Request for CPR, First Aid or TB Payroll Deduction

By completing and signing this form, you are requesting to have CPR, First Aid or TB test costs deducted from your paycheck.  
The CPR and First Aid class code will be given to me upon signing this agreement.  I will be responsible for going online and taking the test.  The deduction on my paycheck will occur after I have completed the test.  I understand that the code given to me will be a one time code and cannot be shared with others.
To have a TB skin or blood test taken, I will receive a partially completed form to take to Nova Medical Center.  I will present the form and have the appropriate test performed.  Once Prosper Home Care receives the proof that the test has been performed, my paycheck will be deducted for the cost of the test.
**Note: TB Chest Xrays are no longer valid unless you have a copy of the original positive TB skin test.  For any employee who uses chest xrays for TB screening, you will have to select the TB blood test from now on.
For Nova Medical Centers, please note that Prosper Home Care will only be providing TB testing for employees.  No blood work, physicals or other testing will be authorized.
Please select the type of deduction you are requesting: *
Office Location *
Please sign below. *