Employment Application

Thank you for your interest in applying to CityCARE Home Care.

The entire application can be completed online using a computer or cell phone and will take approximately 20 minutes.

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Frequently Asked Questions

WHAT ARE THE AGENCIES HOURS?

The Agency Office’s days and hours of operation are Monday to Sunday from 8:00 AM to 4:00 PM. We are on CityCARE Home Care call 24 hours a day and 7 days a week. Unless it is an emergency please call us only during regular office hours.

WHERE ARE YOUR CLIENTS?

CityCARE Home Health services clients in all seven Connecticut counties. Fairfield, New Haven, Middlesex, New London, Windham, Hartford, Litchfield.

WHEN WILL I BE PAID?

City CARE Home Health has a standard 40-hour work week, which is Monday through Sunday, beginning on Monday at 12:01 am and ending on Sunday at 12:00 midnight. The Agency's pay period covers a 7-day timeframe, which starts at 12:01 am on the Monday and ends at 12 Midnight Sunday. Payday is every Friday and occurs 52 times a year. In order to make sure payroll is processed properly and to comply with Connecticut State Laws you must use the telephone clock in/out system. Pay checks will be ready for pickup at the Agency Office by appointment during office hours on Friday. This paycheck will include all hours worked the previous week.

HOW DO I GET A WORK ASSIGMENT?

  • Work assignments for in-home employees are scheduled by the Office Manager. They are offered on the basis of services required, qualifications/expertise needed and availability of employee(s).
  • Keep your contact information current with the Agency office. We must be able to reach you easily and often on short notice.
  • When you receive and accept an assignment, you agree to the hours that the job requires. Should the requirements of that job change, you will be given first option of keeping that assignment, if you are willing to work within the changes. On the other hand, if you are not able to work within the new changes, another employee will be assigned.
  • You may refuse an assignment but doing so does not mean a replacement assignment will become available; or, if one does, it doesn't mean that the replacement assignment will be given to you. There is no guarantee of work assignments, as requests for service are unpredictable and can be sporadic.
  • Sometimes assignments come up on very short-notice. Being willing to accept these last-minute assignments and/or being available to cover for sick employees, will increase your chances of receiving assignments.

DO YOU OFFER DIRECT DEPOSIT?

Direct deposit is offered to all City Care Home Health employees. If you do not wish to receive a direct deposit, Wisely cards are available free of charge and can be funded electronically. Finally, you have the option of picking up a paper check from our office.

WHAT IS THE CLOCK IN SYSTEM?

In accordance with City CARE Home Health Policy # 6.60 - Payroll, employees shall accurately record all hours worked by clocking in/out from the clients home phone. Be sure you clock in and out accurately at the beginning and end of your work shift. Your Supervisor will review your clock in/out time before it is forwarded to payroll for processing. While we make an effort to correct any clock in/out errors which we notice, your payroll hours may not include the times you failed to punch in/out. In such cases payroll correction will be made the following week. Falsifying clock in/out times are grounds for immediate Termination of Employment.

MAY I USE MY CELL PHONE WHEN I AM WITH A CLIENT?

You are not permitted to make or accept telephone calls or texts while you are on duty at clients’ homes, unless they are from Managerial Staff, or an emergency/urgent situation develops. If you carry a cell phone with you, when you are on duty, be sure to either turn it off or put it on "vibrate" to ensure clients are not disturbed. Advise others to phone the Agency Office and leave a message, should they need to reach you, while you are on duty. The Agency Office will contact you with the message. Personal phone calls and/or texting may be done on your breaks or between assignments. Long distance calls may not be made using Agency phones, unless the call is business-related. Neither may Long distance calls be made using a client's phone.

WHAT IF I CANNOT MAKE MY ASSIGMENT?

When you are not able to work because of short-term illness or other reasons, you must contact your Supervisor, as soon as you are aware that you cannot report for duty, in order that a substitute can be arranged, if necessary. As a minimum, you are required to give at least 48-hours’ notice. If you become aware, during non-office hours, that you cannot cover your assignment(s), you must contact the Supervisor on call. If you do not contact a Supervisor and fail to report for your assignment, you will be considered a "no-show" and may be subject to disciplinary action.

    JOB/EMPLOYMENT APPLICATION

    CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

    JOB/EMPLOYMENT APPLICATION

    Personal Information

    Name
    Address

    Please list all addresses where you have resided in the past seven years

    Phone
    Electronic
    Date of Birth
    SSN
    Gender

    Language

    Education

    Formal


    Informal

    Do you currently have a CNA/PCA/HHA license?

