Support Service Worker (SSW) Conditional Employment Agreement In order to process your payments, Public Partnerships, LLC (PPL) must collect all of the information below. Please complete, sign, and date this seven (7) page Conditional Employment Agreement in its entirety and submit it to PPL. PARTICIPANT INFORMATION Participant Last Name:

Participant First Name:

PPL ID# (if known):

SSW First Name:

SUPPORT SERVICE WORKER (SSW) INFORMATION SSW M.I.: SSW Last Name:

SSW Maiden/Alias Name(s):

Relationship to Participant:


Parent
Other Relative


Child
Non-Relative


Sibling

PHYSICAL ADDRESS Physical Address (no P.O. Box):

Physical Address 2 (apt, number, etc…):

City:

State:

Zip Code:

MAILING ADDRESS (if different from Physical Address) Mailing Address:

Mailing Address 2 (apt, number, etc…):

City:

State:

SSW Conditional Employment Agreement V1.1

Zip Code:

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CONTACT INFORMATION Cell Phone Number:

Phone Number:

Fax Number:

E-mail Address:

Emergency Contact Name:

EMERGENCY CONTACT INFORMATION Emergency Contact Phone Number:

Gender:

BACKGROUND CHECK INFORMATION Marital Status:

 Male Date of Birth:

 Female

 Single Social Security Number:

_____ _____ / _____ _____ / _____ _____ _____ _____ City of Birth: State of Birth:

Race: (please check one) Eye Color: (please check one)

Hair Color: (please check one)

 American Indian/Alaskan

 Asian/Pacific Islander

 Married

_____-_____-_____ _____-_____ _____-_____-_____-_____ County of Birth: (if Country of Birth: known)

 Black

 White (includes

 Unknown

Mexicans and Latinos)

 Black

 Blue

 Brown

 Green

 Gray

 Hazel

 Maroon

 MultiColored

 Pink

 Unknown

 Bald

 Black

 Blonde

 Blue

 Brown

 Gray

 Orange

 Purple

 Pink

 Red

 Sandy

 White

 Unknown Height:

Weight: _______Feet

_______Inches

SSW Conditional Employment Agreement V1.1

_______Pounds

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Payment Detail Information (This information is necessary in order to process your payments.)

HOW WOULD YOU LIKE TO BE PAID? Payment Selection: (please check only one box)

 Paper Check

 Direct Deposit

DIRECT DEPOSIT SETUP* Account Type: (Check one box)



Checking Account





Savings Account



Pay Card

I do not have access to the PPL Web Portal, please send me Paper Remittance Advices.

VOIDED CHECK

Attach a Voided Check Here 1. If selecting Savings Account or Pay Card, submit documentation from your financial entity confirming your account and routing numbers – all information must be pre-populated including your full name. 2. Sorry, no Starter Checks.

* If you elect to enroll in Direct Deposit, it will become active after Public Partnerships, LLC (PPL) verifies your account number with your bank or pay card. This process will take 1 to 2 pay cycles from the time we process your application; you will receive paper checks in the interim.

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Relationship Status (This information is necessary, so that we can determine if you are eligible for tax withholding exemptions)

RELATIONSHIP QUESTIONAIRE 1. Are you a non-resident alien temporarily in the United States on an F-1, J-1, M-1, or Q-1 visa admitted to the US for the purpose of providing domestic services?  YES, that description fits my status.

 NO, that description does not fit my status.

2. Are you the child of the employer (includes adopted children)?  YES, my employer is my parent (mother or father).

 NO, my employer is not my parent.

3. Are you the spouse of the employer?  YES, my employer is my spouse (husband or wife).

 NO, my employer is not my spouse.

4. Are you the parent of the employer (includes adopted children)?  YES, my employer is my child (son or daughter).

 NO, my employer is not my child.

5. If you answered, “YES,” to Question 4, check any of the following that apply. If you answered, “NO,” proceed to Question 6.  YES, I also provide care for my grandchild or step-grandchild in my child’s home.  YES, my grandchild or step-grandchild is under 18, or has a physical or mental condition that requires personal care of an adult for at least four continuous weeks during the calendar quarter in which services are performed.  YES, my child (son or daughter) is widowed and divorced and not remarried, or living with a spouse who has a mental or physical condition which prohibits the spouse from caring for my grandchild for at least four continuous weeks during the calendar quarter in which services are performed. 6. Are you under the age of 18 or do you turn 18 this calendar year?  YES, I am under 18 or am turning 18 this calendar year.

 NO, I am over 18.

If you answered, “YES,” to Question 6, answer the following question. If you answered, “NO,” skip the question below. Is this job of performing household services (respite or nursing) your principal occupation? Note: Do not answer, “YES,” if you are a student.  YES, this is my principal occupation.

SSW Conditional Employment Agreement V1.1

 NO, this is not my principal occupation.

