📋

Onboarding Note: You need to fill out each required form. After submitting the last form, you will make the final submission to get your official onboarding confirmation.

⚠️

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ℹ️

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

Employee Information and Attestation — complete no later than first day of employment

Personal Identity

Last Name (Family Name)

First Name (Given Name)

M.I.

Other Last Names Used

Residential Address

Street Address

Apt. / Unit (if any)

City or Town

State

ZIP Code

Personal Details

Date of Birth

U.S. Social Security No.

Employee's Email Address

Telephone Number

⚖️

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions.):

1 A citizen of the United States 2 A noncitizen national of the United States (See Instructions.) 3 A lawful permanent resident (Enter USCIS or A-Number.) 4 A noncitizen (other than Item Numbers 2. and 3. above) authorized to work until (exp. date, if any)

If you check Item Number 4., enter one of these:

USCIS A-Number

Form I-94 Admission Number

Foreign Passport No. & Country

Signature of Employee

✍️ Draw your signature here

Today's Date (mm/dd/yyyy)

📋

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

Verification Submitted Successfully

Thank you. Your Form I-9 Section 1: Employee Information and Attestation has been successfully validated and recorded.

Employee Name: -

Submission Date: -

Attestation Code: -

Submission Failed

An error occurred while processing your verification form. Please try again.

Beacon of Light Home Health Care

Drug and Alcohol Prohibition Policy · DHS Licensed Provider

Policy & Procedure

ℹ️

EMPLOYEE NOTE: Please review the policy statement and rules below. You must print your name, fill in the dates of policy review/revision, sign inside the digital pad, and submit this document to complete this step.

Program Metadata

Program Name: Beacon of Light Home Health Care

I. Policy Statement

It is the policy of this DHS licensed provider (program) to support a workplace free from the effects of drugs, alcohol, chemicals, and abuse of prescription medications. This policy applies to all of our employees, subcontractors, and volunteers (employees).

II. Procedures & Conduct Rules

A
All employees must be free from the abuse of prescription medications or being in any manner under the influence of a chemical that impairs their ability to provide services or care.
B
The consumption of alcohol is prohibited while directly responsible for persons receiving services, or on our property (owned or leased), or in our vehicles, machinery, or equipment (owned or leased), and will result in corrective action up to and including termination.
C
Being under the influence of a controlled substance identified under Minnesota Statutes, chapter 152, or alcohol, or illegal drugs in any manner that impairs or could impair an employee's ability to provide care or services to persons receiving services is prohibited and will result in corrective action up to and including termination.
D
The use, sale, manufacture, distribution, or possession of illegal drugs while providing care or to persons receiving services, or on our property (owned or leased), or in our vehicles, machinery, or equipment (owned or leased), will result in corrective action up to and including termination.
E
Any employee convicted of criminal drug use or activity must notify **Abshir Mohamed** no later than **five (5) days** after the conviction.
F
Criminal conviction for the sale of narcotics, illegal drugs or controlled substances will result in corrective action up to and including termination.
G
The program's designated staff person will notify the appropriate law enforcement agency when we have reasonable suspicion to believe that an employee may have illegal drugs in his/her possession while on duty during work hours. Where appropriate, we will also notify licensing boards.

Policy Verification & Review Dates

Date of Last Policy Review

Date of Last Policy Revision

EMPLOYEE PRINT NAME

Signature of Reviewer / Employee

✍️ Draw your signature here

Today's Date

📋

Legal Authority: MS §§ 245A.04, subd. 1 (c) and 14.

Acknowledgment Submitted Successfully

Thank you. Your signature and acknowledgment of the Drug and Alcohol Prohibition Policy have been successfully validated and recorded.

Name & Title: -

Program Name: -

Submission Date: -

Submission Failed

An error occurred while processing your authorization. Please try again.