    Other

    Restrictions

    Work Limitations

    List any work limitations that you may have and briefly describe:

    Availability for Work

    Hours & Days Available for Work


    Indicate Days and List Hours Available for Work:

    Client Types and Work Duties

    Type of Position(s) Preferred

    Live-in care usually requires that you to in a client’s home continuously for 3-4 days at a time every week. Indicate which shifts you will accept:

    Clients Not Willing/Able to Work With
    Duties Not Willing/Able to Perform
    Experience
    Assignment Location

    Transportation

    Type
    Type
    Transporting Clients

    Investigations

    Have you ever been convicted of a crime in a state court or federal court in any state. If “yes”, please explain
    Have you ever been investigated for abuse, neglect or domestic violence? If “yes”, explain:
    Were you subject to any decision imposing disciplinary action by a licensing agency in any state, or the District of Columbia. If “yes” please explain.

    Reference Information

    Work Related #1 (Last Position)
    Work Related #2 (2 nd Last Position)
    Personal #1

    JOB/EMPLOYMENT APPLICATION

    I certify that I have read and understand this application. The answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. Additionally, any prospective employee who makes a false written statement regarding prior criminal convictions or disciplinary action can be guilty of a class A misdemeanor.

    I authorize former employers, references and any other individual/organizations to provide information to CityCARE Home Health and I hereby release and discharge any of the above and CityCARE Home Health from any liability of any kind or nature. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and completion of a background check. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

    PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

    CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

    Pre-Employment Background Check Authorization

    Understand that as part of the employment process, CityCARE Home Health needs to complete a background check on me regarding:

    1. Criminal record;
    2. Sex and violent offenders record;
    3. Employment verification;
    4. Education verification;
    5. License verification;
    6. Motor vehicle Records;
    7. Personal/professional reference verification;
    8. Medical suitability;
    9. Social security verification;
    10. Drugs/alcohol.
    • I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to CityCARE Home Health or its authorized agent(s).
    • I understand that this authorization is to be part of the written and signed employment application.
    • I also understand that i do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.
    • I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.
    • I further authorize that a photocopy of this authorization may be considered as valid as the original.
    • I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. CityCARE Home Care I understand that employment with CityCARE Home Health is contingent upon successful complection of a background check.
    Name
    Phone Number
    Former Name(s)
    Date(s) Used
    Current Address *
    Date of Birth
    Social Security Number *
    Current driver’s license number
    State
    List any other cities, states and dates of residency during last 10 years

    CityCARE Home Health complies with state and federal regulations for conducting criminal background checks and sexual offender investigations: Our background check will include a review of any application materials prepared or requessted by the agency and completed by the prospective employee; an in-person interview of the registry established and maintained pursuant to section 54-257 a review of criminal conviction information obtained through a search of current criminal matters of public record in this state based on the prospective employee’s name and date of birth; If the prospective employee has esided in this state less than three years prior to the date of the application with the agency, a review of criminal conviction information from the state or states where such prospective employee resided during such three-year period; a review of any other information that the agency deems necessary in order to evaluate the suitability of the prospective employee for the position.

    ACKNOWLEDGMENT OF HANDBOOK

    CityCARE Home Care 2494 Whitney Avenue, Hamden CT 06518

    Acknowledgment of Handbook

    I have been oriented to CityCARE Home Care Employee Handbook. I understand the Agency’s policies and procedures and hereby agree to abide by them. I also understand that all jobs are “Per Diem” positions and, being such, are not permanent.

    Employee’ Name
    Todays Date

    CITYCARE HOME CARE

    PCA LIVE-IN RESPONSIBILITIES

    CITYCARE HOME CARE

    Meals: The client is responsible for providing meals for you while you provide live-in services. You are to eat what the client eats, whether you prepare it for them or it is prepared by the family. If you have a special diet, you are excused from the general rule requiring you eat what the client eats, however, you are responsible for bringing this food with you and taking the time to prepare it during the time that you prepare the client’s food. Neither the client nor their family is required to provide food for your special diet

    Time off: There is no extended period of time required for you to maintain a caregiver relationship with a client. If you would like time off, you must make a written request at least 2 weeks in advance. If you do not request time off with at least a 2 week notice, the time off may not be approved. If there is an emergency, we ask that you call immediately and allow us to find someone to fill the case before you leave. You cannot walk out on a Client under any circumstances until your replacement Caregiver arrives. All changes in shifts of Caregivers will only take place at 9:00 AM on the day you arrive and on the day you leave without pre-approval from City Care Home Care. You are not, under any circumstance, allowed to schedule your own fill-in for a time off request. All scheduling changes are to be conducted through and by a scheduling coordinator only, any violation will result in immediate disciplinary action.

    Hospitals: If the client goes into the hospital, you must immediately notify the office by telephone. You are not, under any circumstance, allowed to go to the Hospital with the client. After the client leaves for the hospital you are to immediately clock out, inform City Care Home Care of the hospitalization and you are to then follow the directions they provide to you. Make sure that the client has their ID and keys before they leave for a hospital stay.

    Ambulance: If the Client falls or otherwise experiences a medical emergency, you must first call 911 immediately and then call City Care Home Care to report the incident. If the client is placed in an ambulance, you are to stay behind, immediately clock out, inform City Care Home Care of the ambulance trip, and you are to then following the direction they provide to you. Make sure that the client has their ID and keys before they leave on an ambulance.

