PERSONAL CARE AGREEMENT

(Non-Family Caregiver/Home Care Worker)

PARTIES

This Personal Care Agreement ("Agreement") is entered into as of [DATE] ("Effective Date") by and between:

EMPLOYER/CARE RECIPIENT:

Name: _______________________________________________

Address: _______________________________________________

Phone: _______________________________________________

Email: _______________________________________________

(hereinafter referred to as "Employer")

AND

CAREGIVER/EMPLOYEE:

Name: _______________________________________________

Address: _______________________________________________

Phone: _______________________________________________

Email: _______________________________________________

Social Security Number: _______________________________________________

(hereinafter referred to as "Caregiver" or "Employee")

RECITALS

WHEREAS, the Employer requires personal care assistance for [self/Name of Care Recipient] due to [age, illness, disability, or other condition];

WHEREAS, the Caregiver possesses the skills and qualifications to provide such personal care services;

WHEREAS, the Employer wishes to employ the Caregiver to provide personal care services under the terms set forth herein;

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

ARTICLE 1: EMPLOYMENT RELATIONSHIP

1.1 Employment Status

The Caregiver is employed as a household employee of the Employer. This is not an independent contractor arrangement.

1.2 At-Will Employment

Employment is at-will, meaning either party may terminate the employment relationship at any time, with or without cause, subject to the notice requirements in this Agreement.

1.3 Care Recipient (If Different from Employer)

The primary care recipient is:

☐ The Employer
☐ [Name]: _______________________________________________
Relationship to Employer: _______________________________________________
Address (if different): _______________________________________________

ARTICLE 2: JOB DUTIES

2.1 Position

The Caregiver is employed as a Personal Care Attendant/Home Care Worker.

2.2 Duties and Responsibilities

The Caregiver shall perform the following duties:

Personal Care:
☐ Assist with bathing, showering, and personal hygiene
☐ Assist with dressing and grooming
☐ Assist with toileting and incontinence care
☐ Assist with eating and drinking
☐ Assist with mobility, transfers, and positioning
☐ Provide medication reminders (NOT administration)
☐ Monitor health conditions and report changes

Household Tasks:
☐ Light housekeeping (cleaning, laundry, dishes)
☐ Meal planning and preparation
☐ Grocery shopping and errands
☐ Mail and correspondence handling

Transportation:
☐ Transport to medical appointments
☐ Transport for personal errands
☐ Use of: ☐ Employer's vehicle ☐ Caregiver's vehicle

Companionship:
☐ Provide companionship and social interaction
☐ Assist with recreational activities
☐ Escort on walks and outings

Other Duties:
☐ _______________________________________________
☐ _______________________________________________

2.3 Duties NOT Included

The Caregiver is NOT responsible for:
- Skilled nursing or medical care
- Administration of medications (injections, etc.)
- Heavy lifting or transfers without proper equipment
- Care of other household members (unless agreed)
- Major home repairs or maintenance
- Pet care (unless specifically agreed)
- [Other exclusions]: _______________________________________________

2.4 Training

☐ The Employer will provide training on specific care needs
☐ The Caregiver will complete the following required training:
_______________________________________________

ARTICLE 3: WORK SCHEDULE

3.1 Regular Schedule

The Caregiver's regular work schedule is:

Total Weekly Hours: _______________

3.2 Live-In vs. Hourly

☐ Hourly Position: The Caregiver works the scheduled hours and does not live on the premises.

☐ Live-In Position: The Caregiver resides on the premises. Specific live-in arrangements:
- Room provided: ☐ Private ☐ Shared
- Meals provided: ☐ Yes ☐ No
- Hours on duty per day: _______________
- Sleep time (uninterrupted): _______________ hours minimum
- Days off per week: _______________

3.3 Overtime

Hours worked over 40 in a workweek will be compensated at 1.5 times the regular hourly rate, as required by the Fair Labor Standards Act (FLSA) and applicable state law.

Note: Live-in domestic employees may be exempt from overtime requirements in some jurisdictions. Verify applicable law.

3.4 Schedule Changes

Schedule changes require:
☐ Mutual agreement
☐ _______________ days' advance notice (except emergencies)

3.5 Attendance

The Caregiver is expected to be punctual and reliable. If the Caregiver cannot work a scheduled shift, the Caregiver must notify the Employer at least _______________ hours in advance (except in emergencies).