Beacon of Light Home Health Care

Clients Hospitalized or Otherwise Not Receiving Services at Home · HR Onboarding Portal

Policy Acknowledgment

Clients Hospitalized or Otherwise Not Receiving Services at Home

Policy & Procedures Statement

As an employee of Beacon Of Light Home Health, I have been informed that when clients are hospitalized, I cannot turn in timecards for those days even if I am at the hospital with the client. When clients are hospitalized, payment is made to the hospital for their care and the home care provider cannot bill for any services provided by caretakers.

I also understand that if my client is on vacation or out of town and as a caretaker I am not with the client, I cannot claim these hours. If timecards are turned in for these hours, this is fraudulent claims for payment.

In both situations listed above, documenting that services were provided in the home is against agency policy, against the care assistance Program and is considered falsifying records. Violation of these regulations is grounds for termination.

I acknowledge that I have been informed of these policies and I understand that I may not claim these hours as hours worked. I am to notify the office when my client is not available to receive services at home.

Employee Acknowledgment

Employee Print Name

Employee Signature

✍️ Draw your signature here

Employee Today's Date

Acknowledgment Submitted Successfully

Thank you. Your signature and acknowledgment of the Client Hospitalization Policy have been successfully validated and recorded.

Employee Name: -

Submission Date: -

Submission Failed

An error occurred while processing your authorization. Please try again.

Beacon of Light Home Health Care

Conditional Job Offer · HR Onboarding Portal

Job Offer

Conditional Job Offer

Beacon of Light Home Health Care would like to extend to you this conditional job offer.

Requirements of the Position

This offer is based on the condition that you meet the following requirements of the position:

Acceptable references are found.

Your previous work history is verified.

Criminal background study is satisfactory.

You are able to perform the essential functions and physical requirements with or without reasonable accommodation listed on the job description.

You are authorized to work in the United States by completing the I-9 form. (You will be asked to complete this information on your 1^st day of work.)

Once the above conditions are verified and acceptable, you will be eligible for work with Beacon of Light Home Health Care.

Acceptance & Authorization

I accept the conditional job offer and hereby authorize Beacon of Light Home Health care to verify the above information.

Applicant Print Name

Applicant Signature

✍️ Draw your signature here

Applicant Date Signed

Offer Accepted & Submitted

Thank you. Your acceptance of the Conditional Job Offer has been successfully validated and recorded.

Applicant Name: -

Date Signed: -

Submission Failed

An error occurred while processing your acceptance. Please try again.

Beacon of Light Home Health Care

Employee Handbook Acknowledgement · HR Onboarding Portal

Handbook

Employee Handbook Acknowledgement

By signing below, I acknowledge that I have received, read, and understand the Beacon of Light Employee Handbook. I agree to abide by the policies and procedures outlined within the handbook. I understand that it is my responsibility to seek clarification from my supervisor or Human Resources if I have any questions regarding the content of the handbook.

I understand that this handbook is not a contract of employment and that Beacon of Light reserves the right to modify, amend, or terminate policies and procedures described in the handbook at any time.

Employee Acknowledgement

Employee Name (Printed)

Date

Employee Signature

✍️ Draw your signature here

Handbook Acknowledged & Submitted

Thank you. Your acknowledgement of the Employee Handbook has been successfully validated and recorded.

Employee Name: -

Date Signed: -

Submission Failed

An error occurred while processing your acknowledgement. Please try again.

Beacon of Light Home Health Care

Fraud & Abuse Training · HR Onboarding Portal

Fraud & Abuse

Fraud and Abuse Training

I have received Fraud and Abuse training. I have reviewed the policy on Fraud and Abuse.
I have been provided information on what is considered fraud and abuse.
I understand that acts of fraud and/or abuse may result in termination from my position.
It is a federal crime to provide materially false information on service billings for medical assistance or services provided under a federally approved waiver plan as authorized under Minnesota Statutes, sections 256B.0913, 256B.0915, 256B.092, and 256B.49.

Signatures & Date

Employee Signature

Draw Signature

✍️ Draw your signature here

Date Signed

Training Acknowledged & Submitted

Thank you. Your acknowledgement of Fraud & Abuse Training has been successfully validated and recorded.

Employee Date Signed: -

Submission Failed

An error occurred while processing your training acknowledgement. Please try again.

