Fillable Form 1724 - New Employee Packet Cover Sheet printable pdf download

Form 1724

August 2015-E

Consumer Directed Services

New Employee Packet Cover Sheet

Employer Name

Name of Individual Receiving Services

Employee Name

Date of Hire

First Day of Work

Employer

Agency

FMSA

Document Description / Form Information

Before Hire: (1) Original or Copy for Employer’s Personnel Files and (2) Original or Copy to FMSA

DADS

DADS Form 1725, Criminal Conviction History and Registry Checks

DADS Form 1729, Applicant Verification for Employees;

DADS

DADS Form 1734, Service Provider and Employer Certification of Relationship Status for CDS

USCIS

USCIS Form I-9, Employment Eligibility Verification

DADS

DADS Form 1728, Liability Acknowledgement

DADS

Professional license verification (nursing, professional therapies)

At Time of Hire: (1) Original or Copy for Employer’s Personnel Files and (2) Original or Copy to FMSA

IRS Form W-4, Employee’s Withholding Allowance Certificate — Due before first payroll check is

IRS

calculated; provide to the Financial Management Services Agency (FMSA) on date of hire.

OAG

Texas Employer New Hiring Reporting Form ( )

DADS Form 1730, Wage and Benefits Plan Employee Compensation, and any court-ordered

DADS

garnishment(s); DADS Form 1731, Employee Work Schedule and Assigned Tasks; DADS Form

1737, Employer and Employee Service Agreement; DADS Form 1739, Service Provider Agreement

CLASS, DBMD and MDCP only: Cardiopulmonary resuscitation (CPR) certification — Effective

DADS

at time of service delivery initiation, and maintained. Verify again before expiration date.

Texas Department of Public Safety driver’s license (if transporting client) — Verify again before

DADS

expiration date.

DADS

Proof of minimum auto insurance (if transporting client)

CDC

DADS Form 1727, Occupational Exposure to Bloodborne Pathogens (Acknowledgement: Hepatitis B

OSHA

Vaccination and Universal Precautions)

TWCC

Notice to Employees Concerning Workers’ Compensation in Texas (TWC Notice 5)

DADS

If hiring a nurse: DADS Form 1747, Acknowledgment of Nursing Requirements

CDS

If applicable: DADS Form 1733, Employer and Employee Acknowledgement of Exemption from

DADS

Nursing Licensure for Certain Services Delivered through Consumer Directed Services

DADS Form 1732, Management and Training of Service Provider — Initial training must be

DADS

conducted within 30 days of hire.

Ongoing: (1) Original or Copy for Employer’s Personnel Files and (2) Original or Copy to FMSA

DADS Form 1732, Management and Training of Service Provider — Evaluation, employment status

changes, documentation of training, documentation of conflict and job performance issues.

DADS

(The employer must send the original or a copy to the FMSA within 30 calendar days of an initial

orientation or annual evaluation and when an action affects the service provider's continued status

with the employer, e.g., termination, change in payment.)

DADS Form 1732-EMR, Management and Training of Service Provider Addendum — Must be signed

DADS

by the employee within five days of hire.

Time sheets/service logs — DADS Form 1745, Service Delivery Log with Written Narrative/Written

DADS

Summary, or facsimile approved by the FMSA

Vendors

Receipts and invoices

Code

Action

Code

Agency

CDC

Centers for Disease Control and Prevention

Employer checks off each item for the personnel file and retains

original or copy.

CDS

Consumer Directed Services

DADS

Texas Department of Aging and Disability Services

Employer checks each required item when completed and sends

IRS

Internal Revenue Service

original or copy to the FMSA as indicated. Employer retains

OAG

Office of the Attorney General, State of Texas

original or copy.

OSHA

Occupational Safety and Health Administration

Items the employer is not required to send to the FMSA, but

TWCC

Texas Workers’ Compensation Commission

which the employer must maintain on file in the employee’s

U.S. Citizenship and Immigration Services (formerly known as

personnel file.

USCIS

the INS, Immigration and Naturalization Services)

Form 1724 - New Employee Packet Cover Sheet

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