Public Partnerships Form – Fill Out and Use This PDF

Employment Packet Forms Checklist

Forms Required from Interventionists for each Child Served

____ Application for Employment: This form is the standard application for employment for a

potential employee under the ATAP program.

____ ATAP Child Relationship Information Form: This form identifies family members

providing services. Both the interventionist and the authorized representative need to sign the form.

____ PPL Nevada Employment Agreement: This form is a joint agreement between PPL

Nevada (employer of record), the Authorized Representative (supervisor) and the Interventionist (employee) for the terms of services.

____ATAP Ethics Form: Guidelines for Interventionists: Outlines expected standards

in Professionalism, Confidentiality, Limitations of Training, Treatment Delivery, Data Requirements, Attendance, Staff Relations and performance.

Forms Required from Interventionists for only the FIRST Client served (you

are only required to turn these forms in once)

____ Security and Confidentiality Policy for Protected Data Form: All PPL Nevada

employees are expected to read, understand and sign this form which confirms that the employee will follow PPL Nevada’s policies and procedures regarding security and confidentiality.

____ Criminal Background Check Authorization Form: This form provides PPL Nevada all

the necessary demographic information to run the mandatory criminal background check.

____ USCIS Form I-9: Department of Homeland Security - Employment Eligibility

Verification. This form is used to confirm your immigration and US citizenship information. The form contains instructions developed by the USCIS. Your supervisor must certify and sign Section 2 of the I-9 Form in order to hire you as his/her employee. Copies of the documents used for verification must be submitted to PPL Nevada along with this form. Documents that verify your identity are your Driver’s License, Passport, Birth Certificate, along with many others. These are listed on page 21.

____ IRS Form W-4: Employee’s Withholding Allowance Certificate. This form is used to

calculate your federal tax withholding. The form contains instructions developed by the IRS.

____ Employee Driver’s License and Auto Insurance Verification Form: This form provides

PPL Nevada with a copy of a valid driver’s license and proof of valid auto insurance, which is required if you plan to use your vehicle within the scope of your employment. NOTE: Only required if using vehicle within scope of employment.

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Informational & Optional Forms to Keep

You will use these for the Program

Requirements for Criminal Background Check: This form provides a list of crimes that are considered barrier crimes to employment. Any potential employee convicted of one of these crimes may not provide services under the ATAP program.

ATAP Authorized Representative Acceptance of Responsibility for Employment: When an employee is convicted of a crime the authorized representative may choose to still hire that employee, however they must sign an acceptance of responsibility form.

Employees convicted of crimes which fall under the barrier crimes list are not eligible for employment.

Interventionist Rate Change Form: If an Authorized Representative decides to change a previously agreed upon rate, they must do so by submitting this form. Forms must be submitted 7 days in advance of the pay period in which the changed rate will take effect. This is the ONLY way to change rates.

Interventionist Change or Separation from Employment Form: This is a two part

form: The first half is to be used if an Interventionist’s demographic information changes. PPL Nevada needs the most current information as soon as possible to ensure that any mailings are sent to the appropriate location. The second part of this form should be submitted if an interventionist no longer works for the Child.

Payroll Schedule: Follow this schedule to complete timesheets and submit them to PPL Nevada twice per month. Properly completed and approved timesheets must be received by the payroll deadline in order for you to be paid according to the payroll schedule.

EFT Application: This form is used to establish direct deposit of your paycheck by PPL Nevada. Direct Deposit is highly recommended by PPL because it is the most dependable and quickest way to receive pay checks.

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What should I expect as an interventionist in the ATAP program?

Before you are eligible to provide services to a participating child, you must:

•Complete and submit to PPL Nevada all applicable forms as identified in the employment packet checklist listed under “Forms Required from Interventionist.”

•Submit to a Criminal Background Check and if charges are identified on your Criminal Background Check the authorized representative that you serve has the option to sign an “Acceptance of Responsibility Form” if he/she still wants to hire you.

•Receive your Employee ID number which will serve as notification from PPL Nevada that all documents have been properly completed and you are authorized to begin providing services.

After you start working for a participating child, you will:

•Submit time worked to the Authorized Representative for approval,

•Receive a paycheck from PPL Nevada, based on properly submitted timesheets twice per month.

•Receive a W-2 Wage Statement from PPL Nevada every year.

Who is responsible for submitting timesheets to PPL Nevada?

The Child’s Authorized Representative and the assigned Care Manager will approve your timesheets and submit them directly to PPL Nevada twice per month according to the pay schedule. Timesheets must always be approved by all parties before PPL Nevada will be able to process them. PPL provides a convenient online method using the PPL Web Portal that is the preferred method.

What is the U.S. Citizenship and Immigration Services (USCIS) Form I-9?

The USCIS Form I-9 is your employment eligibility verification. You must bring this form, and the documents listed on page 3 of the I-9 to the Authorized Representative. The Authorized Representative will review the documents, confirm your identity and verify your identity by signing this form. Documents that verify your identity are your Driver’s License, Passport, Birth Certificate, along with many others. These are listed on page 21. You are only required to complete this once and supply it to PPL. Detailed instructions are also included with this form in your packet. Copies of the documents used for verification must be submitted to PPL

Nevada along with this form.

What taxes will be withheld? Will I see them on my paycheck stub?

PPL will withhold Social Security, Medicare (FICA), state taxes and federal income taxes from your paycheck as applicable. A summary of all tax withholdings will appear on your paycheck stub throughout the calendar year. PPL Nevada will also mail you a W-2 form each January.

You will need this W-2 form to file your individual tax return by April of each year. The Authorized Representative will receive regular reports from PPL Nevada about your total hours worked.

If you have any additional questions as you review this packet please feel free to call our

customer service number: 1-888-805-1074

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PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

ATAP Child Relationship Information Form

What is the purpose of this form?

