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Alora/EVV
Alora
EVV
Home
About
Services
Skilled Services
Nursing Services
Wound Care
Ostomy Care
Catheter Care
G-Tube Feeding
Vital Signs Monitoring And Report To PCP Doctor
Safety Supervision
Symptom Monitoring
Mobility Support
Speech Therapy
Evaluation/Diagnosis/Prevention of speech impairment
Swallow evaluation and management
Cognitive communication
Medical Social Worker
Providing adequate resources for clients in the community
Implement Short/long term planning of care
Physical Therapy
Improve Mobility & Strength
Aid inside/outside ambulation
Range of motion, Positioning & Transfers
Balancing & Gait
Create an exercise plan
Occupational Therapy
Restore Function
Promote ADL functions
Non-Skilled Services
Home Health Aide
Medication reminders
Vital signs monitoring & Report to Clinical Nurse
Mobility support
Forms
Administrator Competency & Job Description Form
Clinical Manager Job Description Form
Home Health Aide Competency & Job Description & Skill Validation
LPN Competency Job Description Form
MSW Competency Job Description Form
Occupational Therapist Assistant Job Description Form
Occupational Therapist Job Description Form
Physical Therapist Assistant Job Description Form
Physical Therapist Job Description Form
RN Job Description & Performance Evaluation & Competency Form
Speech Therapist Job Description Form
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Employement
Alora/EVV
Alora
EVV
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Written Authorization to Request a CAPS Check
Written Authorization to Request a CAPS Check
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This employer is required to request a check of the Colorado Adult Protective Services (APS) data system (CAPS) during the hiring process of new employees who provide direct care to at-risk adults. Additionally, this employer has statutory authority to request a CAPS check for current employees. The CAPS check will alert the employer as to whether or not a prospective or current employee has a substantiated finding as a perpetrator of mistreatment of an at-risk adult, to include physical abuse, sexual abuse, caretaker neglect, and/or exploitation. More information on the CAPS check requirement can be found in the Colorado Revised Statutes (C.R.S.) under §26-3.1-111 and in the Colorado Code of Regulations (CCR) under 12 CCR 2518-01. Written authorization from the applicant/employee using this form is required. Please complete the form in its entirety. Failure to complete the form, omission of pertinent facts, and/or inclusion of misleading facts may result in disqualification or termination of employment. You may keep a copy of this form for your records.
EMPLOYER INFORMATION
Employer Name:
(Required)
CAPS Check Employer ID # (XXX-##########):
(Required)
REQUESTOR INFORMATION
Requestor Name:
(Required)
Requestor Title:
(Required)
Requestor Phone Number:
(Required)
Requestor Phone Extension:
(Required)
Requestor Email:
(Required)
APPLICANT/EMPLOYEE INFORMATION
First Name:
(Required)
Middle Name:
(Required)
Last Name:
(Required)
Date of Birth:
(Required)
SSN (Last 4 digits):
(Required)
Maiden Name/Previous Name(s)/Alias(es):
(Required)
DORA License #
(Required)
Home Phone (Including Area Code):
(Required)
Cell/Mobile Phone (Including Area Code):
(Required)
Work Phone (Including Area Code):
(Required)
Work Phone Extension:
(Required)
Home Email:
(Required)
Work Email:
(Required)
Current Address Street:
(Required)
Current Address City:
(Required)
Current State:
(Required)
Current Zip/Postal Code:
(Required)
Current Address Start Date:
(Required)
All Applicants/Employees are required to have 5 years of residential history provided. If the individual listed above has less than 5 years at their current address, please list the previous addresses for the past 5 years. Use another sheet of paper, if necessary.
Previous Address (street number, street, unit, city, state, zip):
(Required)
Address Start and End Dates:
(Required)
Previous Address (street number, street, unit, city, state, zip):
(Required)
Address Start and End Dates:
(Required)
Previous Employer(s) Agency Name(s):
(Required)
I,
(Required)
by my signature below, authorize the employer referenced above to request a CAPS Check to determine if I have a substantiated finding as a perpetrator of mistreatment of an at-risk adult. I acknowledge that a substantiated finding resulting from such a check, unless the finding was expunged through a successful appeal, shall be provided to the person directly involved in the employer’s hiring process and may be used to inform their hiring decision of me. I acknowledge notification may occur through CAPS to this employer, for the duration of my employment with them, of any future substantiated findings against me. I attest that all information provided in this written authorization is true and complete to the best of my knowledge.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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Services
Skilled Services
Nursing Services
Wound Care
Ostomy Care
Catheter Care
G-Tube Feeding
Vital Signs Monitoring And Report To PCP Doctor
Safety Supervision
Symptom Monitoring
Mobility Support
Speech Therapy
Evaluation/Diagnosis/Prevention of speech impairment
Swallow evaluation and management
Cognitive communication
Medical Social Worker
Providing adequate resources for clients in the community
Implement Short/long term planning of care
Physical Therapy
Improve Mobility & Strength
Aid inside/outside ambulation
Range of motion, Positioning & Transfers
Balancing & Gait
Create an exercise plan
Occupational Therapy
Restore Function
Promote ADL functions
Non-Skilled Services
Home Health Aide
Medication reminders
Vital signs monitoring & Report to Clinical Nurse
Mobility support
Forms
Administrator Competency & Job Description Form
Clinical Manager Job Description Form
Home Health Aide Competency & Job Description & Skill Validation
LPN Competency Job Description Form
MSW Competency Job Description Form
Occupational Therapist Assistant Job Description Form
Occupational Therapist Job Description Form
Physical Therapist Assistant Job Description Form
Physical Therapist Job Description Form
RN Job Description & Performance Evaluation & Competency Form
Speech Therapist Job Description Form
Resources
Employement
Alora/EVV
Alora
EVV
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