    Sleep: You are expected to receive 8 hours of sleep during each 24-hour period. This 8 hour period of sleep will be from 12a.m. to 8a.m. each day and will be unpaid. You do not need to clock out at 12a.m. nor back in at 8a.m., this will be done administratively for your overnight periods. However, if you do not experience at least 5 hours of uninterrupted sleep (if the client wakes up during your sleep time and requires your assistance), you must record the time that you use taking care of the client when you should be sleeping. To record this time you must first re-set the call in system by calling to “clock out,” and then call back immediately to “clock in” again, complete what is required of you, call again to “clock out” and then one final time to “clock in” again for the remainder of the day prior to going back to sleep. This is to document the amount of time that you spent taking care of the client during the night. This must be done for each time the client wakes up during the night if you are unable to obtain 5 hours of uninterrupted sleep.

    Meals Time: You are expected to receive three separate 1 hour meal time breaks during each 24-hour period. Each of these three 1-hour meal periods will be unpaid. You do not need to clock out nor back in for these periods, this will be done administratively for your meal periods. However, if you do not experience the full hour of uninterrupted meal time (if the client requires your assistance during such period of time), you must notify City Care Home Care that you were unable to take one or more of your one-hour meal breaks during any 24-hour period.

    Personal Time: You are expected to receive four1-hour personal breaks during each 24-hour period. Each of these two personal break periods will be unpaid. You do not need to clock out nor back in for these periods, this will be done administratively for your personal break periods. However, if you do not experience the full period of uninterrupted personal time (if the client requires your assistance during such period of time), you must notify City Care Home Care that you were unable to take one or more of your personal breaks during any 24 hour period.

    Clocking In and Out: You must clock in immediately upon your arrival at the clients home. You must clock out at 8 a.m. every day. If you are staying after 9 a.m. on any day, immediately after you have clocked out, you are to clock back in to begin the shift for the next day. If you are taking time off or your shift with the client has ended, you must then clock out when the replacement aide arrives at the client’s home. You may not leave the client until your replacement arrives.

    Should you have any questions about the above, or anything at all, please be sure to contact City Care Home Care. We will be glad to answer any questions you may have in reference to company policy and procedure. You must always speak with City Care Home Care in reference to time off, leaving a client, and anything that has to do with a schedule.

    By signing this memorandum, you confirm that you have received the information as it pertains to meals, time-off, hospitalizations and ambulance needs of the clients, sleep and mealtime, and calling in and out. You further confirm that you understand and agree with all of the information provided in the memorandum and that if you have any questions about any of the topics here presented it is your responsibility to call the office and speak with [*] in order to better understand this information. You also understand that by signing this memorandum you are liable for fulfilling the policies and complying with the policies as described in this memorandum.

    Agreed and Accepted By
    Printed Name
    Todays Date

    EMPLOCityCARE Home Care

    CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

    Employee non-solicitation

    During the term of employment of the person signing below (“Employee”) with CityCare Home Health Corp. (“CityCare”) and for 120 days thereafter, whether for compensation or not, Employee (directly or indirectly, either as an employee, employer, consultant, agent, principal, partner, stockholder, corporate officer, director, or in any other individual or representative capacity):

    1. Shall not lure away or hire, or encourage any other person or entity to lure away or hire, any employee of CityCare to perform services for any other person or entity, or attempt to lure away any such employee to leave their job with City Care; or
    2. Shall not try to take or actually take, or help any other person or entity to try to take or actually take any client of CityCare to do business with or seek to do business with any other person or entity; and shall not seek or attempt to cause any client of CityCare to reduce, terminate, or otherwise modify its relationship with CityCare.

    Employee hereby agrees to account for and pay over, the compensation, earnings, profits, monies, accruals, or other beCityCARE Home Careceived by Employee as a result of any transaction constituting a breach of any of the covenants provided in this agreement.

    mployee understands that it is impossible to measure in money the damages that will accrue to CityCare in the event that Employee breaches these covenants, thus CityCare shall also be entitled to such equitable relief (including specific performance) without the requirement to post bond in order to restrain the Employee from violating such covenant.

    The remedies provided for in this agreement are cumulative and in addition to any other rights and remedies CityCare may have under law or in equity.

    This agreement is binding on and is for the benefit of the parties and their respective successors and assigns. The obligations of Employee under this agreement may not be assigned without CityCare’s written consent. This agreement may only be changed or modified by an instrument in writing signed by all of the parties to this agreement. A failure of either party to insist upon strict compliance of any term of this agreement shall not be deemed a waiver of such provision or any other provisions of this agreement. This agreement may be executed on separate pages by each person and reproductions of signatures (e.g., .pdf, .jpg) shall be as enforceable as an original.



