Fillable COVID-19 PRIORITIZED ESSENTIAL WORKERS CHILD CARE APPLICATION

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COVID-19 PRIORITIZED ESSENTIAL WORKERS CHILD CARE APPLICATION

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State of Illinois, Department of Human Services – Bureau of Subsidy Management
COVID-19 PRIORITIZED ESSENTIAL WORKERS
CHILD CARE APPLICATION
During the declared COVID-19 Public Health Emergency, the children of Prioritized Essential Workers are eligible to
receive child care through the Illinois Department of Human Services (IDHS) Child Care Assistance Program (CCAP).
Prioritized Essential Workers include those working in Health Care, Human Services, essential Government services (e.g.
Corrections, law enforcement, fire department), and essential Infrastructure. If you have any questions about your
eligibility, please contact your Child Care Resource and Referral Agency (CCR&R). To find your local CCR&R, please
visit: https://www.inccrra.org/about/sdasearch. Instructions on completing this form can be found beginning on page 4.
PLEASE TYPE OR PRINT CLEARLY IN BLUE OR BLACK INK. If a question does not apply, please write "n/a" in the
box – do not leave any field blank.
SECTION 1 – APPLICANT INFORMATION
The applicant must meet the definition of a Prioritized Essential Worker in order to be determined eligible.
First Name
Last Name
Date of Birth (mm/dd/yyyy)
Home Address
Apt #
City
State
Zip Code
Mailing Address Same as above
Apt #
City
Zip Code
County of Residence
Gender
Primary language spoken in the home:
Male
Female
English Other (list):
Spanish
Telephone Number
Type
Email Address
Home Cell Other
SECTION 2 – OTHER PARENT/GUARDIAN INFORMATION
This section must be completed if the other parent/guardian is living in the same home as the applicant and child(ren).
First Name
Last Name
Date of Birth (mm/dd/yyyy)
Gender
Telephone Number
Type
Email Address
Male Female
Home Cell Other
SECTION 3 – WORK INFORMATION
To qualify, each parent/guardian in the home must be an essential worker unable to work remotely. The applicant must
meet the definition of a Prioritized Essential Worker. Please submit documentation as proof of each parent/guardian’s
employment status along with this application. Acceptable documentation includes a pay stub within the past 30 days
or a letter from your employer. If submitting a letter from your employer, please have them list 1) the company name;
2) your job title; 3) standard working hours; and, 4) your salary and frequency of pay (e.g. weekly, biweekly).
Applicant Work Information
Employer/Company Name
Industry Type
Job Title
Health Care
Government
Human Services
Infrastructure
Address
City
State
Zip Code
Work Telephone Number:
Other Parent/Guardian Work Information
Employer/Company Name
Job Title
Work Telephone Number
Address
City
State
Zip Code
Does this individual have the option to work from home?
If yes, please explain why child care is needed.
Yes No
Page 1 of 7
State of Illinois, Department of Human Services – Bureau of Subsidy Management
COVID-19 PRIORITIZED ESSENTIAL WORKERS
CHILD CARE APPLICATION
SECTION 4 – REQUESTED CHILD CARE SCHEDULE
Identify below the days and hours that child care is needed. Only the times that both parents are working (including
travel time to and from work) should be listed in this section.
MON
TUES
WED
THURS
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
SECTION 5 – CHILD INFORMATION
Please complete the section below for each child in need of child care from an Emergency Child Care provider.
Child 1
Child First Name
Last Name
Date of Birth
Gender
US Citizen?
Male
Female
Yes
No
Ethnic Origin (check all that apply)
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Other
Child 2
Child First Name
Last Name
Date of Birth
Gender
US Citizen?
Male
Female
Yes
No
Ethnic Origin (check all that apply)
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Other
Child 3
Child First Name
Last Name
Date of Birth
Gender
US Citizen?
Male
Female
Yes
No
Ethnic Origin (check all that apply)
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Other
Child 4
Child First Name
Last Name
Date of Birth
Gender
US Citizen?
Male
Female
Yes
No
Ethnic Origin (check all that apply)
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Other
Child 5
Child First Name
Last Name
Date of Birth
Gender
US Citizen?
