* Required Information

Thank you for your interest in applying for a position at Impeccable Healthcare Services

The application must be filled out entirely before being considered for a position.

  1. Please attach copies of the following documents:
  2. Resume (for LPN and RN)
  3. A basic health screening, including Tuberculosis screening
  4. Driver’s License or State approved Identification Card
  5. Social Security Card/Passport
  6. Tax ID Letter and EIN
  7. First Aid/CPR
  8. Professional Certification.
  9. Criminal Background Check Report – (request for authorization #)
  10. Salary Payment method: Please note that we will either pay by check or Direct Deposit; One week after the end of each pay-period

Once your application is completed with the items above attached, your application will be reviewed to see if you qualify for the position you applied for. You will then be scheduled for an interview.

For Office Use Only:

New Hire Check List: Date Completed

For Office Use: New Hire Check List:

Documents provided by the Agency

  • Employment Application
  • Previous Employments
  • Professional Reference (2)
  • Disclaimer and Signature
  • Release of Information
  • Employment Reference Form
  • Permission For PPD Test
  • Employee Acknowledgement of Handnote
  • In-Service Requirement
  • Drug and alcohol policy
  • Policy and Procedure Agreement
  • Character Reference (2)
  • Hepatitis B Vaccination Acknowledgement
  • Signed Job Description
  • Employer/Employee (Contractor-Client Agreement)
  • Non-Compete Agreement
  • Confidentiality Agreement
  • In-Person Interview
  • Skill Assessment
  • Training
  • Annual Evaluation
  • Salary Payment Method
  • Form I9
  • Tax Withholding Form

Documents provided by the applicant

  • Professional Certification
  • Physical Exam (included: PPD/Chest X-Ray & MMR)
  • First Aid/CPR
  • Social Security Card/Passport
  • Driver’s License/State ID
  • Tax ID Letter and EIN
  • Criminal Background Check Report
  • Others

Application For Employment

In Case of Emergency, please notify:


License/Certification Verification

Previous Employment (Begin with most recent one)

Dates of Employment

Dates of Employment

Dates of Employment

Professional References Please furnish the names and addresses of two professional references to



Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge I Impeccable Healthcare Services To make a detailed investigation of my employment history and all other facts stated on my application form. I hereby release from liability or responsibility all individuals, companies, employers, educational institutions, and/ or agencies supplying such information.

I do/do not have any pending charges within or outside the United States.

Release of Information to Impeccable Healthcare Services

I hereby release from liability or responsibility all individuals, companies, employers, educational institutions, and/ or agencies supplying such information.

Applicant Name

The undersigned, having applied for a position with our company, hereby authorizes you to release any information necessary relating to employment. This hereby releases your organization unconditionally from all liability for damage whatsoever that might result from furnishing this information.

Section I (To be completed by Applicant)

I acknowledge filing an application with Impeccable Healthcare Services and authorize the release of information from my former employer.

Section II

(Supervisor, please confirm information in Section I and complete Section II.)

Section II: Evaluation of Performance

I, , voluntarily take the PPD test intradermally as a screening method for tuberculosis. I understand that a PPD test must be administered and read annually. A chest X-Ray must be done every five years as a pre-requisite for employment at Impeccable Healthcare Services I release Impeccable Healthcare Services of any liability. I confirm that I have/have not had a PPD test within the last year; and I have no known allergy to the PPD test.


I acknowledge the receipt of Impeccable Healthcare Services Employee Handbook. In consideration of my employment I agree to read and abide by the rules and the policies of this handbook. Since the information, policies, and benefits described in this booklet may be subject to change, I understand and agree that any such change can be made unilaterally by the company in its sole and absolute discretion, and that material changes will be made known to employees through the usual methods of communication within a reasonable period of time.


It is the policy of Impeccable Healthcare Services that each licensed employee or independent contractor attends a minimum of four in-service hours per year. This is best accomplished by doing one (3) hour in-service every three (3) months, for a total of 12 hours per year.

Impeccable Healthcare Services offers a variety of in-services throughout the year. You will be notified of scheduled in-services by memo in your paycheck.

OSHA, Infection Control, and Tuberculosis are required annually. These courses must be home care focused. Should you attend an in-service elsewhere (i.e. hospital, nursing home, and/or other agencies), we will gladly accept a copy of your attendance record/certificate and will credit you with that in-service requirement.

By signing below, you acknowledge and understand that you must comply with the above requirement to remain in an “Active Status” with Impeccable Healthcare Services

Informed Consent and Release of Liability

I authorize Impeccable Healthcare Services or Client Company (“Company”) to obtain a specimen of my urine for chemical analysis. I understand that this analysis is to determine or exclude the presence of alcohol, drugs or other substances, in accordance with the Substance Abuse and drug Testing Policy of Company. I understand that decisions regarding my continued employment may be made as a result of this analysis. I understand that test results will be divulged only to authorized personnel. I hereby consent to this test and release Company from any liability for decisions resulting from this test.