Beacon of Light Home Health Care

HHA Job Description · HR Onboarding Portal

Job Description

Home Healthcare Aide (HHA) Job Description

Please review the job description below for the Home Healthcare Aide position.

Job Title

Home Healthcare Aide

Job Overview

We are seeking a compassionate, reliable, and professional Home Healthcare Aide to provide in-home assistance to individuals who are elderly, disabled, or recovering from illness or injury. The ideal candidate will be dedicated to enhancing the quality of life for clients while ensuring their comfort, safety, and independence at home.

Key Responsibilities

Assist clients with daily personal care tasks, including bathing, grooming, dressing, and toileting.
Monitor vital signs such as temperature, pulse, and blood pressure, and report any concerns to the healthcare team.
Provide companionship and emotional support, promoting the mental and emotional well-being of the client.
Communicate regularly with family members, caregivers, and healthcare professionals to ensure the best care.

Qualifications

High school diploma or equivalent (preferred).
Previous experience in home healthcare or a similar caregiving role is a plus.
Strong communication skills and the ability to build positive relationships with clients and their families.
Compassionate, patient, and attentive to the needs of clients.
Ability to work independently and as part of a team.
Reliable transportation to and from client locations.

Benefits

Competitive pay based on experience.
Flexible work hours.
Ongoing training and development opportunities.
Supportive work environment with a focus on employee well-being.

I have read, understood, and accept the responsibilities, qualifications, and benefits of the Home Healthcare Aide position. I acknowledge that I can perform the duties outlined in this job description.

Job Description Acknowledged

Thank you. Your acknowledgment of the Home Healthcare Aide Job Description has been successfully recorded.

Status: Accepted & Completed

Acknowledged At: -

Submission Failed

Please check the acknowledgment checkbox before proceeding.

Application for Employment

Beacon of Light Home Health Care · HR Onboarding Portal

Step 9 of 11

General Profile

Personal & Position

History & Grids

Optional

Sign-off

Self-ID & Signature

Personal Information

Application Date

Social Security Number

Last Name

First Name

Middle Name / Initial

Other surnames that I have used (if any)

Present Address

Street Address

City

State

Zip Code

Permanent Address

Same as Present Address

Street Address

City

State

Zip Code

Contact & Emergency Details

Home Phone Number

Alternate Phone Number

How did you hear about this position?

Referred By

Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, or public assistance.

Are you legally entitled to work in the U.S.?

YES NO

Are you at least 18 years of age?

YES NO

In Case of Emergency Notify:

Name

Phone #

Relationship to you

U.S. Military or Naval Service:

Military Rank (if any)

Present Membership in National Guard or Reserves?

YES NO

Professional Licenses, Certifications, and Registrations

Do you have any professional licenses, certifications, and/or registrations?

YES NO

List your professional licenses/certifications (up to 4):

License/Cert/Reg #	Type	State Issued	Date Expires	Status (Active/Pending/etc)

References

Give below the names of three work related references.

Name	Address	Company / Position	Phone Number

Education

Level	Name and Location of School	Years Attended	Graduated?	Degree / Certification
HIGH SCHOOL			Yes No
COLLEGE			Yes No
COLLEGE			Yes No
ADDITIONAL TRAINING			—

Former Employers

List below your complete employment history for the last 5 years, starting with the most recent position first.

Date (Mo/Yr)	Name & Address of Employer / Supervisor Name	Salary	Position	Reason for Leaving
	May we contact?
	May we contact?
	May we contact?
	May we contact?

Application Submitted Successfully

Thank you. Your Employment Application has been successfully completed, signed, and saved locally.

Applicant Name: -

Submission Date: -

Receipt Code: -

Submission Failed

An error occurred while validating your employment application. Please check all fields.