    CITYCARE:
    CITYCARE HOME HEALTH CORP.

    EMPLOYEE:
    Name/Title:
    Todays Date:

      Employment Eligibility Verification

      Department of Homeland Security

      U.S. Citizenship and Immigration Services

      USCIS
      Form I-9

      OMB No. 1615-0047
      Expires 05/31/2027

      START HERE: Employees must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

      ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees to present only certain documents to verify information in Section 1, or specify which acceptable documentation must be presented for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

      Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer

      I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

      Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

      1. A citizen of the United States
      2. A noncitizen national of the United States (See Instructions.)
      3. A lawful permanent resident (Enter USCIS or A-Number):
      4. An alien authorized to work until

      If you check Item Number 4., enter one of these

      OR
      OR

      If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

      Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee s first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions.

      List A

      Document Title 1
      Issuing Authority
      Document Number (if any)
      Expiration Date (if any)
      Document Title 2 (if any)
      Issuing Authority
      Document Number (if any)
      Expiration Date (if any)
      Document Title 3 (if any)
      Issuing Authority
      Document Number (if any)
      Expiration Date (if any)
      OR

      List B

      AND

      List C

      Additional Information
      2. Check here if you used an alternative procedure authorized by DHS to examine documents

      Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the abovenamed employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

      For reverification or rehire, complete on Supplement B, Reverification and Rehire Page 4.

      Form I-9 Edition 01/20/25)

      Page 1 of 2

      LISTS OF ACCEPTABLE DOCUMENTS

      All documents containing an expiration date must be unexpired.


      * Documents extended by the issuing authority are considered unexpired.


      Employees may present one selection from List A or a

      combination of one selection from List B and one selection from List C.

      Examples of many of these documents appear in the Handbook for Employers (M-274).

      LIST A
      Documents that Establish Both Identity and Employment Authorization
      OR
      LIST B
      Documents that Establish Identity
      AND
      LIST C
      Documents that Establish
      Employment Authorization
      1. U.S. Passport or U.S. Passport Card
      2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
      3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
      4. Employment Authorization Document that contains a photograph (Form I-766)
      5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole:
      1. Foreign passport; and
      2. Form I-94 or Form I-94A that has the following:
        1. 1) The same name as the passport; and
        2. 2) An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form
      6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
      1. Driver s license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
      2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, sex, height, eye color, and address
      3. School ID card with a photograph
      4. Voter s registration card
      5. U.S. Military card or draft record
      6. Military dependent s ID card
      7. U.S. Coast Guard Merchant Mariner Card
      8. Native American tribal document
      9. Driver s license issued by a Canadian government authority
      For persons under age 18 who are unable to present a document listed above:
      10. School record or report card
      11. Clinic, doctor, or hospital record
      12. Day-care or nursery school record
      1. A Social Security Account Number card, unless the card includes one of the following restrictions:
      (1) NOT VALID FOR EMPLOYMENT
      (2) VALID FOR WORK ONLY WITH INSAUTHORIZATION
      (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
      2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
      3. Original or certified copy of birth certificate issued by a State, county, municipal uthority, or territory of the United States bearing an official seal
      4. Native American tribal document
      5. U.S. Citizen ID Card (Form I-197)
      6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
      7. Employment authorization document issued by the Department of Homeland Security

      For examples, see Section 7 and Section 13 of the M 274 on uscis.gov/i-9-central.

      The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document.

      Acceptable Receipts

      May be presented in lieu of a document listed above for a temporary period.
      For receipt validity dates, see the M 274.

      • Receipt for a replacement of a lost, stolen, or damaged List A document.
      • Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the individual.
      • Form I-94 with RE notation or refugee stamp issued to a refugee.
      OR
      Receipt for a replacement of a lost, stolen, or damaged List B document.
      Receipt for a replacement of a lost, stolen, or damaged List C document.

      * Refer to the Employment Authorization Extensions page on I-9 Central for more information

      Form I-9 Edition 01/20/25)

      Page 2 of 2

      Form W-4

      Department of the Treasury Internal Revenue Service

      Employee’s Withholding Certificate

      Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

      Give Form W-4 to your employer.

      Your withholding is subject to review by the IRS.

      OMB No. 1545-0074
      2025

      Step 1:
      Enter
      Personal
      Information

      (a) First name and middle initial *

      Last name *

      (b) Social security number *

      Address *

      		 ► Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

      City or town, state, and ZIP code
      (c)

      TIP: Consider using the estimator at www.irs.gov/W4App to determine the most accurate withholding for the rest of the year if: you are completing this form after the beginning of the year; expect to work only part of the year; or have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), dependents, other income (not from jobs), deductions, or credits. Have your most recent pay stub(s) from this year available when using the estimator. At the beginning of next year, use the estimator again to recheck your withholding.

      Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.

