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Perfect Touch Homecare Services LLC

Caregiver

54 Sugar Creek Center Blvd. Suite 203 Sugarland. Tx

Overview Application

Personal Information


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Professional / Personal References (Must Complete)

Persons who can furnish information about job performance or personal information about you.

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Skill Questions


1) List all states in which licensed. Give registration and expiration date. (Optional)


2) Summarize special job-related skills and qualifications acquired from employment or other experience. *


General Questions


1) How many hours a week are you available for work? *


2) Are you legally eligible for employment in the United States? *



3) How did you learn of our organization? *



4) Are you willing to work *



5) Have you ever applied for employment with us before? *



6) Are you currently employed? *



7) Do you have reliable transportation / the ability to reach multiple clients? *



8) Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency? If yes, describe in full. (Conviction will not necessarily disqualify an applicant from employment.) *


9) Are you capable of performing the job set forth in the job description? If No, which job requirement can you not meet? *


Texas Criminal History Statement

I hereby profess that I have not been convicted of any following crimes which are a permanent automatic bar to employment by this agency.
An offense under Section 19, Penal Code (criminal homicide);
An offense under Section 20, Penal Code (kidnapping and false imprisonment);
An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
An offense under Section 21.08, Penal Code (indecent exposure);
An offense under Section 21.11, Penal Code (indecency with a child);
An offense under Section 21.12, Penal Code (improper relationship between educator and student);
An offense under Section 21.15, Penal Code (improper photography or visual recording);
An offense under Section 22.011, Penal Code (sexual assault);
An offense under Section 22.02, Penal Code (aggravated assault);
An offense under Section 22.021, Penal Code (aggravated sexual assault);
An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
An offense under Section 22.041, Penal Code (abandoning or endangering a child);
An offense under Section 22.05, Penal Code (deadly conduct);
An offense under Section 22.07, Penal Code (terroristic threat);
An offense under Section 22.08, Penal Code (aiding suicide);
An offense under Section 25.031, Penal Code (agreement to abduct from custody);
An offense under Section 25.08, Penal Code (sale or purchase of a child);
An offense under Section 28.02 Penal Code (arson);
An offense under Section 29.02, Penal Code (robbery);
An offense under Section 29.03, Penal Code (aggravated robbery);
An offense under Section 33.021, Penal Code (online solicitation of a minor);
An offense under Section 34.02, Penal Code (money laundering);
An offense under Section 35A.02, Penal Code (Medicaid fraud); and health care fraud
An offense under Section 42.09, Penal Code (cruelty to animals); or
A conviction under the laws of another state, federal law, of the Uniform Code of Military Justice for an offense containing elements that are substantially like the elements of an offense listed by this subsection.
I also hereby profess that I have not been convicted of any of the following crimes within the past 5 years (applicable only to those hired on or after September 1, 2007 unless otherwise noted):
An offense under Section 22.01, Penal Code (assault punishable as a Class A Misdemeanor or felony) [applicable to those hired on or after September 1, 2003];
An offense under Section 30.02, Penal Code (burglary) [which occurred within the previous five years];
An offense under Section 31, Penal Code (theft punishable as a felony) [which occurred in the previous five years];
An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution punishable as a Class A Misdemeanor or felony which occurred in the previous five years)
An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A Misdemeanor or felony) [which occurred in the previous five years]
An offense under Section §33.021 — Online solicitation of a minor
An offense under Section §34.02 — Money laundering An offense under Section 35A.02 — Medicaid fraud
An offense under Section §36.06 — Obstruction or Retaliation
An offense under Section 37.12, Penal Code (false identification as peace officer); A conviction which occurred in the previous five years
An offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct associated with the discharge or display of a firearm in a public place: a conviction which occurred in the previous five years
An offense under Section §42.09 — Cruelty to animals
An offense under Section §42.092 — Cruelty to nonlivestock animals
A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially like the elements of an offense listed above.
Additional to Bars to Employment Bars pursuant to Texas Administrative Code, Title 40, Part 1, Chapter 3, §3.201 Texas Health and Safety Penal Code
An offense under Section 15.01 — Criminal Attempt of any offense listed as a bar
An offense under Section §43.03 — Promotion of Prostitution
An offense under Section §43.04 — Aggravated Promotion of Prostitution
An offense under Section §43.05 — Compelling Prostitution
An offense under Section §43.25 — Sexual Performance by a Child
An offense under Section §43.26 — Possession or Promotion of Child Pornography
I understand that it is required by law that to check the Employee Misconduct Registry and, if appropriate, the Texas Nurse Aide Registry using my Social Security Number. And I further understand that any applicant listed on the Employee Misconduct Registry is unemployable at this agency.
I understand that if I have been placed on deferred adjudication community supervision for an offense listed above, successfully completed the period of deferred adjudication community supervision, and received a dismissal and discharge according to Section 5(c), Article 42.12, Code of Criminal Procedure, I am not considered convicted of the offense.
I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment.
I understand that all information obtained by this agency regarding my criminal history will remain confidential.
I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

OIG/LEIE Background Checks

POLICY

We comply with licensure requirements regarding criminal history record checks, the HHSC employee misconduct registry and the HHSC nurse aide registry for employees, subcontractors, and volunteers.