I, , have read, understand and agree to abide by the policies and procedures set forth by Impeccable Healthcare Services I also understand that I may view or copy any or all of Impeccable Healthcare Services policy and procedure manual for review or retention. I also agree to adhere to all local, state, and federal procedures regulated as precedent for the home health care industry for compliance in providing care to Agency clients as designated.


Release MUST be signed and dated by applicant.

I have applied for employment as a with Impeccable Healthcare Services. I hereby authorize to release information about my prior performance with your Agency/Client. In signing this authorization, I release your Agency, its employees, agents, Clients or individuals from any liabilities that occurs as a result of completing this employment Character reference form.

If we have any specific questions, can we contact you? Please enter your phone number or email for further details.

Release MUST be signed and dated by applicant.

I have applied for employment as a Impeccable Healthcare Services I hereby authorize to release information about my prior performance with your Agency/Client. In signing this authorization, I release your Agency, its employees, agents, Clients or individuals from any liabilities that occurs as a result of completing this employment Character reference form.

If we have any specific questions, can we contact you? Please enter your phone number or email for further details.

Hepatitis B Vaccine

1. What is hepatitis B?

Hepatitis B is a serious disease that affects the liver. It is caused by the hepatitis B virus (HBV). HBV can cause:

Acute (short-term) illness. This can lead to:

  • jaundice (yellow skin or eyes)
  • loss of appetite
  • tiredness
  • pain in muscles, joints, and stomach
  • diarrhea and vomiting

Acute illness is more common among adults. Children who become infected usually do not have acute illness.

Chronic (long-term) infection. Some people go on to develop chronic HBV infection. This can be very serious, and often leads to:

  • liver damage (cirrhosis)
  • liver cancer
  • death

Chronic infection is more common among infants and children than among adults. People who are infected can spread HBV to others, even if they don’t appear sick.

  • In 2005, about 51,000 people became infected with hepatitis B.
  • About 1.25 million people in the United States have chronic HBV infection.
  • Each year about 3,000 to 5,000 people die from cirrhosis or liver cancer caused by HBV.

Hepatitis B virus is spread through contact with the blood or other body fluids of an infected person. A person can become infected by:

  • - contact with a mother’s blood and body fluids at the time of birth;
  • - contact with blood and body fluids through breaks in the skin such as bites, cuts, or sores;
  • - contact with objects that could have blood or body fluids on them such as toothbrushes or razors;
  • - having unprotected sex with an infected person;
  • - sharing needles when injecting drugs;
  • - being stuck with a used needle on the job.

2. Hepatitis B vaccine: Why get vaccinated?

Hepatitis B vaccine can prevent hepatitis B, and the serious consequences of HBV infection, including liver cancer and cirrhosis.

Routine hepatitis B vaccination of U.S. children began in 1991. Since then, the reported incidence of acute hepatitis B among children and adolescents has dropped by more than 95%

– and by 75% in all age groups

Hepatitis B vaccine is made from a part of the hepatitis B virus. It cannot cause HBV infection. Hepatitis B vaccine is usually given as a series of 3 or 4 shots. This vaccine series gives long-term protection from HBV infection, possibly lifelong.

3. Who should get hepatitis B vaccine and when?

Children and Adolescents
  • All children should get their first dose of hepatitis B vaccine at birth and should have completed the vaccine series by 6-18 months of age.
  • Children and adolescents through 18 years of age who did not get the vaccine when they were younger should also be vaccinated.

• All unvaccinated adults at risk for HBV infection should be vaccinated. This includes:

  • - sex partners of people infected with HBV,
  • - men who have sex with men,
  • - people who inject street drugs,
  • - people with more than one sex partner,
  • - people with chronic liver or kidney disease,
  • - people with jobs that expose them to human blood,
  • - household contacts of people infected with HBV,
  • - residents and staff in institutions for the developmentally disabled,
  • - kidney dialysis patients,
  • - people who travel to countries where hepatitis B is common,
  • - people with HIV infection.

• Anyone else who wants to be protected from HBV infection may be vaccinated

4. Who should NOT get hepatitis B vaccine?

  • Anyone with a life-threatening allergy to baker’s yeast, or to any other component of the vaccine, should not get hepatitis B vaccine. Tell your provider if you have any severe allergies.
  • Anyone who has had a life-threatening allergic reaction to a previous dose of hepatitis B vaccine should not get another dose.
  • Anyone who is moderately or severely ill when a dose of vaccine is scheduled should probably wait until they recover before getting the vaccine.

Your provider can give you more information about these precautions. Pregnant women who need protection from HBV infection may be vaccinated.

5. Hepatitis B vaccine risks

Hepatitis B is a very safe vaccine. Most people do not have any problems with it.