This form is used to identify the relationship between the Interventionist (employee) and the Child (program participant)

Instructions:

1)Check the box that describes your relationship with the child for whom you will provide Intervention services. If none of the relationships apply, check ‘none of the above.’

2)The Authorized Representative and Interventionist must sign and date at the bottom to confirm that the information is correct.

3)Return this form to PPL Nevada with employee tax forms included in this packet.

I will be paid through the ATAP program for services I provide to:

฀My sibling

฀My relative

฀None of the Above

I hereby certify that the information presented above is correct.

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PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

This Employment Agreement is a three-party agreement by and among: (1) PPL Nevada (employer); (2) the participating Child’s Authorized Representative (supervisor); and (3) the Interventionist (employee). The Employment Agreement establishes the responsibilities, rights, options and expectations of each party relating to each other and the provision of Autism Treatment Assistance Program (“ATAP”) services for the participating child.

This Employment Agreement is effective as of(“the Effective

Date”). It may be modified only upon the signed written agreement of all parties.

1. Terms of Employment

PPL-Nevada serves as the employer of record and co-employer with the participating child’s Authorized Representative in the ATAP program. PPL-Nevada is responsible for all employer of record obligations including: processing payroll and timesheets; withholding, filing and paying federal and state income tax withholding, and FICA, FUTA and SUTA to the appropriate tax authorities; issuing W-2 forms; the provision of workers’ compensation insurance; and maintaining up-to-date financial records, copies of all forms, applications, agreements and consent documents.

The Authorized Representative, who is the managing employer serves as the Supervisor and is responsible for the recruitment, hiring, scheduling, wage setting, supervision and, where necessary, discipline and termination of the Interventionist(s). The Authorized Representative(s) ensures employees participate in training delivered by the provider overseeing the child’s treatment. Ensuring that the provider observes the child and the team of interventionists for a minimum of _____ hours per month to

provide input of treatment delivery. That Authorized Representative(s) commit to participating in training.

The Interventionist (employee) agrees to provide services in a safe, courteous, and professional manner; to provide quality services as scheduled, to keep all information regarding the child confidential, and to respect the Child’s and Family’s privacy. The Interventionist further acknowledges that any physical, sexual or mental abuse or neglect of the Child by the Interventionist will result in the immediate termination of this Agreement and possible criminal changes.

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Child Name: _______________________________

Interventionist Name: _______________________________

2. Compensation

PPL-Nevada agrees to compensate the Interventionist at a wage rate determined by the Authorized Representative, provided that the rate is either equal to or greater than the Nevada state minimum wage. As of July 1, 2010 the Nevada state minimum wage is $8.25. Rates are also subject to any maximum rates that may be defined by the Aging and Disability Services Division (“Division”).

The agreed upon rates are set forth below:

Shadowing

Workshop Training

Behavioral

Intervention

The Authorized Representative and the Interventionist may change these rates only by completing and submitting to PPL Nevada an “Interventionist Program Rate Change Form.” The change form must be received by PPL Nevada by 5:00 pm Pacific Standard Time no less than one week (7 days) prior to the start of the payroll period when the new rate is scheduled to go into effect.

The Interventionist will only be paid by PPL Nevada for services that are rendered after all necessary paperwork has been submitted to PPL Nevada. Prior to providing authorization to begin work, PPL Nevada will ensure that a criminal background check has been passed. Under certain circumstances an Authorized Representative may hire an Interventionist with issues identified on a criminal background check, provided they complete and submit a “Family Acceptance of Responsibility for Employment” form.

The Interventionist understands that s/he must submit timesheets documenting time worked for review and approval by the Authorized Representative and appropriate ADSD Care Manager and that the Care Manager must then submit the time worked to PPL Nevada for payment. Interventionist further understands that if the Interventionist fails to submit time worked to the Authorized Representative in a timely manner, or if the Authorized Representative submits the time worked after the time submission deadline, payment may be delayed. The preferred method for timesheet submission is via the PPL Web Portal. PPL Nevada will issue paychecks twice per month.

Payment to Interventionist(s) is from State funds. Any false claims, statements, documents, or concealment of material facts may be subject to prosecution under applicable state laws.

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Any payment requirements resulting from work performed in excess of the number of hours authorized in the ATAP Plan of Services shall be the responsibility of the Authorized Representative.

Interventionists may not provide more than 40 hours of service within the defined work week, nor may they provide over 8 hours in a consecutive 24 hour period for the combined total of all families whom they provide services to. Accordingly, Employees will not receive overtime premium pay from program funds. Any payment requirements resulting from work performed in excess of 40 hours of service within the defined work week or over 8 hours in a consecutive 24 hour period for the combined total of all families whom the Interventionist provides services will be the responsibility of the Authorized Representative.

3. Job Duties

The Interventionist shall provide services as outlined in the Child’s Plan of Services. These services include, but are not limited to:

a.Behavior

b.Cognitive Skills

c.Communication

d.Community Support/Participation

e.Daily Living Skills

f.Data

g.Desensitization (Food or other)

h.Educational Support

i.Fine Motor Skills

j.Gross Motor Skills

k.Imitation

l.Learning to Learn Skills

m.Parent Training

n.Peer Facilitation

o.Social Skills

p.Play Skills

q.Vocational

4. Employment-At-Will

This is an “employment-at-will” relationship. This Employment Agreement may be terminated by any party at any time without advance notice or cause. PPL Nevada encourages the Authorized Representative and the Interventionist each to provide the other parties two weeks’ advance written notice prior to termination or resignation.

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5. Service Provision Limitation

An authorized representative of a Child may not be paid as an Interventionist for the Child.