      Step 2:
      Multiple Jobs
      or Spouse Works
      Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.
      Do only one of the following.
      (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4). If you or your spouse have self-employment income, use this option; or
      (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or
      (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job.
      This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the
      higher paying job. Otherwise, (b) is more accurate

      Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

      Step 3:
      Claim Dependent and Other Credits
      If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
      Multiply the number of qualifying children under age 17 by $2,000
      Multiply the number of other dependents by $500
      Add the amounts above for qualifying children and other dependents. You may add to
      this the amount of any other credits. Enter the total here
      		3

      Step 4 (optional):
      Other Adjustments
      (a) Other income (not from jobs). If you want tax withheld for other income you
      expect this year that won’t have withholding, enter the amount of other income here.
      This may include interest, dividends, and retirement income
      		 4(a)
      (b) Deductions. If you expect to claim deductions other than the standard deduction
      and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter
      the result here
      		 4(b)
      (c) Extra withholding. Enter any additional tax you want withheld each pay period.
      		 4(c)

      Step 5:
      Sign Here

      		 Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
      Employee’s signature * (This form is not valid unless you sign it.) Date *

      Employers Only

      		 Employer’s name and address

      		 First date of employment

      		 Employer identification number (EIN)
      For Privacy Act and Paperwork Reduction Act Notice, see page 3.
      Cat. No. 10220Q
      Form W-4 (2025)
      Form W-4 (2025)
      Page 2

      General Instructions

      Section references are to the Internal Revenue Code unless otherwise noted.

      Future Developments

      For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

      Purpose of Form

      Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505, Tax Withholding and Estimated Tax.

      Exemption from withholding. You may claim exemption from withholding for 2025 if you meet both of the following conditions: you had no federal income tax liability in 2024 and you expect to have no federal income tax liability in 2025. You had no federal income tax liability in 2024 if (1) your total tax on line 24 on your 2024 Form 1040 or 1040-SR is zero (or less than the sum of lines 27, 28, and 29), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2025 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 17, 2026.

      Your privacy. Steps 2(c) and 4(a) ask for information regarding income you received from sources other than the job associated with this Form W-4. If you have concerns with providing the information asked for in Step 2(c), you may choose Step 2(b) as an alternative; if you have concerns with providing the information asked for in Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c) as an alternative.

      When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:

      1. Are submitting this form after the beginning of the year;
      2. Expect to work only part of the year;
      3. Have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), or number of dependents, or changes in your deductions or credits;
      4. Receive dividends, capital gains, social security, bonuses, or business income, or are subject to the Additional Medicare Tax or Net Investment Income Tax; or
      5. Prefer the most accurate withholding for multiple job situations.

      TIP: Have your most recent pay stub(s) from this year available when using the estimator to account for federal income tax that has already been withheld this year. At the beginning of next year, use the estimator again to recheck your withholding.

      Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.

      Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

      Specific Instructions

      Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

      Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work. Submit a separate Form W-4 for each job.

      Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

      Instead, if you (and your spouse) have a total of only two jobs, you may check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

      Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

      Step 3. This step provides instructions for determining the amountof the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 501, Dependents, Standard Deduction, and Filing Information. You can also include other tax credits for which you are eligible in this step, such as the foreign tax credit and the education tax credits. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

      Step 4 (optional).

      Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

      Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2025 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

      Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

      Form W-4 (2025)
      Page 3

      Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

      If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job. To be accurate, submit a new Form W-4 for all other jobs if you have not updated your withholding since 2019

      Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

      1 Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have onejob, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that
      value on line 1. Then, skip to line 3
      		 1
      2 Three jobs.. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.
      a) Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying jobin the “Lower Paying Job” column. Find the value at the intersection of
      the two household salaries and enter that value on line 2a
      		 2a
      b) Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying
      Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b
      		 2b

      c) Add the amounts from lines 2a and 2b and enter the result on line 2c
      		2c
      3 Enter the number of pay periods per year for the highest paying job. For example, if that job
      pays weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc.
      		 3
      4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional amount
      you want withheld)
      		 4

      Step 4(b)—Deductions Worksheet (Keep for your records.)

      1 Enter an estimate of your 2025 itemized deductions (from Schedule A (Form 1040)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000),
      and medical expenses in excess of 7.5% of your income
      		1
      2
      Enter:
      • $30,000 if you’re married filing jointly or qualifying widow(er)
      • $22,500 if you’re head of household
      • $15,000 if you’re single or married filing separately
       
      		 2
      3
      If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-”
      		 3
      4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
      adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information
      		 4
      5
      Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4
      		5

      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 with no other entries on the form; 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 territories 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.

      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 6103.

      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.

