<p> EXPERT IN HOME HEALTH MANAGEMENT PAYROLL/NEW HIRE/CHANGE OF STATUS </p><p>LAST NAME: ______FIRST NAME______MIDDLE INITIAL______SOC SEC NUMBER: _____ -_____ -______DR.LICENSE # ______ADDRESS: ______PHONE: (_____)______CITY ______STATE:______ZIP:______EMERGENCY CONTACT: ______PHONE: ______RELATIONSHIP: ______(THE FOLLOWING INFO IS USED FOR BACKGROUND CHECKS ONLY) </p><p>D.O.B. _____/_____/______PLACE 0F BIRTH (STATE)______(COUNTRY)______HEIGHT______WEIGHT______HAIR COLOR______EYE COLOR______RACE ______MALE______FEMALE______PROF. LICENSE #______</p><p>(OFFICE USE ONLY BELOW THIS BOX)</p><p>DEPT/STATUS:  OFFICE  FULL TIME  RN  OT  FULL TIME  PART TIME  LPN  OTA  PART TIME  TEMPORARY  PT  ST  PRN  PTA  CHHA</p><p> NEW HIRE DATE_____/____/_____  RE HIRE DATE_____/______/_____  PROMOTION DATE_____/____/_____  TERMINATION DATE_____/______/______ CHANGE OF ADDRESS  CHANGE W4 WITHHOLDING  CHANGE OF PHONE#  STATUS CHANGE  CHANGE PAY RATE  OTHER______</p><p>JOB TITLE: ______</p><p>CHANGE EFFECTIVE DATE: ______/______/______</p><p>PAY RATE:  HOURLY ______ BI-WEEKLY ______ FEE FOR SERVICE:______NOTES:______</p><p>ATTACHMENTS:  FEDERAL W4  STATE W4  I-9  MEMO  OTHER ______</p><p>NEW HIRE REPORT SUBMITTED:  YES  NO DATE: ______</p><p>HUMAN RESOURCES: ______DATE: ______</p><p>ADMINISTRATION: ______DATE: ______</p>