Male
Female
Yes
No
Ethnic Origin (check all that apply)
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Other
SECTION 6 – CHILD CARE PROVIDER INFORMATION
15-digit CCMS Provider ID
Provider Type
Licensed center License exempt center
Licensed home License exempt home
First Name
Last Name
Date of Birth
Corporate Name
Doing Business As (DBA)
DCFS Emerg. Child Care Lic. #
Page 2 of 7
State of Illinois, Department of Human Services – Bureau of Subsidy Management
COVID-19 PRIORITIZED ESSENTIAL WORKERS
CHILD CARE APPLICATION
Service Address
Apt #
City
State
Zip Code
Telephone Number
Email Address
Date Care will Begin
Provider’s relationship to child(ren):
SECTION 7 – APPLICATION AUTHORIZATION
I have provided all required information. After reading each of the following statements, I certify that:
• I am responsible for the selection of the child care provider(s) for my child(ren).
• I understand that I must be working as a Prioritized Essential Worker, defined as working in Health Care,
Human Services, essential Government services (e.g. Corrections, law enforcement, fire department), or
essential Infrastructure (e.g. e.g. utility maintenance, construction, airport operations) to be determined eligible
to receive child care benefits at this time.
• I understand that if there is another parent or guardian in the home, they must be identified as an essential
worker by their company and required to work outside of the time in order to be determined eligible to receive
child care benefits at this time.
• The information provided will be disclosed only for administrative purposes and that I may be required to verify
the information that I have provided.
• I declare under penalty of perjury that I have read all statements on this form and the information I give is true,
correct, and complete to the best of my knowledge. I understand that giving false information or failing to
provide correct information can also result in an overpayment which I will have to pay back and could result in
my prosecution for fraud.
My signature is my consent and authorization for information to be released by or to the Illinois Department of
Human Services or its agents that may establish my eligibility, or my continued eligibility for the Child Care
Assistance Program.
Parent/Guardian’s Signature: ____________________________________________ Date: ________________
Please submit your completed application to your local CCR&R, along with any necessary supporting
documentation. Please keep a copy of your submitted application for your records. To find your local CCR&R,
please visit: https://www.inccrra.org/about/sdasearch
.
Page 3 of 7
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State of Illinois, Department of Human Services – Bureau of Subsidy Management
COVID-19 PRIORITIZED ESSENTIAL WORKERS
CHILD CARE APPLICATION
APPLICATION INSTRUCTIONS
IDHS is offering child care assistance as a support to the priority essential workers that do not have the
option to work remotely. This service should be treated as an option of last resort. If at all possible, it is
best for your children to remain at home and practice social distancing during the COVID pandemic.
Prioritized Essential Workers include those working in Healthcare and Public Health Operations, Human
Services Operations, Essential Governmental Functions (including Corrections, law enforcement, fire
department), and Essential Infrastructure. See below for a detailed explanation of these jobs. If you have any
questions about your work status, email GOV.OECD@illinois.gov
or go to
https://www2.illinois.gov/Pages/news-item.aspx?ReleaseID=21288
Emergency child care services are provided in accordance with the most recent IDPH and CDC guidance.
SECTION 1 – PARENT/GUARDIAN INFORMATION
Note: In a 2-parent family, both parents must be employed and working outside of the home. The parent
listed as the first parent on the application must be as Prioritized Essential Worker working outside of the
home during the time care is requested to be approved for CCAP. Both parents must supply documentation
that verifies their worker status (pay stub, letter from employer…)
• Enter the parent’s first name, last name and date of birth.
• Enter the address where the family is living.
• Enter the mailing address where forms and notices can be mailed to the family.
o If it the same as the Home Address, mark the “SAME AS ABOVE” box.
• Enter the county that the Home Address is in.
• Mark “Male” or “Female” for the gender of the parent.
• Mark the primary language spoken by the parent.
o Some forms and notices can be printed in Spanish.
• Enter the best phone number to reach the parent and indicate the type of phones (home, cell or other).
• Provide the best email address where information may be sent to the parent.
SECTION 2 – OTHER PARENT/GUARDIAN INFORMATION
If there is not a second parent or guardian living in the home with the applicant and child(ren), please write
“N/A” in this section.
• Enter the other parent’s first name, last name and date of birth.
• Mark “Male” or “Female” for the gender of the other parent.
Page 4 of 7
State of Illinois, Department of Human Services – Bureau of Subsidy Management
COVID-19 PRIORITIZED ESSENTIAL WORKERS
CHILD CARE APPLICATION
• Enter the best phone number to reach the other parent and indicate the type of phones (home, cell or
other).
• Provide the best email address where information may be sent to the other parent.
SECTION 3 – WORK INFORMATION
NOTE: Each parent listed on the application must submit proof that they are working as a Prioritized
Essential (first parent) Worker or an Essential Worker (2nd parent) outside of the home. This can include
pay stubs and/or a note from the employer.