6. Pre-Employment Background Screening

Before beginning employment, an Interventionist must sign a Criminal Background Check Authorization Form and submit to the completion of a criminal background check. As the employer of record, PPL Nevada maintains the right to conduct additional background check investigations on Interventionists as deemed appropriate and by signing this agreement the Interventionist authorizes the conduct of these checks. Interventionists will be responsible for assuming the cost of the pre-employment criminal background check. PPL Nevada will assume responsibility for performing the criminal background checks. Additionally, PPL Nevada will verify that your Interventionists are authorized to work in the US through an electronic verification process provided by the Department of Homeland Security.

7. Rights and Options of Interventionist

In accordance with Nevada law, the following provisions will apply to ATAP Interventionists:

a.PPL Nevada will provide Workers’ Compensation Insurance for Interventionists hired by the Authorized Representative for the provision of service in the ATAP program.

b.The Nevada Unemployment Insurance program provides temporary and partial wage replacement to workers who have become unemployed through no fault of their own.

c.Employees will not be paid overtime premium pay for holidays.

d.Employees will not be paid for sick or leave time.

e.Employees will not receive severance pay.

f.Employees will not be offered or receive health insurance benefits.

8. Incident/Accident Reporting

The Interventionists must immediately report all work-related incidents and accidents to the Authorized Representative, including incidents or accidents involving the Authorized Representative, Child or the Interventionist. The reporting of incidents or accidents is critical to ensure the proper handling of workers’ compensation claims. All work-related injuries must be reported in writing to PPL Nevada within four working days of the injury.

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10. Automobile Transportation and Liability Insurance

Transportation is not an authorized task under the ATAP program. Interventionists are not authorized to provide transportation services.

If an Interventionist will be driving his or her personal vehicle while accompanying a Child as part of ATAP services, the Interventionist must provide PPL Nevada with proof of a valid driver's license and automobile liability insurance at the time of employment.

The Interventionist must maintain the insurance coverage in good standing during the time of employment, and the coverage must meet minimum Nevada state requirements. A Child cannot be transported by the Interventionist until the above documentation has been provided to PPL Nevada using the “Driver's License and Auto Insurance Verification Form” and PPL Nevada has notified the Interventionist that s/he is authorized.

The Interventionist must notify PPL Nevada of any change in his/her auto insurance and Nevada driver's license status that would compromise this requirement. Interventionists may not use any electronic devices, including cell phones or message texting devices, while operating an automobile or other motor vehicle while providing services to a Child. All passengers must use seat belts while the vehicle is being operated.

11. Non- Harassment Policy

It is the policy of the Authorized Representative and PPL Nevada to ensure that the working environment gives every Interventionist an equal opportunity to succeed, regardless of race, color, religious creed, national origin, gender, sexual orientation, age, disability, veteran status, marital status or any other protected states. Both the Authorized Representative and PPL Nevada are committed to ensuring a work environment free from all forms of discrimination and unlawful harassment, including sexual harassment. Neither the Authorized Representative nor PPL Nevada will tolerate any form of unlawful harassment in the workplace. While this policy sets forth the goal of promoting a workplace that is free of unlawful harassment, it is not designed or intended to limit the authority of PPL Nevada or the Authorized Representative to discipline or take remedial action for workplace conduct that the Authorized Representative or PPL Nevada deems unacceptable, regardless of whether that conduct constitutes unlawful harassment.

•Sexual Harassment: Sexual Harassment can result from sexual conduct directed from an Authorized Representative toward an Interventionist or from an Interventionist toward an Authorized Representative or Child.

Sexual harassment can involve male or female Authorized Representatives/Children and includes sexual advances, requests for sexual favors, or verbal or physical conduct of a sexual nature when:

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•submission to such conduct is made either explicitly or implicitly a term or condition of employment; or

•submission to or rejection of such conduct is used as the basis for employment decisions; or

•such conduct has the purpose or effect of unreasonably interfering with an employees work performance or creating an intimidating, hostile or offensive working environment.

B.Hostile Work Environment: It can be unlawful to have conduct in the workplace that denigrates or shows hostility or aversion towards an individual because of his or her race, color, gender, religion, sexual orientation, age, national origin, physical or mental disability, ancestry, marital status, veteran status or other protected category that:

•has the purpose or effect of creating an intimidating, hostile, humiliating, or offensive working environment; or

•has the purpose or effect of unreasonably interfering with an attendant’s work performance

If an Interventionist believes that he or she has been subject to conduct that may be sexual or other harassment, the Interventionist must inform PPL Nevada immediately and is also strongly encouraged to inform the Authorized Representative immediately. PPL Nevada will investigate any reported allegations of sexual or other harassment. If, as a result of the investigation, it is determined that any Interventionist or Authorized Representative engaged in conduct that may be harassment, appropriate remedial or disciplinary action will be taken. Depending on the nature, severity and frequency of the conduct, such actions could include discipline and termination of employment for the Interventionist, and will be reported to the Division.

12. Drug Free Workplace

Illegal or inappropriate drug and/or alcohol use is detrimental to the safety of the Child and negatively affects productivity. No Interventionist is allowed to consume, possess or be under the influence of illegal drugs and/or alcohol at any time during hours of service provision for ATAP Children. Manufacturing, distributing, transferring, purchasing or selling illegal drugs and/or alcohol during hours of service provision to a Child likewise is forbidden. Such activities may lead to disciplinary action up to and including termination.

Interventionists who are convicted of any criminal drug violation during the term of this Employment Agreement must report such conviction to both the Authorized Representative and PPL Nevada within 5 business days. An Interventionist using a prescription drug that might impair the ability to perform his or her duties should inform

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his or her Authorized Representative and PPL Nevada that he or she is taking such medication on the advice of a physician. Documentation from a physician including possible side effects that could jeopardize the safety of the Child and negatively impact employee performance must be provided to PPL Nevada immediately.

13. Statement of Responsibility

The Interventionist has been recruited and hired by the Authorized Representative and will receive orientation and necessary training from the Authorized Representative, who shall manage the Interventionist workplace activities and duties. The Interventionist and Authorized Representative may access PPL Nevada for information and clarification on any of the stipulations set forth in this Employment Agreement.