2025 Form W-4MN

Minnesota Withholding Allowance / Exemption Certificate

Minnesota Dept. of Revenue · 2025

Employee
Info

Withholding
Section

Details &
Allowances

Signature &
Certification

👤 Employee Information

First Name & Initial Required

Last Name Required

Social Security Number Required (XXX-XX-XXXX)

Permanent Address (Street) Required

City Required

State Required

ZIP Code Required

💍 Marital Status (check one)

Single; Married, but legally separated; or Spouse is a nonresident alien

Married

Married, but withhold at higher Single rate

Head of Household (see instructions)

📋 Complete Section 1 OR Section 2

Complete Section 1 to calculate your Minnesota withholding allowances, or complete Section 2 if you believe you are exempt from Minnesota income tax withholding. Then sign the form and give it to your employer.

Section 1

Determining Minnesota Allowances

For regular employees — calculate the correct allowances for withholding.

Section 2

Exemption From Withholding

Claim exempt if you had no MN tax liability last year and expect none this year.

Note: Complete Section 1 OR Section 2 — not both. Completing both makes this form invalid.

🔢 Section 1 — Minnesota Allowances Worksheet

Personal allowance Enter "1" if no one else can claim you as a dependent.

Single/Sole job allowance Enter "1" if any of the following apply:

You are single and have only one job
You are married, have only one job, and your spouse does not work
Your wages from a second job or your spouse's wages are $1,500 or less

Married allowance Enter "1" if you are married. Or choose to enter "0" if you are married and have either a working spouse or more than one job. (Entering "0" may help avoid too little tax withheld.)

Dependents Enter the number of dependents (other than your spouse or yourself) you will claim on your tax return.

Head of Household Enter "1" if you will use the filing status Head of Household (see instructions).

Total (Steps A – E) Add steps A through E. If you plan to itemize deductions on your 2025 Minnesota income tax return, you may also complete the Itemized Deductions and Additional Income Worksheet.

Line 1 — Minnesota Allowances
Enter Step F total (or Step 10 from Itemized Deductions Worksheet)

➕ Line 2 — Additional Minnesota Withholding

Additional Amount Per Pay Period ($)Optional — enter a flat dollar amount (not a percentage)

🛡️ Section 2 — Exemption From Minnesota Withholding

Complete Section 2 if you claim exempt from Minnesota income tax withholding. Check one box below to indicate why you believe you are exempt:

⚠️ You cannot claim exempt if: (a) another person can claim you as a dependent and (b) your annual income exceeds $1,100 or includes more than $350 of unearned income.

✓

I meet the requirements to claim exempt from both federal and Minnesota income tax withholding.

✓

Even though I did not claim exempt from federal withholding, I claim exempt from Minnesota withholding, because:

I had no Minnesota income tax liability last year
I received a refund of all Minnesota income tax withheld
I expect to have no Minnesota income tax liability this year

✓

All of these apply — Military spouse exemption:

My spouse is a military service member assigned to a military location in Minnesota
My domicile (legal residence) is in another state
I am in Minnesota solely to be with my spouse.

Enter your state of domicile:

✓

I am an American Indian that resides and works on a reservation for which I am enrolled (see instructions).

Reservation name:

CDIB / Enrollment number:

✓

I am a member of the Minnesota National Guard or an active-duty U.S. military member and claim exempt from Minnesota withholding on my military pay.

✓

I receive a military pension or other military retirement pay calculated under U.S. Code, title 10, sections 1401–1414, 1447–1455, and 12733, and I claim exempt from Minnesota withholding on this retirement pay.

Reminder: If you complete Section 2, you must complete a new Form W-4MN by February 15 in each following year.

⚖️ Certification

I certify that all information provided in Section 1 OR Section 2 is correct. I understand there is a $500 penalty for filing a false Form W-4MN.

Employee Signature *

✍️ Sign here with mouse or touch

Date *Required

Daytime Phone Number

✅

Form Submitted Successfully

Your 2025 Form W-4MN has been completed.
Print a copy and give the completed form to your employer.

Beacon of Light Home Health Care

Finalize & Submit Onboarding Packet · HR Onboarding Portal

Step 9 of 9

ℹ️

REVIEW REQUIRED: Please verify your completion status for the onboarding documents below. Once all forms are complete, you can safely submit your complete onboarding packet.

Onboarding Packet Checklist

⚠️