The following mild problems have been reported:

  • Soreness where the shot was given (up to about 1 person in 4).
  • Temperature of 99.9°F or higher (up to about 1 person in 15).

Severe problems are extremely rare. Severe allergic reactions are believed to occur about once in 1.1 million doses.

A vaccine, like any medicine, could cause a serious reaction. But the risk of a vaccine causing serious harm, or death, is extremely small. More than 100 million people have gotten hepatitis B vaccine in the United States.

6. What if there is a moderate or severe reaction? What should I look for?

• Any unusual condition, such as a high fever or behavior changes. Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat or dizziness.

What should I do?
  • Call a doctor or get the person to a doctor right away.
  • Tell your doctor what happened, the date and time it happened, and when the vaccination was given.
  • Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form.
  • Or you can file this report through the VAERS web site at www.vaers.hhs.gov, or by calling
  • 1-800-822-7967.
  • VAERS does not provide medical advice.

7. The National Vaccine Injury Compensation Program

In the event that you or your child has a serious reaction to a vaccine, a federal program has been created to help pay for the care of those who have been harmed.

For details about the National Vaccine Injury Compensation Program, call 1-800-338-2382 or visit their website at www.hrsa.gov/vaccinecompensation.

8. How can I learn more?

Source: http://biosafety.utk.edu/files/2012/12/vis-hep-b.pdf

Hepatitis B Vaccination Acknowledgement

Employers must ensure that all occupationally exposed workers are trained about the vaccine and vaccination, including efficacy, safety, method of administration, and the benefits of vaccination.

Employers must ensure that workers who decline vaccination sign a declination form. The purpose of this is to encourage greater participation in the vaccination program by stating that a worker declining the vaccination remains at risk of acquiring hepatitis B.

I have received the vaccination (provide proof)

I decline the vaccine (please sign the declination form below)

Record of Hepatitis “B” vaccine Declination

I, understand that due to the possibility of my exposure to blood or other potentially infectious materials during my home health care service. I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at any Health Center for a fee. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have exposure to blood or other potentially infectious materials during my assigned home health care work while employed by Impeccable Healthcare Services, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at any Health Center free of charge.


This agreement is made effective this day of , 20, between (Contractor) and (Impeccable Healthcare Services)

The purpose of this agreement is to establish an independent contractor relationship between Contractor and Impeccable Healthcare Services

Whereas, Impeccable Healthcare Services is in the business of supplying quality nursing and home care services on an as needed basis and when a client (Employer) is in need of home care consistent with a plan of care authorized by the Client's physician and assessed by Impeccable Healthcare Services skilled nurse; and

Whereas a Contractor is either qualified as a Registered Nurse (RN), or Licensed Practitioner Nurse (LPN), or Certified Nurse Aide (CNA), Certified Medication Technician (CMT) or unlicensed family member.