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Support Service Worker Agreement As a Support Service Worker (SSW), I recognize that my employment is contingent upon the participant’s enrollment in the Participant Directed Services Program (PDS). If the participant is no longer in the waiver or the PDS program, I will no longer be employed. In order to acknowledge the terms of my employment, I agree to the following: 1. To provide the supports/services as identified and authorized in the Individual Support Plan (ISP) in accordance with the outcomes and health and safety requirements identified and consistent with ODP’s approved waivers related to waiver service definitions. 2. To complete the required training as required and identified in the ISP, ODP policies and procedures, and 55 Pa. Code, Chapter 51. 3. To maintain the necessary documentation and records as required by the PDS program and by my employer. All records I may have or assist in maintaining will be kept confidential. 4. To complete incident reports, including suspected abuse, neglect, exploitation or any event involving error in service/support implementation, critical events involving personal injury, illness, medical emergency or any event determined to be atypical as required by ODP or my employer. 5. To take part in any meetings if requested by and/or regarding the participant. 6. To abide by all applicable rules, regulations and policies pertaining to providing support services through the PDS program. 7. I hereby acknowledge that I have received, read, and understand all of the following information: a. ODP program policies and procedures regarding PDS b. The Individual Support Plan (ISP) c. Pennsylvania Guide to Participant-Directed Services 8. To review any/all programmatic updates made available to me by my employer. 9. I understand that in consideration of the above stated agreement, I shall be compensated through this program for only those services approved by my employer and authorized in the ISP. 10. I understand and acknowledge that Public Partnerships, LLC (PPL) is not my employer. 11. I understand that the participant or their appointed surrogate/representative is my legal employer, also referred to as the common law employer (CLE).

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12. I understand that the common law employer will be responsible to compensate me for services that I provide when the services are not authorized in the ISP. 13. I understand that my paychecks will be processed by the Public Partnerships, LLC (PPL). PPL is considered a Financial Management Service (FMS) Organization. I understand that PPL is not authorized to pay for any services not approved and authorized in the ISP or any request that exceeds the participant’s budget and funds for the PDS program as stated in the ISP. 14. I understand and consent to having State Police criminal background checks, Child abuse clearances (when required) and Federal criminal history records (when required), completed on me and that my employment is contingent upon the results. 15. I understand that the results of my background checks will be made available to my prospective employer and other program administrators as necessary and/or required. 16. I understand that I cannot begin providing services and receive payment in this program before I have successfully cleared the background checks, have been determined to be qualified, and receive notification of such. 17. To submit qualification documentation by the expiration date specified by the Department in accordance with 55 Pa. Code §51.13 and as required in the approved Waiver. 18. I understand that the common law employer will be responsible to compensate me for services that I provide if I am deemed no longer qualified to provide services. 19. To correctly complete all required paperwork and be approved prior to providing any services under the PDS program. 20. I understand and acknowledge that any untruthful submission of services provided in an attempt to obtain improper payment is subject to investigation as Medicaid Fraud. Medicaid Fraud is a felony and can lead to substantial penalties and/or imprisonment. 21. I agree to comply with 55 Pa. Code Chapter 51, Office of Developmental Programs Home and Community-based Services. 22. In accordance with 55 Pa. Code Chapter §51.33, I agree to self-disclose a conflict of interest to the Department. Conflict of interest is a situation in which a person, corporation or entity has a personal or professional relationship which is able to be exploited by that person, corporation or entity for personal, professional or financial benefit or gain.

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Attestation By signing below, I, the SSW, and my Common Law Employer attest that we have read and understand all program rules and responsibilities. I understand I must sign and return this form as a condition of employment in this program, and that I cannot begin working until this form and all other required program forms are completed and returned to Public Partnerships, LLC. I further attest by signing below, that I understand what is being requested of me, and I agree to abide by these terms and conditions. I understand and agree that violation of any of the terms and/or conditions may result in termination of this agreement. I authorize Public Partnerships, LLC to proceed with all registry and criminal record checks required by state and federal law. Further, I give my permission to PPL to electronically sign for any and all registry and criminal record checks that they conduct on my behalf. I certify that the information I have provided is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code). The Common Law Employer understands that it is their responsibility to properly execute the USCIS Form I-9, as defined in Instructions for Employment Eligibility Verification by the Department of Homeland Security. PPL provides the Form I-9 in the employment packets, and the Common Law Employer retains the original Form I-9 and forwards a completed copy to PPL; which PPL will retain in the SSW’s files. If I request the Direct Deposit payment selection, I authorize PPL to process payments owed to me for services authorized by PA ODP Program. PPL will deposit my payment directly into my account using an Automated Clearing House (ACH) transaction. I recognize that if I fail to provide complete and accurate information on this form, processing may be delayed or made impossible, or my electronic payments may be erroneously made. I certify I have read and agree to comply with PPL rules governing payments and electronic transfers. I authorize PPL to withdraw from the designated account all amounts deposited electronically in error. If the designated account is closed or has an insufficient balance to allow withdrawal, then I authorize PPL to withhold any payment owed to me by PPL until the erroneous deposited amounts are repaid. If I decide to change or revoke this authorization, I recognize that I must forward such notice to PPL.

Participant Name: Common Law Employer Name: Common Law Employer Signature:

Date:

Support Service Worker Name: Support Service Worker Signature: SSW Conditional Employment Agreement V1.1

Date: Page 7 of 7