PROCEDURE
  1. Inform the individual who applies for employment that the agency is required to conduct a background check which includes a search of the NAR and EMR.
  2. Review the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General, and the LEIE maintained by the HHSC Office of Inspector General:
    • before hiring an applicant for employment or contracting with a potential subcontractor; and
    • at least monthly, for each employee and subcontractor.
  3. Not employ an applicant for employment or contract with a potential subcontractor to perform any duties that may be paid for directly or indirectly through a contract if the applicant or potential subcontractor is listed on either LEIE described in TAC 49.304 (f) in paragraph (1) of this subsection;
  4. Prohibit an employee or subcontractor listed on either LEIE described in TAC 49.304 (f) paragraph (1) of this subsection from performing any duties that may be paid for directly or indirectly through a contract; and
  5. if an employee or subcontractor is listed on either LEIE described in TAC 49.304 (f) paragraph (1) of this subsection, immediately report to the HHSC Office of Inspector General, in accordance with the self-reporting protocol of the HHSC Office of Inspector General:
    • the identity of an excluded employee or subcontractor; and
    • the amount paid by the contractor to the employee or subcontractor for services provided under a contract.
  6. Before an unlicensed volunteer’s first face-to-face contact with a client, the agency will conduct a search of the NAR and the EMR using the DADS Internet website to determine if an unlicensed applicant is listed in either registry as unemployable. Submit names of the person via the internet computer system to the NAR and EMR. The agency will not employ an unlicensed applicant who is listed as unemployable in either registry.
  7. In addition to the initial verification of employability, the agency will search the NAR and the EMR to determine if the employee is listed as unemployable in either registry as follows:
    • for an employee most recently hired before September 1, 2009, by August 31, 2011, and at least every twelve months thereafter; and
    • for an employee most recently hired on or after September 1, 2009, at least every 12 months.
  8. The agency will immediately discharge an unlicensed employee whose duties would or do include face-to-face contact with a client when the agency becomes aware that the employee is designated in the NAR or the EMR as unemployable.
  9. A printed copy of the results of the initial nurse aide registry (NAR) and employee misconduct registry (EMR) obtained from the DADS will be placed on the employee personnel file. The yearly check will be noted on an agency spread sheet.

Employee Criminal History Check - I



I have been informed that in compliance with Texas Senate Bill 332 (House Bill 1466) passed by the 71st Legislature, the Agency is required to perform criminal history checks on all employees who provide care or have access to medical records of patients in an adult facility or in a client's home.

I have been informed that the criminal history check will be conducted by the Texas Department of Human Services, office of the Inspector General, on behalf of the Texas Department of Health and Texas Department of Human Services Contract Administrators.

I understand that any records received by TDHS are privileged information and are for the exclusive use of TDHS, the Texas Department of Health, and the facility for which TDHS requested the information. The records may not be released or otherwise be disclosed to any person or agency except on court order or with the written consent of the person being investigated.

I understand that the offer of employment with the Agency is conditional. This will be made permanent once the criminal history check is returned and reveals that there have been no convictions or offenses prohibiting work as outlined by the law.



Signature: __________________
Name: ____________________
Date: July 16, 2025

Employee Criminal History Check - II



The State of Texas requires Agency to inform the applicant of our request for a criminal check 115.54 (4). Before you are considered for employment a criminal check must be conducted. Your signature will permit us to proceed with State Regulations.

I ____________________ , give Agency to conduct a criminal history check.
I ____________________ , have not been convicted of any offense in the last 5 years described in the Health and Safety Code 250.005 that would bar employment with Agency.


Signature: __________________
Name: ____________________
Date: July 16, 2025

Employee Misconduct Registry Rules



The State of Texas requires Agency to inform the applicant of our request for employee misconduct checks in the Employee Misconduct Registry. Before you are considered for employment, employee misconduct checks must be conducted. Your signature will permit us to proceed with state regulations.

I ____________________ , give Agency permissions to conduct an Employee Misconduct check on me.
I ____________________ , have no offense in the Employee Misconduct Registry (established under Health and Safety code, chapter 253) as unemployable due to a finding that I have committed an act constituting "reportable conduct."
I ____________________ , give Agency permissions to conduct a Nurse Aide Registry Check.
I ____________________ , have no offense in the Nurse Aide Registry Check (established under Health and Safety code, chapter 253) as unemployable due to a finding that I have committed an act constituting “reportable conduct.”


Signature: __________________
Name: ____________________
Date: July 16, 2025

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