It is agreed as follows:
  • Contractor agrees that he/she will provide nursing assistance as required by the Employer and Client.
  • Contractor warrants that he/she is trained appropriately in their area of work and under appropriate laws and regulations in the State of Maryland.
  • This Agreement constitutes the entire agreement between Contractor and Impeccable Healthcare Services There is no other agreement between the parties.
  • Impeccable Healthcare Services will place Contractor on a job-by-job basis: by calling the Contractor and determine the Contractor availability. If a Contractor is not available, the job will be referred to another Contractor Impeccable Healthcare Services does not guarantee that any job will be available at a particular time or that the Contractor is guaranteed employment on a particular basis.
  • Contractor is not required to follow any routine or schedule established by Impeccable Healthcare Services except as to verifying time worked on a particular job. Contractor shall submit all time worked on a particular job as required and by so that the client/ patient can be billed properly.
  • Impeccable Healthcare Services will provide Contractor with all of the necessary forms to facilitate the work of Contractor.
  • Independent Contractor shall be responsible for any equipment, supplies or materials required by the client in the performance of duties for the Employer. Impeccable Healthcare Services shall supply no equipment, materials, or supplies, nor provide any transportation to and from the Client's premises.
  • All expenses incurred by Contractor in the performance of his or her services for Impeccable Healthcare Services, shall be paid by Contractor, including, but not limited to, insurance and transportation. No reimbursement shall be available to Contractor for Contractor's expenses.
  • Contractor shall be paid on a bi-weekly basis for any work performed on a given day. The payment shall be a lump sum payment for the work performed that pay period. Impeccable Healthcare Services will guarantee Contractor hourly pay rate.
  • Impeccable Healthcare Services is not obligated to advance any pay to Contractor.
  • Impeccable Healthcare Services will not provide any benefits such as health insurance, pension plans, bonuses, vacation pay, or sick pay to any contractor.
  • Contractor is solely responsible for maintaining Contractor's own insurance, including worker's compensation insurance Impeccable Healthcare Services shall not be responsible for any injuries sustained by Contractor on any job undertaken by Contractor. Any injuries sustained by Contractor while Contractor is working for an Employer shall be the responsibility of the Client, Contractor or such other person who may cause injury to Contractor.
  • Impeccable Healthcare Services will not deduct any Social Security taxes, Federal, state, or local income taxes. Contractor is solely liable for all these deductions and for paying their income taxes. Contractors are therefore advised to liaise with their personal tax accountant on the modalities of paying estimated taxes.
  • Impeccable Healthcare Services will report Contractor's pay to the Internal Revenue on form 1099.
  • Contractor shall provide Impeccable Healthcare Services with Contractor's Social Security number and address and inform Impeccable Healthcare Services of any changes in contact phone #, address, and personal information in general.
  • Impeccable Healthcare Services will not provide any form of bond for Contractor.
  • Contractor is free to accept or reject any placement offered. The decision to work a given placement is solely the decision of the Independent Contractor. The hours worked on a particular placement will be determined by Impeccable Healthcare Services and Client.
  • This agreement may be terminated at any time for any reason by either party.
  • Contractor is free to contract with any placement services at any time for similar placement.
  • Impeccable Healthcare Services have no priority over any other placement service in the placement of the Contractor. Impeccable Healthcare Services shall not be liable for the failure to place Contractor on a given job or for a given number of jobs in any particular period. The placement of Contractor is solely based on the requirement of the Employer and the availability of the Contractor. Impeccable Healthcare Services shall not be liable for unemployment insurance.
  • All work performed by Contractor shall be under Contractor's own name or business name. Impeccable Healthcare Services is merely a placement service and does not warrant in any other, the services performed by Contractor.
  • Contractor shall not be liable to report to Impeccable Healthcare Services on a daily basis in order to be placed, nor is Contractor required to maintain a physical presence on the premises of Impeccable Healthcare Services
  • All licenses and necessary document shall be accurate and up to date at all time during the existence of this Agreement. Contractor is responsible for any cost and fees incurred in maintaining any necessary licenses or document.
  • This agreement shall be governed by the laws of the State of Maryland.

By signing this Agreement the Contractor agrees that he/she will abide by all terms and conditions above and is under the obligation to update his/her address, and any name change as necessary in order for Impeccable Healthcare Services to comply with reporting requirement on form 1099 to the IRS. This contract is a legally enforceable Agreement and is governed by the Laws of the State of Maryland.

Note; if you are Impeccable Healthcare Services full time employee, the agency will comply with reporting requirement on form W2 to the IRS

In Witness Where off, the parties hereunder subscribe their names as of the dates indicated below:

Non-Compete Agreement

I, agree that I cannot and will not work for any client/clients or be employed/contracted under another agency with any client/clients/patient/patients assigned to me byImpeccable Healthcare Services located at 13209 Ailesbury Ct, Upper Marlboro, MD. 20772 : for 180 days following the termination of my contract or employment with Impeccable Healthcare Services I agree that these current patient/patients/client/clients was assigned to me Impeccable Healthcare Services and I am not to work with the patient/patients/client/clients through another agency or any other Health Care Provider under any circumstances. If I attempt or decide to work for any client/clients/patient/patients or work with another company for the same client/clients/patient/patients assigned to me by Impeccable Healthcare Services, I agree that I will pay to Impeccable Healthcare Services three (3) months’ worth of my weekly payment. I agree that Impeccable Healthcare Services has the right to pursue me and my current employer through the court of law and obtain all necessary payment/payments and dues to be received by Impeccable Healthcare Services My three (3) months’ worth weekly payment will serve as compensation to Impeccable Healthcare Services If I decide to work for another Agency/Company, I agree to give Impeccable Healthcare Services full authority to hold my last paycheck until all court proceedings are concluded. I am signing this in agreement to the above contract

I agree not to be employed or contracted by any client/clients assigned to me by Impeccable Healthcare Services for a period of 180 days following the termination of my employment/contract assignment.

I agree not to be employed or go into any contract with another agency for any patient/patients/client/clients assigned to me by Impeccable Healthcare Services for a period of 180 days following the termination of my contract or employment.

Patient / Client Confidentiality

I, hereby agree to treat and keep all personal and medical information on Impeccable Healthcare Services, and/or its patients/clients, confidential. Furthermore, I will agree not to release any information to any outside organization or agency without the approval of the patient/client, or as required by law or third-party payment contract.


I acknowledge that I will provide the following documents before the date of my interview or employment.

Documents provided by the applicant

Criminal Background Check

Please visit any of the providers listed below, to have your finger print services done:

Call for Authorization Number: XXX-XXX-XXXX


  • Impeccable Healthcare Services
  • 13209 Ailesbury Ct, Upper Marlboro MD
  • 20772
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