810 E Franklin Ave. Mpls, MN 55404 | Tel. (612) 338-5259 | Fax (612) 338-5269

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EDUCATION (Names of institutions and any degrees or certifications completed)

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WORK EXPERIENCE (Start with your most recent employer or attach resume)

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Background Study Information

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Equal Opportunity Employment: Minnesota Professional Health Services, Inc accepts as an employee any qualified person, without regard to age, gender, disability, race, religion, marital status, national origin, sexual orientation, political affiliation, veteran status, or any other status protected by law. (The full statement of MPHS’S Equal Opportunity Employment policy is available on request)

I authorize Minnesota Professional Health Services, Inc to contact any of my previous employers and any professional or academic references that I have given, and I authorize each of them to release to Minnesota Professional Health Services any information related to my position there. I also authorize Minnesota Professional Health Services to provide persons seeking Personal Care Attendants (PCA) with a copy of this application upon request, and to release information about my work history to the employers. I understand that Minnesota Professional Health Services has the right to suspend or remove me from employment as a Personal Care Attendant (PCA) at any time. I also understand that any false information provided on this application will be grounds for termination of employment.

Personal Care Attendant Employment Agreement


MPHS and Employee enter into this Agreement for the purpose of arranging for your services as a Personal Care Attendant for clients with disabilities who have chosen MPHS as a provider organization under the rules of the Minnesota Department of Human Services. A Personal Care Attendant must meet the minimum qualifications as established by MPHS.

Employee is classified as an “at-will” employee. Nothing herein is intended or shall be construed to change or replace, in any manner, the “at-will” employment relationship between the Agency and Employee. Employee or the MPHS may terminate the employment relationship at any time for any reason or no reason.

Employee agrees to provide personal care for MPHS’s clients under these conditions:

