20 CLGS-32-6 (8-11) FOR ALL EMPLOYEES WORKING IN PENNSYLVANIA REGARDLESS OF THEIR STATE OF RESIDENCY. RESIDENCY CERTIFICATION FORM Local Earned Income Tax Withholding TO EMPLOYERS/TAXPAYERS: This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes. This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change. NAME (Last Name, First Name, Middle Initial) EMPLOYEE INFORMATION - RESIDENCE LOCATION SOCIAL SECURITY NUMBER STREET ADDRESS (No PO Box, RD or RR) SECOND LINE OF ADDRESS CITY STATE ZIP CODE DAYTIME PHONE NUMBER MUNICIPALITY (City, Borough or Township) COUNTY RESIDENT PSD CODE TOTAL RESIDENT EIT RATE EMPLOYER INFORMATION - EMPLOYMENT LOCATION EMPLOYER BUSINESS NAME (Use Federal ID Name) EMPLOYER FEIN Premier Therapy STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR) SECOND LINE OF ADDRESS CITY STATE ZIP CODE PHONE NUMBER MUNICIPALITY (City, Borough or Township) COUNTY WORK LOCATION PSD CODE WORK LOCATION NON-RESIDENT EIT RATE SIGNATURE OF EMPLOYEE CERTIFICATION Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying schedules and statements and to the best of my (our) belief, they are true, correct and complete. DATE (MM/DD/YYYY) PHONE NUMBER ADDRESS For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES, please refer to the Pennsylvania Department of Community & Economic Development website:

21 WORKERS COMPENSATION INFORMATION In Pennsylvania, the workers compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first-aid. You should report immediately any injury or work-related illness to your employer. Your benefits could be delayed or denied if you do not notify your employer immediately. If your claim is denied by your employer, you have the right to request a hearing before a workers compensation judge. The Bureau of Workers Compensation cannot provide legal advice; however, you may contact them for additional general information at: Bureau of Workers Compensation 1171 South Cameron Street, Room 103 Harrisburg, Pennsylvania Telephone number within Pennsylvania (800) Telephone number outside of this Commonwealth (717) TTY (800) (for hearing and speech impaired only) PA Keyword: workers comp. ACKNOWLEDGEMENT I,, employee of Premier Employee name (please print) Therapy, hereby certify that I was provided with the above statement on / /. (date) Employee Signature Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

22 PHYSICAL STATEMENT I have reviewed the following (job description title) job description for. (employee name - please print) I have examined this employee and find him/her to be physically capable of performing all essential functions of the position. Comments: Physician Printed Name: Physician Signature: Street Address: (Date) Employees: This form can be used as an alternative to your physician s standard format, if necessary.

23 Additional Items Needed #1 TB Test Results (Mantoux) #2 Professional Licensure (current) #3 CPR Certification (ONLY if providing Home Health Services) #4 Drivers' License (ONLY if providing Home Health Services) #5 Automobile Insurance Certificate (ONLY if providing Home Health Services) May 1, 2013

24 EMERGENCY CONTACT INFORMATION EMPLOYEE NAME: IN CASE OF AN EMERGENCY, PLEASE CONTACT: PRIMARY CONTACT: NAME: PHONE: ADDRESS: RELATIONSHIP: ALTERNATE CONTACT: NAME: PHONE: ADDRESS: RELATIONSHIP:

25 VOLUNTARY SELF IDENTIFICATION The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO 1 report each year. The EEOC has recently announced several changes to the job categories and rearranged its race and ethnicity groupings. Therefore, we are asking employees to complete a new voluntary self identification sheet below so that we can properly update our records according to these new report requirements. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. This form will be used for EEO 1 reporting purposes only and will be kept separate from all other personnel records only accessed by Human Resources Department. Please return completed forms to the Human Resources Department. PLEASE PRINT: Name: Job Title: GENDER: Male Female RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.) White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races. Date completed: PLEASE RETURN FORM TO HUMAN RESOURCES DEPARTMENT AT Jan. 23, 2012 rev.

26 AUTHORIZATION AGREEMENT FOR AUTOMATIC DIRECT DEPOSITS EFFECTIVE JANUARY 1, 2013 DIRECT DEPOSIT IS MANDATORY FOR ALL EXISTING AND NEW EMPLOYEES IF YOU DON T HAVE A BANK ACCOUNT, A PAY CARD WILL BE ISSUED. YOU MUST COMPLETE A SEPARATE FORM FOR EACH ACCOUNT YOU ARE ADDING OR CHANGING. If this is a new account: 1. The account must be established and active at your bank before you request direct deposit. 2. Confirm the bank accepts direct deposits and verify the transit routing and account numbers. 3. For savings account, you MUST confirm the transit routing number with your bank. 4. Notify the bank that you are going to set up direct deposit though payroll. Please check the appropriate box and complete: Canceling account (Item C below.) Payroll must cancel direct deposit BEFORE you cancel account. Direct deposit already set up, changing dollar amount only (C through E below.) A new account (A though E below.) A new account to replace an existing direct deposit (A through E below.) Account number you are replacing (REQUIRED): A. Bank Name B. Bank Transit Routing Number. C. Bank Account Number. D. Checking Savings E. Full Deposit Partial Deposit (amount per paydate) $ Please fax this completed form along with a voided check for checking, or a deposit slip for savings accounts to 724/ (Payroll Department). Each new account will go through a pre-note process that will take one payroll period. I authorize CTR and the bank listed above to deposit my net pay or portion thereof as indicated into my account each paydate. If funds to which I am not entitled are deposited to my account, I authorize CTR to direct the bank to return said funds to CTR. I understand that my deposit may not be credited to my account until 5:00 PM on the paydate indicated on the check voucher. Employee Name (Print): Employee Signature: Date:

27 Global Cash Card Pay Card Enrollment Form AUTHORIZATION FORM The undersigned, by evidence of their signature below and provision of the necessary information hereby authorizes Premier Therapy to process a pay period ACH transaction (Debit Card) Employee for the express purpose of payroll deposit and services provided by CTR to the Customer. The undersigned, by evidence of their signature below hereby acknowledges that they are authorizing ACH (Debit Card) for payroll deposit. Signature Title Printed name Date If you are enrolling in the Pay Card payroll feature, please complete this form and fax to or mail to: ATTN: Payroll Department Premier Therapy 701 Sharon Road Beaver, PA 15009