14. Indemnification

The Authorized Representative agrees to hold PPL Nevada and NV ADSD harmless for any acts, errors or omissions committed by the Interventionist or Authorized Representative causing harm to any other person or entity, including but not limited to the following:

•breach of this agreement or any of its provisions;

•failure to adhere to any of the Policies or Procedures of PPL Nevada, Inc. or the ATAP program; or

•failure to comply with any state or federal employment or anti-discrimination laws.

The Interventionist agrees to hold PPL Nevada and NV ADSD harmless for any acts, errors or omissions committed by the Interventionist or Authorized Representative causing harm to any other person or entity, including but not limited to the following:

•breach of this agreement or any of its provisions;

•failure to adhere to any of the Policies or Procedures of PPL Nevada, Inc. or the ATAP program; or

•failure to comply with any state or federal employment or anti-discrimination laws.

Interventionist and Authorized Representative each agree that the information provided in this employment agreement is true, correct and complete.

15.Signatures

Each party agrees to this Employment Agreement by signature on the following Signature Page.

Please be sure to include the signature page when you return this document to PPL Nevada.

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Employment Agreement Signature Page

Interventionist

I acknowledge that I have received, read and understand the terms of the PPL Nevada Employment Agreement. I understand that I am an employee-at-will and may separate or be separated from employment by PPL Nevada or the Authorized Representative at any time without advance notice or cause.

Interventionist Signature:

Date:

Print Interventionist Name:

Date: _____________________________________

Authorized Representative

As the Authorized Representative, I understand that should I terminate an employee or receive notification that an employee will no longer provide services on my behalf, I will complete and submit an Interventionist Change or Separation of Employment Form within 24 hours to PPL Nevada so that PPL Nevada can deliver the employee’s final paycheck.

Authorized Representative Signature:

Date:

Print Authorized Representative Name:

Date: _____________________________________

PPL Nevada

PPL Nevada Representative Signature: Marc Fenton (Signature on File)

We recommend you retain a copy of this document prior to remitting to PPL Nevada.

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PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

Ethics Guidelines for Interventionists

The Autism Treatment Assistance Program is a State administered program; therefore, it is the responsibility of all interventionists to conduct themselves in a professional manner and to adhere to the following guidelines:

1. Professionalism

The children served by The Autism Treatment Assistance Program expect to receive a high level of professional treatment. Therefore, it is our obligation to provide consistent, quality treatment to the families we serve. Each interventionist is expected to behave appropriately at all times to ensure professionalism throughout service. Interventionist should be on time and work their scheduled hours. Provide notice when unable to do so. When possible request another team member to cover your session. Failure to provide notice may result in dismissal.

2. Confidentiality

Children served in the Program are protected by the Health Insurance Portability and Accountability Act (HIPAA). Considering the availability of confidential information to which an interventionist may have access regarding a child and his/her family, it is vital that the child’s and family’s right to privacy is respected at all times. As a professional, it is your duty to never mention child’s last names, addresses, or school placements. Furthermore, children's’ case histories or unusual incidents on a particular case should not be discussed with individuals who are not professionally involved with the child served. These include: school personnel, staff for other cases, friends, relatives, spouses, and parents of other children. Any case discussions should be conducted in a professional manner and in an appropriate place, behind closed doors. Remember that your voice may carry and you could be heard through closed doors. Children are never to be discussed in public. Areas outside the child’s home are considered public. Never discuss any client on web sites such as Facebook or blog pages.

All data (such as intake assessments, correspondence, etc.) are kept in each child’s binder or box, protected in a safe place. If you are working with a child and collecting data, safeguard against the loss of data and ascertain that the data are kept confidential.

You are not permitted to take photographs of the child or the family. An exception can be made for photos taken to use as stimuli in child’s program, an example would be, photos taken to teach emotions or family members. In addition, you are not permitted to ask the family for photographs. You may, however, accept a photograph if offered to you, while maintaining all confidentiality guidelines. Do not upload photographs to the internet or email to anyone.

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3. Limitations of Training

Remember that, as an interventionist, you have received training to work with a specific child under the supervision of his/her qualified Provider. You will receive on-going training to work effectively using research-driven programs and applied behavioral analysis procedures. This knowledge will be valuable and beneficial to you and the children you serve, but does not qualify you to implement treatment which has not been specifically recommended by the child’s Provider. Interventionists should follow the verbal and / or written recommendations from the Provider. Treatment should be implemented using guidelines demonstrated by the overseeing Provider. If there are issues or questions regarding a specific recommendation or implementing a specific program during the month, the interventionist should contact the Lead and / or Provider or put the program on hold until it can be discussed with the Provider.

During treatment the Provider may require the child to participate in learning activities he/she does not want to participate in, which may lead to a tantrum. The Provider and interventionist will follow through using the least restrictive procedures possible. Possible procedures may include: requiring the child to sit at a table during instruction, using hand over hand prompts, picking a child up from the floor and guiding him/her to the treatment area, sitting in front of the child to keep the child in his/her seat or from leaving the area designated for treatment delivery, and waiting for the child to calm himself/herself.

4. Physical Restraints

At times there will be extreme behaviors which may result in the need for physical restraints. Interventionists must be trained on the proper procedures to apply restraints before being allowed to implement them.

Please initial that you have read and understand:

_____ I am only to restrain children I serve if they pose a physical threat to themselves, others or

property. Restraint is intended to minimize bodily harm or damage to property.

_____ Restraint, while restricting movement, is NOT intended as a strategy to reduce

behavior(s). Once the child is calm, interventionist is to immediately release.

_____ Every act of restraint must be documented with a detailed description of the incident and

behavior displayed by the child.

5. Timeouts

Please initial that you have read and understand:

Seclusion: Also known as solitary confinement. Seclusion has been cited as unconstitutional for children (Morales v. Turman).

