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1724
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I-9
1728
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1730
1731
1737
1739
1732
1727
TWC Notice 5
1733
Employer Forms
1736
1720
1721
1725
SS-4
8822
2678
C-1
C-42
8821
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Employee Forms
* 1724 New Employee Packet Coversheet: This coversheet is used as a
check off list to make sure the ER and the CDSA have a copy of all the
correct forms needed.
* 1725 Texas Department of Public Safety (DPS) Criminal Conviction
History check: This form is used for the Employer and Employee to
complete before any one is hired. The Employer and the Agency need make
sure the employee does not have a felony, misdemeanor, Employee
misconduct registry, Nurse aide registry, and Medicaid exclusion.
* 1729 Applicant Verification: The employer must verify that the
applicant meets each criterion. The employer must ensure the following
forms and/or copies of documentation to verify the criteria are met and
kept in the employee’s personnel file. CDSA also needs a copy of form to
verify applicant can be hired.
* 1734 Service Provider and Employer Certification of Relationship
Status for CDS: This form is to verify the relationship between the
Employer/ Client and Employee. If any of these boxes are checked off as
yes the employee that can not be hired. The employer and the service
provider certify that the responses are accurate.
* I-9 Employment Eligibility Verification: The purpose of this form
is to document that each new employee (both citizen and non citizen) are
authorized to work in the United States. Employers are required to
verify all documentation before hire.
* 1728 Liability Acknowledgement: The employer is solely responsible
and liable for any negligent acts or omissions by the employer: the
employee: other employees or service provider: the individual receiving
services, or if applicable, the Designated Representative. Employees or
Service providers are not employed by the Texas Department of Aging and
Disability Services (dads): any other state or federal government
agency: or by the Consumer Direct Services Agency.
* W-4 Form: Purpose of this form is so that your employer can
withhold the correct federal income tax from your pay. Consider
completing a new W-4 form each year and when your personal or financial
situation changes. Available in
(english) or (spanish)
* Texas Employer New Hire Reporting Form: Purpose of this form is to
allow employers to fulfill new hire reporting requirements. Employers
are required to keep photocopies or electronic records of all reports
submitted.
* 1730 Wage and Benefits Plan: Employee and employer agree to the
compensation, benefits, withholdings and all information above and agree
that any changes or revisions must be documented and provided to the
employee, the employer and the Consumer Direct Services Agency.
* 1731 Employee Work Schedule and Assigned Tasks: This is an
agreement for the employee and employer that assigned tasks and schedule
will be performed.
* 1737 Employer and Employee Service Agreement: This is an agreement
between the Employer and the employee. The employee agrees that all
information given to the employer is correct (ie.) Social Security,
name, address. The employer agrees: (ie.) to give employee notice of any
changes in hours, schedule, pay-rate.
* 1739 Service Provider Agreement: This agreement is between the
Texas Health and Human Services Commission (HHSC), the state Medicaid
agency; the Texas Department of Aging and Disability Services (DADS),
the state operating agency: a Consumer Direct Services Agency (CDSA) and
a service provider.
* 1732 Management of Service Provider: Purpose of form is to evaluate
an employee on their performance. This can be done every 30 days,
3 months, 6 months, and or Annual. This form must be completed at least
once a year.
* 1727 Occupational Exposure to Bloodborne Pathogens: All employers
are required to make the Hepatitis B vaccine and vaccination available
to all employees who have exposure. The cost for the vaccinations is an
administrative expense to the employer and is reimbursable through the
consumer's budget.
* Notice to employees concerning workers compensation in Texas: As an
Employee of a non-covered employer, the employee is not eligible to
receive workers compensation benefits under the Texas Workers
Compensation Act.
* 1733 Employer and Employee Acknowledgement of Exemption from
Nursing Licensure for Certain Services delivered through Consumer Direct
Services: The employer may choose to have certain nursing services
provided by an unlicensed person employed in the CDS option. The
Employer must be able to train the unlicensed employee in the
performance of the task and train and supervise the employee performing
the tasks. The employee who delivers the service must not have been
denied a license.
Employer Forms
* 1736 Documentation of Employer Orientation by Consumer Directed
Services Agency- This form is to be used at the end of Orientation. This
certifies the training was complete, and the Employer of record was
given all the CDS training as far as the Texas Administrative rules
(Ch.41), CDS Training manual, and also to certify that the information on the
form is correct.
* 1720 Appointment of a Designated Represenative- To document the
employer's (the individual or their legally authorized representative)
appointment of a designated representative (DR) to perform employer
responsibilities in the Consumer-Directed Services (CDS) option offered
by the individual's program.
* 1721 Revocation of Appointment of Designated Represenative- Any
previous appointment of a DR is revoked upon the effective date of a
change (new appointment). If the employer does not wish to appoint
another DR, Form 1721, Revocation of Appointment of a Designated
Representative, is completed. The employer keeps the original on file
and gives a copy to the DR, the consumer-directed services agency (CDSA)
and the individual's case manager/service coordinator.
* 1725 Criminal Conviction History and Registry Checks- This form is
used for the Employer and Employee and/or Designated Representative (DR)
to complete before any one is hired. The Employer and the Agency need
make sure the employee does not have a felony, misdemeanor, Employee
misconduct registry, Nurse aide registry, and Medicaid exclusion.
* Agreement to Forward- An agreement to forward to my Consumer
Directed Services agency (In Home Attendant Services, LTD) all
correspondence from Internal Revenue (IRS) and Texas Workforce
Commission (TWC) regarding employment of Attendants in the Consumer
Directed Services Option.
* Emergency & Other contact information- This form is to be
completed by the Employer of record with Family, friends, neighbors, and
hospital numbers. The Employer must have the form somewhere in the home
where the provider can have access to it in the case of an Emergency.
* SS-4 Application for Employer Identification number- Is used to apply for a Federal Identification number.
* 8822 Change of Address- You can use form 8822 to notify the
Internal Revenue Service if you changed your home or business mailing
address or your business location.
* 2678 Employer/Payer Appointment of Agent- This form is used
to request an agent such as In-Home Attendant Services,
LTD.to file your payroll tax reports and to make payments of employment or other
withholdings taxes.
* C-1 Status Report- This report is required of every employment
unit and will be used to determine liability under the Texas
unemployment Compensation Act. Also see http://www.twc.state.tx.us/ui/tax/c1i.html
* C-42 Written Authorization- The CDSA must have an Employer
Registration Identification Number assigned by TWC as verification that
the registration process for the CDSA to represent the CDS employer has
been completed.
* 8821 Tax Information Authorization- The appointee is authorized to
inspect and/or receive confidential tax information in any office of the
IRS for the tax matters listed.
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