  1. You agree to provide services as specified in the client service plan and Minnesota regulations, and as directed and supervised by the client.
  2. It is the client’s responsibility to interview, select, schedule and supervise Personal Care Attendants.
  3. MPHS will not guarantee a minimum number of hours of work to a Personal Care Attendant, nor will MPHS assign a Personal Care Attendant to a client without the client’s approval.
  4. After you are accepted for employment by MPHS, your name and availability information will be placed on a roaster of available Personal Care Attendants that will be given to clients looking for Personal Care Attendants to hire.
  5. If a client decides that you are no longer acceptable as Personal Care Attendant for any reason, no matter how long or short a period you may have worked, your work with that client will be terminated upon request of that client. You agree to cease working for that client without arguing a with or expressing animosity or hostility towards that client.
  6. You will keep an accurate written record of the hours you work for each client on MPHS’s time sheets, and sign the time sheets to certify that the information is correct and that you performed the authorized services during the times recorded on the time sheet. You will have your client sign the time sheets to certify their acceptance of your work, assisting them in reading and understanding the time sheets if necessary, you will submit the time sheets to MPHS promptly.
  7. You may provide services to more than one client, or you may perform similar work for other provider agencies, but only if your responsibilities to each of your clients can be fulfilled and you don’t use overtime hours.
  8. You agree to participate with MPHS's Supervisory Nurse in your own naming and certification, and in the client’s regular assessment and evaluation visits. You will also attend MPHS's Professional Training.
  9. You must notify MPHS in writing immediately of any changes in your availability, name, address, telephone number, and other personal information.
  10. You will notify a client immediately by telephone or you cannot appear at an interview or scheduled work session, or if you will be late for any reason. If you fail to notify client, MPHS may be suspended or terminate your employment.
  11. Employee shall follow all MPHS’s policies including but not limited to MPHS’s Employee Policies and Procedures.
  12. Standard of Performance: In performing its obligations under this Agreement, Employee shall at all time act in good faith and in best interests of MPHS.
  13. No Solicitation of Customers: Employee agrees that during his/her status as an Employee with MPHS, and for a period of one (1) year following the end of Employee’s employment with MPHS, the Employee will not directly or indirectly solicit the business of any MPHS customer.
  14. No Solicitation of Employees: Employee agrees that during his employment with MPHS and for a period of one (1) year following the end of the Employee’s employment with MPHS, the Employee shall not directly or indirectly, on the Employee’s own behalf or on behalf of any other person or entity, hire or solicit to hire for employment or consulting or other services, any person who is actively employed or engaged or in the preceding 6 months was actively employed or engaged by the MPHS. This includes but is not limited to, inducing or attempting to induce, or influence or attempting to influence, any person employed or engaged by MPHS to terminate his/her relationship with the Company.
  15. Confidentiality: All recipient and MPHS information is confidential and should be handled as such. Information about a recipient may be discussed with MPHS and PCA’s working with the recipient for purposes of assuring the recipient’s welfare and best interest. Information should not be discussed openly outside of the company regarding a specific recipient for any reason. MPHS information including trade practices, trade secrets, customer lists, policies and procedures, or processes should not be discussed with any person outside of the MPHS during and after Employee’s employment ends.
  16. Non-Disparagement: The employee and the Company each agree not to disparage or otherwise criticize the other or its agents during the employment relationship and therefore.
  17. Post Termination Obligations: Employee shall continue to be bound by the provisions of Sections 13 and 16 of this Agreement following termination of this Agreement.
  18. This Agreement shall be constructed and enforced in accordance with the laws of the State of Minnesota. Any legal proceeding related to this Agreement shall be brought in the State or Federal Court in Hennepin County, Minnesota, and each of the parties hereto hereby consents to the exclusive jurisdiction of the courts of Hennepin County, Minnesota for this purpose.
  19. Execution of Own Free Will and Freedom to Accept: The Employee acknowledges and agrees that he/she has executed this Agreement of his/her own free will after opportunity to consult with his/her own counsel and in exchange for valuable consideration. Furthermore, Employee acknowledges and represents that he/she is not bound by any other agreement, including but not limited to a non-compete, non-solicitation, or confidentiality agreement, which would in anyway adversely affect Employee’s ability to perform services of the company.
  20. The Employee agrees that the restrictions and agreements contained in this Agreement are reasonable and necessary to protect the legitimate interests of the MPHS and that any violation of these Sections will cause substantial and irreparable harm to the MPHS that would not be quantifiable and for which no adequate remedy would exist at law accordingly injunctive relief shall be available for any violation of these Sections.
  21. Overtime: While employee may work hours that amount to more than 40 hours in a single work week, Employee understands that Company cannot and will not pay any amount more than the Employees regular hourly salary for such hours.

MPHS will:

  1. Orient and train new Personal Care Attendants in (if requested) personal services.
  2. Include your name on MPHS’s roster of available Personal Care Attendants, or remove it uponyour request.
  3. Provide the Personal Care Attendant roster to eligible clients who request it.
  4. Pay you for your services documented on your time sheets. Your initial rate of pay will be per hour. MPHS will manage all applicable payroll tax and employment-related services for you and provide you with such benefits, as are authorized by MPHS’s Board of Directors.
  5. Authorize you to provide personal services to a client who has requested your services, subject to the client’s authorized hours of service.
  6. Provide you access to MPHS's Employee Policies and Procedures which further describe in detail the conditions of your employment, and notify you of any changes in policies or procedures. MPHS will also inform you of rights and grievance procedures to follow if you have a dispute with your client or with MPHS.
  7. Suspend or terminate your employment if you are found to have broken any applicable laws or rule governing the provision of personal services or your employment with MPHS.
  8. On your request, mediate any problems with your Personal Care Attendant work or clients. You have the right to file a grievance regarding any matter related to the Personal Care Attendant services you provide.

MPHS have the responsibility to operate the Personal Care Attendant program under the requirements of Minnesota Department of Human Services rules, which you can read yourself by requesting a copy. Services provided under this agreement are limited to the Personal Care Attendant Program operated under the regulations of the Minnesota Department of Human Services.

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