_____ I understand placing a child in an isolated room is illegal and will result in immediate

termination.

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Exclusionary Timeout: Involves moving the child to a different room, another part of the room or behind a physical barrier.

_____ I understand placing a child in an exclusionary timeout will result in immediate

termination.

Parents may implement timeout procedures listed above, however it is not part of treatment and is not to be delivered by an interventionist or a Provider. An interventionist is never to ask a parent to put a child into timeout. If implemented, by any staff member, please contact the child’s Care Manager immediately.

6. Aversive Interventions

Under no circumstances should any form of aversive stimulation/intervention be used, even if the parents request its usage. Nevada prohibits the use of aversive behavior interventions. If implemented, by any staff member, please contact the child’s Care Manager immediately.

7.Augmentative Communication

•All changes to the augmentative communication device must to be approved by the Parent or Provider.

•Once changes have been made either the Parent or the Interventionist must back-up the device.

•The augmentative communication device must be easily accessible to the child at all times, especially during discrete trial training, generalization, socialization or community trainings.

•The Parent has the right to limit access to those permitted to program the device.

•All electronic equipment, including augmentative communication equipment, must be handled with care and respect. Do not lean on the equipment, place it where it might get wet, or put it on an uneven surface.

•The Interventionist is to return the equipment to its place in the house and ensure it is plugged in at the end of the therapy session.

8.Data

Data collection is the basis for any behavioral intervention. Data ensures objectivity and supplies a basis for comparison between procedures and programs. Data also provides accountability in intervention; they show clearly whether or not progress is occurring. It is required that interventionists record data during each session. The importance of keeping accurate data can not be stressed enough. Falsification of data is grounds for immediate termination.

It is very important that you be as careful and scientific in your data collection as possible. Careless record keeping could potentially be detrimental to the child’s program, as well as the future funding. Data efficiency should be carried out in all programs.

Please remember that anecdotal notes and data collected and entered into log books are part of the client’s record and can be used as court documents. Therefore, it is imperative that notes be

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accurate and professional. Data is also subject to review at any time by the Care Manager overseeing the child.

If and when data is emailed, it must be sent via secure and protected files.

9. Treatment Area

Interventionists are to keep session area organized and clean. At the end of each session, all stimuli should be returned to its designated areas and logbook secured, ready for the next session.

10.Quality Control

a.From time to time, interventionists may be videotaped or observed as part of the ongoing quality control procedures. These procedures provide staff an opportunity for more specific feedback regarding their treatment skills. They also assist the Provider in identifying areas in which additional staff training might be helpful.

b.Interventionists are required to participate and attend provider’s meetings and trainings for the child they provide intervention for. If the interventionist is absent from these meetings for any reason, it is mandatory that these sessions be made up as soon as possible. These should take place monthly for at least 3 hours in duration.

11.Performance Evaluations

All interventionists will be evaluated by the overseeing Provider on a periodic basis, usually a minimum of twice per year. Areas for evaluation vary according to your training, demonstrated skill level, and may include the following: professionalism, contribution to consultations, administrative skills, effort to learn/teach/supervise, attendance and punctuality, report writing, timeliness of reports, and therapy skills. Performance evaluations are typically conducted by the overseeing provider. Authorized Representatives may have their own performance evaluations.

12. Attendance

Interventionists are expected to be at all scheduled sessions, team meetings and training/workshops (at the child’s home, school or clinic site) and are expected to be on time. If the interventionist is going to be late, or anticipates missing a session he or she must make an effort to inform the parent 24 hours in advance. Workshops are a priority, given that fact, it is understood that they may conflict with other children’s sessions you may work with. Please provide the parents of the non-workshop family at least one week's notice of your attending the other child’s workshop, so they may schedule another interventionist to cover your session. When possible secure another team member to cover your session.

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13. Relationship with Parents/Family

Parents and family members are clients of the Autism Treatment Assistance Program; they are not your friends or confidantes. You are not to discuss your personal life with parents. Pleasantries, however, may be exchanged when greeting and saying “goodbye” to family members. Contact with the family must be limited to the context of therapy. No baby-sitting will be permitted.

At times, parents may ask for advice or they may wish to discuss their own problems with you. This is not your role; you are not trained or qualified as a family counselor to the parent(s) or family. In the event of this situation, please advise them your role is to deliver services recommended by your child’s supervising behaviorist.

Under no circumstances should you discuss diagnosis or prognosis, suggest treatment programs, or give medical advice for the child, even if you are asked to do so. Similarly, do not make any comments about the comparative level or progress of the child, or the programming of other clients. Speak with the parents in a professional manner at all times, avoiding unprofessional labels (e.g., “brat,” “spacey,” “stimmy,” “freaked out,” “low-functioning,”) even if such terminology is used by the parents. Encourage other team members to use professional language at all times. If the child has established health issues, the parent should inform the child’s provider and team of interventionists of these concerns. A Health Protocol should be written by the family and taught to all interventionists to address future situations.

Do not make disparaging remarks about the child in front of the child as if the child was not present (e.g. he or she looks grouchy today). If a child engages in a behavior that you find to be inappropriate such as a child picking his or her nose, do not make negative emotional comments such as, “gross” or “how disgusting”. Instead, offer the child a tissue and assist them in wiping his/her nose. Address concerns about inappropriate behavior with the child’s Provider.

Do not discuss the administrative issues (e.g., staff changes, business or policies) or the personal life of other staff members with parents. If questioned by the parent about administrative issues, refer them to your Supervisor.

Listen to what the parent(s) have to say regarding services. Remember that most parents have much more extensive experience with their children’s specific behaviors than you, even if they don’t know terminology, and principles and procedures related to ABA. Attempt to involve the parents in the treatment of their children as much as possible. If the parent has ideas or questions about programs or procedures, encourage them to bring them up in workshops. If a parent is opposed to a particular program or procedure, discontinue it for that session and speak to your Provider or Supervising Behavior Consultant.

