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
Employment Packet
I nformation for I nterventionists
Dear Interventionist:
You are receiving this Employment Packet because you intend to continue to provide services as an employee to a child participating in the Nevada Autism Treatment Assistance Program (ATAP). While the Authorized Representative (parent/caregiver) for the child that you provide services for will serve as your Supervisor, PPL Nevada will serve as your Employer of Record and is therefore responsible for all personnel, tax and payroll processing services. The enclosed paperwork must be completed and returned to PPL Nevada immediately. After you have submitted the documents you should receive notification from PPL. Documents must be properly completed before you can be paid. Therefore, if you do not hear from PPL within 10 business days from when you submitted your packet, please contact PPL customer service at 1-888-805- 1074 to follow up. As a newly hired employee you must pass or have passed a criminal background check in the past year. ATAP interventionist positions are part time positions.
A complete set of forms is required for the first child you work for. Only certain forms are required to be completed for each additional family you serve. These requirements are identified on the enclosed Employment Packet Checklist. PPL cannot pay for any services provided to a child until a properly completed Employment Packet is received.
PPL Nevada will issue paychecks to you based on properly submitted timesheets. These paychecks will reflect tax withholdings based upon federal and state law and the information you provide to us on the tax documents within this packet. The Employment Packet provides instructions on how to properly complete and submit a timesheet. PPL provides a convenient online method using the PPL Web Portal that is the preferred method for timesheet submission.
If you have any questions regarding this process, please feel free to contact PPL Nevada Customer Service at 1-888-805-1074. We would be more than happy to assist you.
Please Fax all required forms to our Administrative Fax line: 1-877-409-2655 or
Please mail all required forms to:
PPL NEVADA
6 Admirals Way
Chelsea, MA 02150
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.
I n f o r m a t i o n a l
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.
I n f o r m a t i o n a l
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
I n f o r m a 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
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Check Box if you have had a background check within the past calendar year.
If so, you will also need to provide proof with supporting documents.
IN CASE OF EMERGENCY, PLEASE NOTIFY:
TRANSPORTATION
(Please complete if you are providing transportation)
Do you have a valid Driver’s License?
Do you have a safe vehicle that meets all transportation service requirements?
Vehicle Ins. Company Name:
Vehicle Ins. Company Policy Number:
Note to Applicants: Involvement in the NV ADSD Autism Treatment Assistance Program requires that you have a Criminal Background Check in progress and have the Criminal Background Check Authorization Form to: Public Partnerships LLC -Nevada 6 Admirals Way Chelsea, MA 02150 prior to the start of work. If you do not successfully pass a criminal background check you will need to discontinue providing services in the Autism Treatment Assistance Program.
(Applicant’s signature is required on following page)
R e q u i r e d
APPLICANT’S STATEMENT
I certify that all answers given herein are true and complete to the best of my knowledge. I authorize investigation of all matters contained in this application and I understand that misrepresentations, omissions of fact or incomplete information requested in this application may remove me from further consideration for employment.
PPL Nevada
FMA Services
6 Admirals Way
Chelsea, MA 02150
Phone: 1- 888-805-1074 |
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Admin Fax: 1-877-409-2655 |
Child Name: ________________ |
TTY: 1-800-360-5899 |
Interventionist Name: ________________ |
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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Print Interventionist Name: |
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Print Authorized Representative Name: |
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R e q u i r e d
PPL Nevada
FMA Services
6 Admirals Way
Chelsea, MA 02150
Phone: 1- 888-805-1074 |
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Admin Fax: 1-877-409-2655 |
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TTY: 1-800-360-5899 |
PPL-Nevada Employment Agreement |
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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.
R e q u i r e d
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:
Services |
Rates |
Effective Date |
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.
R e q u i r e d
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.
R e q u i r e d