ARTICLE 4: COMPENSATION

4.1 Wage Rate

The Caregiver will be paid:

Regular Hourly Rate: $_______________/hour

Overtime Rate (if applicable): $_______________/hour (1.5x regular rate)

4.2 Pay Period

The Caregiver will be paid:
☐ Weekly
☐ Bi-weekly
☐ Semi-monthly
☐ Monthly

Pay day is: _______________________________________________

4.3 Payment Method

Payment will be made by:
☐ Check
☐ Direct deposit (Caregiver to provide banking information)
☐ Cash (receipt required)

4.4 Minimum Wage Compliance

The wage rate complies with:
☐ Federal minimum wage ($7.25/hour as of 2024)
☐ State minimum wage ($_______________/hour)
☐ Local minimum wage ($_______________/hour), if applicable

4.5 Deductions

The following will be withheld from the Caregiver's pay:

☐ Federal income tax (based on W-4)
☐ State income tax (if applicable)
☐ Social Security tax (6.2% of wages)
☐ Medicare tax (1.45% of wages)
☐ [State-specific deductions]: _______________________________________________

4.6 Room and Board Offset (Live-In Only)

If the Caregiver is live-in, the value of room and board is:

Room: $_______________/week
Board (meals): $_______________/week

☐ This amount will be credited toward the Caregiver's wages
☐ Room and board is provided at no charge to the Caregiver

ARTICLE 5: BENEFITS

5.1 Paid Time Off

☐ Vacation: _______________ days per year, accrued at _______________

☐ Sick Leave: _______________ days per year (verify state requirements)

☐ Holidays: The following holidays are paid:
_______________________________________________

☐ No paid time off is provided (Note: Some states require paid sick leave)

5.2 Health Insurance

☐ Health insurance is not provided
☐ Health insurance is offered: [describe]

5.3 Other Benefits

☐ None
☐ Other: _______________________________________________

ARTICLE 6: EMPLOYER RESPONSIBILITIES

6.1 Tax Obligations

The Employer acknowledges responsibility for:

☐ Withholding and remitting Social Security and Medicare taxes (FICA)
☐ Paying employer's share of Social Security and Medicare taxes
☐ Withholding federal income tax (if W-4 provided)
☐ Withholding state income tax (if applicable)
☐ Filing Schedule H with federal tax return
☐ Providing Form W-2 to the Caregiver by January 31
☐ Complying with state unemployment insurance requirements
☐ Complying with workers' compensation requirements (if applicable)
☐ Obtaining an Employer Identification Number (EIN)

6.2 Work Environment

The Employer will provide:

☐ A safe work environment
☐ Necessary supplies and equipment for care
☐ Clear instructions regarding the Care Recipient's needs
☐ Access to emergency contacts and medical information
☐ Orientation to the home and safety procedures

6.3 Workers' Compensation

☐ Workers' compensation coverage is provided through: _______________________________________________

☐ Workers' compensation is not required in this state for household employees (verify state law)

6.4 Immigration Compliance

The Employer will complete Form I-9 to verify the Caregiver's employment eligibility.

ARTICLE 7: CAREGIVER RESPONSIBILITIES

7.1 Performance Standards

The Caregiver agrees to:

☐ Perform all duties in a professional and competent manner
☐ Treat the Care Recipient with dignity and respect
☐ Maintain confidentiality of personal and medical information
☐ Follow care instructions provided by the Employer or healthcare providers
☐ Report any changes in the Care Recipient's condition promptly
☐ Report any incidents or accidents immediately
☐ Maintain accurate time records
☐ Comply with all household rules and policies

7.2 Prohibited Conduct

The Caregiver shall NOT:

☐ Engage in any form of abuse, neglect, or exploitation
☐ Use alcohol or illegal drugs while on duty
☐ Use the Employer's property for personal purposes without permission
☐ Bring unauthorized persons to the workplace
☐ Accept gifts of substantial value from the Care Recipient without Employer approval
☐ Borrow money from the Care Recipient
☐ Make financial decisions for the Care Recipient
☐ Access the Care Recipient's financial accounts
☐ Discuss the Care Recipient's personal information with others

7.3 Confidentiality

The Caregiver agrees to maintain the confidentiality of all personal, medical, and financial information regarding the Care Recipient and Employer, both during and after employment.