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14. Staff Relations

It is important that the staff functions as a team. Employees are not working in competition with one another. Everyone has his or her individual areas of strength and weakness. You will do certain things well and you will also make some mistakes. Both are an important basis for learning and for feedback regarding your own and other staff members’ work. When you are given feedback, it is in your best interest not to interpret such comments as a personal insult, but rather as an important tool to help you learn and improve your consultation skills. Corrective feedback from supervisors is expected to be implemented. If you have a question regarding feedback (e.g. you are unclear about terminology that the Provider used or are unsure how to implement feedback) you are to address your concerns/questions with the Provider in a professional and non-argumentative way.

Under no circumstances should you speak about or criticize other staff members inappropriately. If you have personal or work-related problems with any other staff members, you should direct your concerns to your Supervisor, do not address your concerns directly. Your Supervisor will attempt to resolve the problem in an appropriate manner.

If you are in disagreement with any program or procedure, it is appropriate to discuss it with the behavior consultant overseeing treatment. Procedures for change will be presented at the monthly workshop, where the staff as a team can reach decisions. Disagreement should be presented professionally (e.g., outside of consultations).

15. Visitors

It is not permitted for you to bring any guest or visitor to the child’s home without specific authorization from the parent. This includes professionals in psychology or related fields, parents, students, family members, friends, and former employees.

16. Dress

You are to dress in a neat and appropriate manner for all sessions. Wearing comfortable clothing, which allows free movement during therapy sessions, is recommended. Keep in mind you will be bending over or possibly sitting on the floor, so avoid low cut tops and pants. Do not wear clothes with inappropriate content such as alcohol logos or slogans with profanity.

Print Interventionist Name:

Print Authorized Representative Name:

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PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

Security and Confidentiality Policy for Protected Data

PPL Nevada is committed to ensuring the security and confidentiality of data that is entrusted to it by its clients and others, including “protected health information” under the Health Insurance Portability and Accountability Act (“HIPAA”), “education records” under the Family Educational Rights and Privacy Act (“FERPA”), and other data that is confidential under other applicable laws, regulations, contracts or ethical standards (collectively, “Protected Data”). This policy codifies PPL Nevada practices and procedures relating to the security and confidentiality of Protected Data. All PPL Nevada employees are expected to read, understand, and comply with this policy. For purposes of this policy, the term “security” relates to protection from external threats to Protected Data, such as fire and theft. The term “confidentiality” relates to the proper use and disclosure of Protected Data.

A.Basic Principles

1.PPL Nevada will maintain and use appropriate administrative, physical, and technical safeguards to reasonably protect the security, integrity, and confidentiality of Protected Data.

2.PPL Nevada will not disclose Protected Data to any employee, contractor, or other person unless that person has executed an appropriate agreement relating to the security and confidentiality of the Protected Data.

3.PPL Nevada will not use or disclose the Protected Data except as authorized in writing by the source of the Protected Data.

4.PPL Nevada will immediately investigate any reported breach of its security and confidentiality safeguards. If a breach is confirmed, PPL Nevada will notify the source of the Protected Data, and will take appropriate steps to correct the problem and to mitigate any harm.

B.Security Systems

1.PPL Nevada utilizes physical and electronic systems to secure Protected Data. Physical systems include building access controls. Electronic systems include computer passwords, firewalls, virus detection software, and encryption. Employees are prohibited from bypassing these systems.

2.PPL Nevada maintains detailed procedures for PPL Nevada electronic security

systems, including how the HIPAA Security Rule is addressed, and is responsible for electronic security awareness and training. (signature required on 2nd page)

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Acknowledgement of Security and Confidentiality Policy for Protected Data

The undersigned PPL Nevada employee:

Has read and understands the PPL Nevada Security and Confidentiality Policy for Protected Data (“the Policy”);

Agrees to comply with the Policy;

Agrees to use Protected Data only for authorized purposes;

Agrees to report breaches of security or confidentiality relating to Protected Data to an authorized supervisor;

Understands that misusing or failing to safeguard Protected Data may expose PPL Nevada and the employee to legal claims; and

Understands that violation of the Policy may result in disciplinary action up to and including termination of employment.

Applicant Name: __________________________________________________

Applicant Signature: ________________________________________________

Date: _________________________________

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PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

As an Interventionist once you have received all appropriate training you are required to meet the competencies outlined below:

1.Discrete-trial management. Plan the progression of objectives, discriminative stimuli, and generalized training examples.

2.Discrete-trial procedures. Prepare for a session, rapidly pace the session, use repetition, and maintain child’s attention.

3.Present a clear discriminative stimulus SD

4.Present a well-timed, effective prompt from least to most intrusive based on need of child.

5.Use differential reinforcement based upon observation of the child’s performance.

6.Use differential reinforcement based upon observation of the child’s performance to increase responsiveness during a training session.

7.Shape a behavior using differential reinforcement.

8.Use massed trials and prompt fading to establish a new response.

9.Use expansion, randomization, and generalization to teach a new discrimination.

10.Use a correction procedure.

11.Use behavioral momentum.

12.Demonstrate or describe the use of the following skills:

•Use positive practice

•Extinction conditions, based on behavior function.

•Use behavior contracting

•Use differential reinforcement of incompatible behavior

•Observe behavior and collect data

•Decrease a challenging behavior using a functional analysis

•Use peer programming

•Use peer tutoring

•Use peer prompting

•Use incidental teaching

•Redirection

•Generalization

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PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

The Autism Treatment Assistance program requires that all employees complete a criminal background check.

I will complete this step by:

Passing a criminal background check through PPL Nevada

Providing documentation of a completed background check within the past calendar year Providing documentation of a Nevada State Worker’s Card within the past calendar year

This form provides Public Partnerships, Nevada with the authorization to conduct background checks. PPL Nevada will perform this background check through Kroll. ADSD reserves the right to disqualify a person from employment based on the results of this request. Regardless of your personal situation, please complete the demographic information below.