      Form W-4 (2025)
      Page 4

      Married Filing Jointly or Qualifying Surviving Spouse

      Higher Paying Job Annual Taxable Wage & Salary Lower Paying Job Annual Taxable Wage & Salary
      $0 - 9,999 $10,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 59,999 $60,000 - 69,999 $70,000 - 79,999 $80,000 - 89,999 $90,000 - 99,999 $100,000 - 109,999 $110,000 - 120,000
      $0 - 9,999 $0 $0 $700 $850 $910 $1,020 $1,020 $1,020 $1,020 $1,020 $1,020 $1,020
      $10,000 - 19,999 0 700 1,700 1,910 2,110 2,220 2,220 2,220 2,220 2,220 2,220 3,220
      $20,000 - 29,999 700 1,700 2,760 3,110 3,310 3,420 3,420 3,420 3,420 3,420 4,420 5,420
      $30,000 - 39,999 850 1,910 3,110 3,460 3,660 3,770 3,770 3,770 3,770 4,770 5,770 6,770
      $40,000 - 49,999 910 2,110 3,310 3,660 3,860 3,970 3,970 3,970 4,970 5,970 6,970 7,970
      $50,000 - 59,999 1,020 2,220 3,420 3,770 3,970 4,080 4,080 5,080 6,080 7,080 8,080 9,080
      $60,000 - 69,999 1,020 2,220 3,420 3,770 3,970 4,080 5,080 6,080 7,080 8,080 9,080 10,080
      $70,000 - 79,999 1,020 2,220 3,420 3,770 3,970 5,080 6,080 7,080 8,080 9,080 10,080 11,080
      $80,000 - 99,999 1,020 2,220 3,420 4,620 5,820 6,930 7,930 8,930 9,930 10,930 11,930 12,930
      $100,000 - 149,999 1,870 4,070 6,270 7,620 8,820 9,930 10,930 11,930 12,930 14,010 15,210 16,410
      $150,000 - 239,999 1,870 4,240 6,640 8,190 9,590 10,890 12,090 13,290 14,490 15,690 16,890 18,090
      $240,000 - 259,999 2,040 4,440 6,840 8,390 9,790 11,100 12,300 13,500 14,700 15,900 17,100 18,300
      $260,000 - 279,999 2,040 4,440 6,840 8,390 9,790 11,100 12,300 13,500 14,700 15,900 17,100 18,300
      $280,000 - 299,999 2,040 4,440 6,840 8,390 9,790 11,100 12,300 13,500 14,700 15,900 17,100 18,300
      $300,000 - 319,999 2,040 4,440 6,840 8,390 9,790 11,100 12,300 13,500 14,700 15,900 17,100 19,170
      $320,000 - 364,999 2,040 4,440 6,840 8,390 9,790 11,100 12,470 14,470 16,470 18,470 20,470 22,470
      $365,000 - 524,999 2,790 6,290 9,790 12,440 14,940 17,350 19,650 21,950 24,250 26,550 28,850 31,150
      $525,000 and over 3,140 6,840 10,540 13,390 16,090 18,700 21,200 23,700 26,200 28,700 31,200 33,700

      Single or Married Filing Separately

      Higher Paying Job Annual Taxable Wage & Salary Lower Paying Job Annual Taxable Wage & Salary
      $0 - 9,999 $10,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 59,999 $60,000 - 69,999 $70,000 - 79,999 $80,000 - 89,999 $90,000 - 99,999 $100,000 - 109,999 $110,000 - 120,000
      $0 - 9,999 $200 $850 $1,020 $1,020 $1,020 $1,870 $1,870 $1,870 $1,870 $1,870 $1,870 $2,040
      $10,000 - 19,999 850 1,700 1,870 1,870 2,220 3,220 3,720 3,720 3,720 3,720 3,890 4,090
      $20,000 - 29,999 1,020 1,870 2,040 2,390 3,390 4,390 4,890 4,890 4,890 5,060 5,260 5,460
      $30,000 - 39,999 1,020 1,870 2,390 3,390 4,390 5,390 5,890 5,890 6,060 6,260 6,460 6,660
      $40,000 - 59,999 1,220 3,070 4,240 5,240 6,240 7,240 7,880 8,080 8,280 8,480 8,680 8,880
      $60,000 - 79,999 1,870 3,720 4,890 5,890 7,030 8,230 8,930 9,130 9,330 9,530 9,730 9,930
      $80,000 - 99,999 1,870 3,720 5,030 6,230 7,430 8,630 9,330 9,530 9,730 9,930 10,130 10,580
      $100,000 - 124,999 2,040 4,090 5,460 6,660 7,860 9,060 9,760 9,960 10,160 10,950 11,950 12,950
      $125,000 - 149,999 2,040 4,090 5,460 6,660 7,860 9,060 9,950 10,950 11,950 12,950 13,950 14,950
      $150,000 - 174,999 2,040 4,090 5,460 6,660 8,450 10,450 11,950 12,950 13,950 15,080 16,380 17,680
      $175,000 - 199,999 2,040 4,290 6,450 8,450 10,450 12,450 13,950 15,230 16,530 17,830 19,130 20,430
      $200,000 - 249,999 2,720 5,570 7,900 10,200 12,500 14,800 16,600 17,900 19,200 20,500 21,800 23,100
      $250,000 - 399,999 2,970 6,120 8,590 10,890 13,190 15,490 17,290 18,590 19,890 21,190 22,490 23,790
      $400,000 - 449,999 2,970 6,120 8,590 10,890 13,190 15,490 17,290 18,590 19,890 21,190 22,490 23,790
      $450,000 and over 3,140 6,490 9,160 11,660 14,160 16,660 18,660 20,160 21,660 23,160 24,660 26,160

