WC Home Health Supplemental Application 05.20 Page 3 of 4
Please clarify the following:
MVR’s verified at time of hire? Yes No
Copies of MVR are maintained in personnel files? Yes No
19. Are crime statistics reviewed prior to sending employees to a residential location? Yes No
20. Is there a formal safety program in place that addresses blood born pathogens, chemical hazards,
disease, driver safety, lifting, latex allergies, violent behavior, infection control, proper use of medical
equipment, SHARPS disposal, etc.? Yes No
21. Are employees provided with the proper equipment for individual patient care? Yes No
22. Are documented proper procedures for safe lifting provided to employees? Yes No
23. Is there a formal return to work/modified duty program in place? Yes No
If no, would the insured agree to put a formal return to work in place? Yes No
24. Are pre-employment medical exams completed? Yes No
25. Is there a formal pre-hire drug testing program in place? Yes No
26. Is a formal post-accident drug testing program in place? Yes No
ADDITIONAL SPECIFIC QUESTIONS:
1. What percentages of the insured’s clients are:
- Individuals with Age-related illnesses (Alzheimer’s, dementia): _________%
- Developmentally Disabled Individuals: _________%
- Elderly and/or Physically Disabled: _________%
- Hospice Care: _________%
- Mentally ill individuals: _________%
- Other: _______________________: _________%
Total must equal 100%: _________%
2. What percentages of the risk’s operations are:
Companion Care/Homemaker Services: _________% Skilled Nursing: _________%
3. What percentage of the insured’s employees are over 60 years of age? _________%
4. Does the insured validate licenses and certifications? Yes No
5. Does the insured have a DOCUMENTED set of defined duties which limits what services their
employees can or cannot perform? If so, please provide documentation. Yes No