Part 1: Nevada Criminal Background Check

As a prospective Employee, I authorize PPL to submit my information to Kroll to complete a criminal background check on me. I am providing the below information to support the performance of these checks. I certify that the information below is correct to the best of my knowledge. I authorize PPL Nevada to share the results of these checks with the Authorized Representatives for the child for whom I perform services.

______________________________________

(Prospective) Employee Signature

________________________________________

Maiden Name or Alias (If Applicable)

Date of Birth: _____________ Social Security Number:______________ Sex: F or M

Phone Number: _______________________________________________

Address: _______________________________________________

Only if you are having your check run through PPL NV, please send in a check for $ 26.00 made out to Public Partnerships Nevada for the completion of the background check process.

PPL STAFF ONLY

Request processed by:

Signature of Authorized PPL Employee:

Record Attached: ______________No Record: ________________DATE:________________

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PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

Phone: 1- 888-805-1074

Admin Fax: 1-877-409-2655

TTY: 1-800-360-5899

NV Aging and Disability Services Division

Barrier Crimes to Employment

Autism Treatment Assistance program policy requires all Employees and Independent Contractors who provide services to children in the program to undergo a criminal background check.

The applicant or contractor has been convicted of any offense enumerated in NRS

449.188 or any of the following offenses or statutory violations:

•Murder, voluntary manslaughter or mayhem;

•Assault with intent to kill or to commit sexual assault or mayhem;

•Sexual assault, statutory sexual seduction, incest, lewdness, indecent exposure or any other sexually related crime;

•Abuse or neglect of a child or contributory delinquency;

•Criminal neglect of a patient as defined in NRS 200.495;

•Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property within the immediately preceding 7 years;

•Any felony involving the use of a firearm or other deadly weapon, within the immediately preceding 7 years;

•Abuse, neglect, exploitation or isolation of older persons;

•Kidnapping, false imprisonment or involuntary servitude;

•Any offense involving assault or battery, domestic or otherwise;

•Conduct inimical to the public health, morals, welfare and safety of the people of the State of Nevada in the maintenance and operation of the premises for which a provider contract is issued;

•Conduct or practice detrimental to the health or safety of the occupants or employees of the facility or agency; or,

•Any other offense determined by the Division to be inconsistent with the best interests of all recipients.

If there are any other crimes which are identified during the Criminal Background Check, the Authorized Representative must complete the “Acceptance of Responsibility for Employment Form” and provide it to PPL Nevada prior to the continuation of employment.

O p t i o n a l

PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

Phone: 1- 888-805-1074

Admin Fax: 1-877-409-2655

TTY: 1-800-360-5899

ACCEPTANCE OF RESPONSIBILITY FOR EMPLOYMENT

This is an OPTIONAL form

As the managing employer and authorized representative in the Autism Treatment Assistance program, I have the right to choose to hire and employ an Interventionist who I know has been convicted of a crime. However, there are some crimes which are considered barrier crimes.

Anyone who has been convicted of one of the barrier crimes listed below will be denied employment. You may hire other prospective Interventionists provided you complete and submit this form to PPL Nevada.

Barrier Crimes:

•Murder, voluntary manslaughter or mayhem;

•Assault with intent to kill or to commit sexual assault or mayhem;

•Sexual assault, statutory sexual seduction, incest, lewdness, indecent exposure or any other sexually related crime;

•Abuse or neglect of a child or contributory delinquency;

•Criminal neglect of a patient as defined in NRS 200.495;

•Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property within the immediately preceding 7 years;

•Any felony involving the use of a firearm or other deadly weapon, within the immediately preceding 7 years;

•Abuse, neglect, exploitation or isolation of older persons;

•Kidnapping, false imprisonment or involuntary servitude;

•Any offense involving assault or battery, domestic or otherwise;

•Conduct inimical to the public health, morals, welfare and safety of the people of the State of Nevada in the maintenance and operation of the premises for which a provider contract is issued;

•Conduct or practice detrimental to the health or safety of the occupants or employees of the facility or agency; or,

•Any other offense determined by the Division to be inconsistent with the best interests of all recipients.

I understand that this decision and the consequences thereof are my sole responsibility. In making any and all hiring decisions as the Authorized Representative, I agree to hold harmless from any claims and responsibility Public Partnerships-Nevada and Nevada Aging and Disability Services Division.

Authorized Representative Signature__________________________ Date _____________

This form must be signed and sent to PPL-Nevada if you decide to hire an employee after receiving the results of a Criminal Background Check that indicates that the employee has been convicted of a crime.

O p t i o n a l

PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

Phone: 1- 888-805-1074

Admin Fax: 1-877-409-2655

TTY: 1-800-360-5899

EMPLOYEE I-9 FORM

Fill out Section 1 of the form with your information. This includes your name, address, date of birth and social security number. Remember to check the appropriate box regarding your residency status and to sign at the bottom of Section 1.

Fill out Section 2 of the form with your information. This is information that proves you are legal to work in the United States. Look on the attached “Lists of Acceptable Documents” to see what documents you can use. Remember, if you use something from List A, you do not have to complete List B or List C. If you use something from List B, you must also do something from List C.

Your managing employer (the authorized representative) signs and dates in the certification section. People often forget to do this so make sure your employer signs the form!

We will not be able to pay you until you send this in, so this is very important!

In addition to this letter, there are detailed instructions following this page.

If you need help, please give us a call at 1- 888-805-1074. We look forward to working with you!