      Head of Household

      Higher Paying Job Annual Taxable Wage & Salary Lower Paying Job Annual Taxable Wage & Salary
      $0 - 9,999 $10,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 59,999 $60,000 - 69,999 $70,000 - 79,999 $80,000 - 89,999 $90,000 - 99,999 $100,000 - 109,999 $110,000 - 120,000
      $0 - 9,999 $0 $450 $850 $1,000 $1,020 $1,020 $1,020 $1,020 $1,870 $1,870 $1,870 $1,890
      $10,000 - 19,999 450 1,450 2,000 2,220 2,220 2,220 2,220 3,180 4,070 4,090 4,090 4,290
      $20,000 - 29,999 850 2,000 2,600 2,800 2,820 2,820 3,780 4,780 5,670 5,690 5,890 6,090
      $30,000 - 39,999 1,000 2,220 2,800 3,000 3,020 3,980 4,980 5,980 6,890 7,090 7,290 7,490
      $40,000 - 59,999 1,020 2,220 2,820 3,830 4,850 5,850 6,850 8,050 9,130 9,330 9,530 9,730
      $60,000 - 79,999 1,020 3,030 4,630 5,830 6,850 8,050 9,250 10,450 11,530 11,700 11,930 12,130
      $80,000 - 99,999 1,870 4,070 5,670 7,060 8,280 9,480 10,680 11,880 12,970 13,170 13,370 13,570
      $100,000 - 124,999 1,950 4,350 6,150 7,550 8,770 9,970 11,170 12,370 13,450 13,650 14,650 15,650
      $125,000 - 149,999 2,040 4,440 6,240 7,640 8,860 10,060 11,260 12,860 14,740 15,740 16,740 17,740
      $150,000 - 174,999 2,040 4,440 6,240 7,640 8,860 10,860 12,860 14,860 16,740 17,740 18,940 20,240
      $175,000 - 199,999 2,040 4,440 6,640 8,840 10,860 12,860 14,860 16,910 19,090 20,390 21,690 22,990
      $200,000 - 249,999 2,720 5,920 8,520 10,960 13,280 15,580 17,880 20,180 22,360 23,660 24,960 26,260
      $250,000 - 449,999 2,970 6,470 9,370 11,870 14,190 16,490 18,790 21,090 23,280 24,580 25,880 27,180
      $450,000 and over 3,140 6,840 9,940 12,640 15,160 17,660 20,160 22,660 25,050 26,550 28,050 29,550

      Connecticut Health Benefits Waiver of Coverage

      Mailing Address: Enrollment Dept. ■ 14 Central Park Drive ■ Hookset, NH 03106 ■ 1-888-201-4216 ■ www.oxfordhealth.com

      Group Name: *

      Group Policy Number (if known):

      Employee Name: *

      Marital Status: *

      Date of Employment: *

      Date of Birth: *

      I am employed by and working at least 30 hours per week for the group shown above. I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by Oxford Health Plans (CT), Inc and/or Oxford Health Insurance, Inc and I refuse coverage.

      Reason for Refusal (please check all appropriate boxes)*

      INFORMATION:

      Name of carrier

      Policy number

      I certify that all information provided in this form is true and complete. By refusing group health benefits, I acknowledge that I and/or my dependents may have to wait until the plan’s next anniversary date to be enrolled for group coverage.

      Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 dollars and the stated value of the claim for each violation. Any material misrepresentation within this waiver may subject the group to termination.

      Signature of Employee*

      Date*

      Signature of Benefits Administrator

      Date

      AcknoCityCARE Home Caree Guidelines

      CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

      Acknowledgment of Employee Guidelines

      I have been oriented to CityCARE Home Health Employee Guidelines. I understand the Agency’s policies and procedures and hereby agree to abide by them. I also understand that all jobs are “Per Diem” positions and, being such, are not permanent.

      Employee’ Name
      Todays Date

      ACKNOCityCARE Home CareAND UNIVERSAL PRECAUTIONS TRAINING

      CityCARE Home Health 2494 Whitney Avenue, Hamden CT 06518

      ACKNOWLEDGEMENT OF HIPPA AND UNIVERSAL PRECAUTIONS TRAINING

      Employee’ Name
      Todays Date
      PCA Certification Test
      Clocking in and out.
      Instruction video
      PCA Training
      Employee Handbook

      Universal Precautions Training Video

      Hippa Training Video

      Policies and Procedures Regarding: Client Confidentiality.