7.4 Background Check

☐ The Caregiver consents to a criminal background check
☐ Background check completed (Date: _______________)
☐ The Caregiver has provided references

ARTICLE 8: VEHICLE USE AND MILEAGE

8.1 Transportation Duties

If transportation is a job duty:

☐ The Caregiver will use the Employer's vehicle
- Insurance provided by Employer: ☐ Yes ☐ No
- Fuel provided by Employer: ☐ Yes ☐ No

☐ The Caregiver will use the Caregiver's own vehicle
- Caregiver must maintain valid driver's license
- Caregiver must maintain auto insurance with minimum limits: _______________
- Mileage reimbursement rate: $_______________/mile

8.2 Driving Record

☐ The Caregiver has a valid driver's license
☐ The Caregiver has provided a copy of their driving record

ARTICLE 9: TERMINATION

9.1 Termination by Either Party

Either party may terminate this Agreement:

☐ At any time without cause, with _______________ days' written notice
☐ Immediately for cause (as defined below)

9.2 Cause for Immediate Termination

The following constitute cause for immediate termination without notice:

• Abuse, neglect, or exploitation of the Care Recipient
• Theft or dishonesty
• Intoxication or drug use on duty
• Gross misconduct
• Abandonment (failure to report for scheduled shifts without notice)
• Breach of confidentiality
• Falsification of time records or other documents

9.3 Final Pay

Upon termination:
☐ Final pay will be provided within _______________ days
☐ Final pay will include payment for accrued, unused vacation (if applicable)

9.4 Return of Property

Upon termination, the Caregiver shall return:
☐ Keys
☐ Access cards/codes
☐ Equipment
☐ Uniforms
☐ Any other Employer property

ARTICLE 10: DISPUTE RESOLUTION

10.1 Informal Resolution

The parties agree to attempt to resolve any disputes informally through good-faith discussion before pursuing formal remedies.

10.2 Mediation

☐ The parties agree to submit any disputes to mediation before litigation.

10.3 Governing Law

This Agreement shall be governed by the laws of the State of _______________.

ARTICLE 11: GENERAL PROVISIONS

11.1 Entire Agreement

This Agreement constitutes the entire agreement between the parties regarding the Caregiver's employment.

11.2 Amendments

Any amendments to this Agreement must be in writing and signed by both parties.

11.3 Severability

If any provision of this Agreement is found invalid or unenforceable, the remaining provisions shall remain in effect.

11.4 Notices

Notices shall be given in writing to the addresses listed above.

11.5 Non-Discrimination

The Employer agrees not to discriminate against the Caregiver based on race, color, religion, sex, national origin, age, disability, or other protected characteristics.

ARTICLE 12: EMERGENCY INFORMATION

Emergency Contacts

Care Recipient's Physicians

Emergency Procedures

In case of emergency, the Caregiver should:
1. Call 911 if immediate medical attention is needed
2. Contact: _______________________________________________
3. [Other instructions]: _______________________________________________

SIGNATURES

IN WITNESS WHEREOF, the parties have executed this Agreement as of the date first written above.

EMPLOYER:

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

CAREGIVER/EMPLOYEE:

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

EXHIBIT A: TIME SHEET

Weekly Time Record

Caregiver Name: _______________________________________________

Week Beginning: _______________________________________________

Total Regular Hours: _______________

Total Overtime Hours: _______________

Caregiver Signature: _________________________________

Date: _______________

Employer Signature: _________________________________

Date: _______________

EXHIBIT B: ACKNOWLEDGMENT OF RECEIPT

I, _______________________________________________, acknowledge that I have received a copy of this Personal Care Agreement. I have read and understand its terms, and I agree to abide by its provisions.

Caregiver Signature: _________________________________

Date: _______________

This template is provided for informational purposes only and does not constitute legal advice. Employment of household workers involves federal, state, and local legal requirements. Consult with an employment attorney or payroll professional to ensure compliance with all applicable laws.