I n f o r m a t i o n a l

Employee Form I-9 Instructions

IMPORTANT: This form must be completed by the Employee and Managing Employer within three (3) days of employment. The U.S. Citizenship and Immigration Services (US-CIS) Form I-9 must be completed using the corresponding numbered instructions provided below. PPL will not provide payment to any Employee who has not completed the Form I-9 correctly. This form will be returned to the Managing Employer if any of the required fields are missing or incorrect. This form is a Federal form and must be completed in order for an Employee to be in compliance with the U.S. Department of Homeland Security (DHS) employment eligibility requirements. For more information, see US-CIS Handbook for Employers on Instructions for Completing the I-9, available online at www.uscis.gov/files/form/m-274.pdf.

Section 1 (to be completed by Employee):

The Employee must complete the following fields if he/ she is 18 or older:

If the Employee is under the age of 18, a parent or legal guardian must complete this section and print “employee under 18” in the Signature Line (field 8) and fill out fields 1-13.

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1.Employee’s full legal name: Last Name, First Name, Middle Initial.

2.Other names used by employee, if any (for example, if employee has changed name due to marriage).

3.Employee’s address where Employee currently lives.

4.Employee’s current city, state, and complete zip code.

5.Employee’s birth date. Specify the month, day, and year of birth.

6.Employee’s complete Social Security Number (SSN).

7.Employee’s email address.

8.Employee’s telephone number.

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I-9 Instructions-Version 2.0 Revised 4-2013

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9.Employee must check off the statement that applies to his or her current citizenship or Visa status.

10.If the Employee is a lawful permanent resident, the Employee must enter the Alien #. If the Employee is an alien authorized to work, the Employee must enter the Alien Registration # or Form 1-94 Admission Number (if using an admission number, please list the foreign passport number and county of issuance)

11.Employee’s signature (sign full legal name).

12.The date the Employee completed and signed this Form I-9.

Note: the Employee must sign the form prior to or the same day the Managing Employer signs the form in Section 2.

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I-9 Instructions-Version 2.0 Revised 4-2013

In this section the Managing Employer must verify and list the correct documentation in the appropriate format. Remember, incomplete information will delay payment for services.

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17.The Managing Employer must verify the document(s) provided by the Employee. The Employee must provide one of the documents from List A of the “List of Acceptable Documents” page that accompanies the Form I-9 OR one document from List B AND one document from List C. PPC uses E-Verify; therefore, the List A or List B document provided must contain a clear photo.

The Managing Employer must accept any documents on the “List of Acceptable Documents” other than a List B item that does not contain a photo or a document that has expired. Documents presented by the Employee that require signature must be signed. PPC will return the form I-9 to the Employer if there isn’t appropriate documentation listed in List A or in BOTH B and C. Clear photocopies of all documents used for the verification must be submitted to PPL for verification using E-Verify.

The Managing Employer enters this information for the documents verified from each List:

฀Document Title (for example, “Drivers License” or “Social Security Card”)

฀Issuing Authority (for example, “NV DMV” or “Social Security Administration”)

฀Document # (for example, the Employee’s Social Security number “123-45-6789”)

฀Expiration Date (enter “N/A” if there is no expiration date)

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I-9 Instructions-Version 2.0 Revised 4-2013

In this section the Managing Employer must certify that they have 1) examined the documents presented by the above named employee, 2) the above listed documents appear to be genuine and to relate to the employee named, and 3) to the best of their knowledge the employee is authorized to work in the United States.

Remember, incomplete information will delay payment for services

18.The date the Employee began working. If the Employee has not begun working and the employment begin date is unknown, enter the same date as the Managing Employer signature date in field #20.

19.Managing Employer’s signature (sign full legal name).

20.Managing Employer’s full legal name.

21.Managing Employer’s title. Write: “Managing Employer.”

22.The name of the Employer (Public Partnerships-Colorado, Inc.)

23.Employer address (148 State St. Boston, MA 02109). This section will be pre-populated.

24.The date that the Managing Employer has verified the information on this Form I-9. This date is very important. This date must be no more than three (3) calendar days after the employment start date indicated in field # 15.

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I-9 Instructions-Version 2.0 Revised 4-2013

Read all instructions carefully before completing this form.

Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crt/about/osc.

Iwhat Is the Purpose of This Form?

Employers must complete Form 1-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the Northern Mariana Islands (CNMI), employers must complete Form 1-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employers should have used Form 1-9 CNMI between November 28, 2009 and November 27, 2011.

IGeneral Instructions

Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term "employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Complete, sign, and submit to PPL.d

Form l-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforcement (ICE).

ISection 1. Employee Information and Attestation - Instructions for Employees

Newly hired employees must complete and sign Section 1 of Form Is

Section 1 should never be completed before the employee has accepted a job offer. This must be completed before you can start work. Provide the following information to complete Section 1:

Name: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any.

Other names used: Provide all other names used, if any (including maiden name). If you have had no other legal names, write "N/A."

Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), (l.ity, State, and Zip Code. Do not provide a post office box address (P.O. JJox). Only border commuters from Canada or Mexico may use an international address in this field.

Date of Birth: Provide your date of birth in the mm/dd/yyyy format. For example, January 23, 1950, should be written as 01123/1950.

U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security number is voluntary. However, if your employer participates in E-Verify, you must provide your Social Security number.

E-mail Address and Telephone Number (Optional): You may provide your e-mflil address and telephone number. Department of Homeland Security (DHS) may contact you if DHS learns o'f a potential mismatch between the information provided and the information in DHS or Social Security Administration (SSA) records. You may write "N/A" if you choose not to provide this information.

PPL Nevada

FMA Services

6 Admirals Way

Chelsea, MA 02150

Phone: 1- 888-805-1074

Interventionist Drivers License & Auto Insurance Verification Form

If an Interventionist will be driving his or her personal vehicle while accompanying a Child as part of ATAP services, the interventionist must provide PPL Nevada with proof of a valid driver's license and automobile liability insurance. Use this form to provide this information.

PLEASE PROVIDE A CLEAR PHOTO COPY OF YOUR

DRIVERS LICENSE AND PROOF OF INSURANCE CARD

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