      City Care staff must honor client's legal rights to privacy and confidentiality. City Care staff shall not disclose or share any personal health information (PHI) regarding City Care clientele (past or present) with anyone (including other City Care personnel who are not directly involved in the client's care team) unless the sharing of such information is authorized by the client in writing or required for the purposes of the performance of assigned duties and responsibilities. Failure to follow this policy is a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and punishable by law. If there is any question regarding what constitutes private or confidential information, direct such questions to the City Care management for clarification before disclosing or sharing ANY client information with anyone.

      • City Care staff must not discuss or disclose any details pertaining to their client's personal information (name, date of birth, social security number, address, phone number, financial situation), their physical or mental status (diagnosis) or any details pertaining to the care their client is receiving with anyone outside of: the client's Responsible Party, authorized friends and family members, attending physician, client's pharmacy and City Care direct care team - and only on a need-to-know bases. City Care staff must take precautions to avoid being overheard by unauthorized parties when discussing client PHI and ensure any written PHI is protected from unauthorized access and viewing.
      • When answering client's phone or residence, staff must only acknowledge client's last name unless directed otherwise. Take a detailed message if client is unavailable or unable to communicate, and direct caller/visitor to contact City Care Management if they require immediate information.
      • City Care staff must discard (shred) any printed information and/or delete any electronically transmitted details pertaining to their client's PHI on their personal devises. Electronic transmission of client PHI is only permitted via secured and encrypted sources.
      • City Care staff must report any observed or reasonably suspected HIPAA violation to City Care management as soon as is practical. City Care staff who mishandle client PHI may: receive a written reprimand, be demoted, be suspended without pay or be terminated.
      • City Care staff must not have any visitation from friends, family or pets while working on the premises of a client's home. If an employee requires something while on duty, they must consult with City Care Management before making arrangements to have anything delivered to a client’s home.

      UNIVERSAL PRECAUTIONS

      Follow safety techniques and good hygiene habits to stop the spread of germs and infections. To prevent the spread of infection and disease:

      • Do not touch a person’s body fluids.
      • Maintain a safe and clean work environment.
      • Put waste in the right place.
      • Use standard precautions and protective equipment to prevent spreading blood-borne pathogens (Germs spread from blood are called blood-borne pathogens).
      • Wash hands frequently and correctly.
      • Wear gloves, apron or mask as needed.

      Hand Washing

      Frequent hand washing is an easy way to avoid getting sick and spreading illness. Know when to wash your hands and how to wash the person. While you can never keep your hands germ free, you can limit the transfer of bacteria, viruses and other germs.

      Wash your hands before:

      • Eating
      • Preparing food
      • Providing personal care

      Wash your hands after:

      • Blowing your nose, coughing or sneezing into your hands
      • Cleaning and disinfecting surfaces
      • Contact with any bodily fluid (changing incontinent pads, using the bathroom)
      • Direct contact with person for personal care
      • Handling garbage or contaminated clothing
      • Preparing food
      • Removing gloves and other personal protective equipment

      Use alcohol-based hand rubs if hand washing is not possible. Be aware that hand rubs are not effective against all germs so wash hands with soap and water as soon as possible.

      Protective Equipment

      The agency should provide all necessary protective equipment. Use protective equipment when you are in a setting that may expose you to blood-borne pathogens. Protective equipment includes:

      • Gloves.
      • Containers for "sharps" which are items such as needles and razor blades. If there are no sharps containers in the home, find a safe place to discard them where there is no risk of needle sticks. The agency should tell you what to do and who to contact if you are stuck by a needle.
      • Double-bags for waste. May use plastic laundry bags. Tape bags shut.
      • Masks

      Blood-borne Pathogens

      A pathogen is something that causes disease. Blood borne pathogens are infectious diseases carried in the bloodstream. Blood borne pathogen infection may be caused by being stuck with a used needle or if bodily fluids touch a sore, broken skin or mucous membranes like the eyes, nose or mouth. The most common blood borne pathogens are hepatitis and HIV. If you believe you have been exposed, contact your supervisor immediately. Appropriate use of gloves Use gloves if you are likely to touch contaminated items. Some situations include when you:

      • Change bandages or dressings
      • Clean areas where body fluids have spilled
      • Touch urine or stool
      • Touch dirty items used in personal care
      • Toileting
      • Contaminated laundry
      • Tissues with mucus, saliva

      Application and Removal of Gloves

      • Wash hands.
      • Apply clean gloves, do not reuse gloves. If gloves are not available in the home, contact your agency immediately.

      To remove gloves after caring for the client:

      • With right hand, grab opening of glove on left hand and pull glove over fist, removing the glove inside out. Discard glove.
      • With left ungloved hand, grab glove on right hand near the opening and pull the glove over fist, removing the glove inside out. Discard glove.
      • Always throw gloves away in a plastic garbage bag. An ungloved hand should never touch the outside of the contaminated glove.
      • Wash your hands.