Applicant Work Information:
• Enter the name of the parent’s current employer.
• Mark the industry type of the parent’s employment.
o For example, if they are working as a custodian at a hospital, the Industry Type would be Health Care.
If the parent is employed as a police officer, fire fighter or paramedic, the Industry Type would be
“Government Services”.
o A more detailed explanation of jobs in these industry types can be found below and at this web site
https://www2.illinois.gov/Pages/news-item.aspx?ReleaseID=21288
• Enter the parent’s job title (police officer, correction officer, nurse…).
• Enter the address of the parent’s employer.
o Prioritized Essential or Essential Workers (2nd parent) Workers who are working remotely from home
will not qualify for CCAP at this time.
• Enter a phone number that we can reach the parent’s employer at.
o This is not the parent’s direct work phone number. The employer’s main phone number or the
supervisor’s phone number should be used.
Other Parent/Guardian Work Information:
• Enter the name of the 2nd parent’s current employer.
• Enter the 2nd parent’s job title (cashier, delivery truck driver, nurse).
• Enter a phone number that we can reach the 2nd parent’s employer at.
o This is not the 2nd parent’s direct work phone number. The employer’s main phone number or the
supervisor’s phone number should be used.
• Enter the address of the parent’s employer.
• Please confirm whether the 2nd parent has the option to work from home by checking either “Yes” or
“No.” If “Yes” is checked, please explain why you are seeking child care at this time.
o Prioritized Essential or Essential Workers (2nd parent) Workers who are working remotely from home
will not qualify for CCAP at this time.
Page 5 of 7
State of Illinois, Department of Human Services – Bureau of Subsidy Management
COVID-19 PRIORITIZED ESSENTIAL WORKERS
CHILD CARE APPLICATION
SECTION 4 – REQUESTED CHILD CARE SCHEDULE
• Please fill in the chart with the days and times for which you are requesting child care. Be sure to account
for any travel time to and from work in your schedule request. Child care will be approved for days and
hours when both parents, when applicable, are working.
o This will determine the number of full time days (5 hour or more) and Part Time days (fewer than 5
hour) are approved each week.
• Enter the start time that child care is needed in the “From” row. Check AM or PM as appropriate.
• Enter the end time that child care is needed in the to “To” row. Check AM or PM as appropriate.
• If you do not need child care on a particular day of the week, leave that day blank.
SECTION 5 – CHILD INFORMATION
• Enter all information for all children needing assistance through CCAP that are in care of the provider
listed in Section 4.
o Children must be younger than 13, or younger than 18 with a special need, to be eligible for the
Child Care Assistance Program.
o Citizenship, immigration status and Ethnic Origin of the child's parent cannot be considered and will
not impact the child's eligibility determination. Eligibility will not be denied based on a child's
citizenship status
Section 6 – CHILD CARE PROVIDER INFORMATION
Note: If you have never been approved for the Child Care Assistance Program as a child care provider, the
local CCR&R will contact you for information and will send you forms that are required to be paid.
Individuals must have cleared Background check results on file with DCFS to be approved as a CCAP provider
at this time.
Certification of SSNs or FEIN through a W-9 process is required for the State to issue payments.
• Enter the Provider’s 15-digit CCMS Provider ID.
o This number is assigned to providers when they are approved the first time for CCAP and would
appear on all Approval Notices and monthly Child Care Certificates used for billing.
o If you do not have a CCMS Provider ID Number, leave this box blank.
The CCR&R will contact you for needed information and documents.
• Mark the type of provider.
o Home providers who were licensed by IDCFS but are under current suspension due to COVID-19
should mark “licensed home”.
o You will continue to receive the licensed home daily rate for CCAP children, plus any add-on rates that
apply for the month of services billed.
o All home providers are limited to 6 children in care at any one time, including the providers own
children younger than 13 that live in the home, regardless of what the license capacity was.
Page 6 of 7
State of Illinois, Department of Human Services – Bureau of Subsidy Management
COVID-19 PRIORITIZED ESSENTIAL WORKERS
CHILD CARE APPLICATION
• Enter the name of the child care provider if they are a licensed or license-exempt home.
• For child care centers, enter the corporate name of the center.
• If a home provider has been approved for CCAP under a Doing Business As name, please enter it in the
DBA box.
• Center providers must enter their DCFS Emergency Child Care License number to be approved for CCAP at
this time.
• Enter the address where care is being provided.
• Enter a telephone number and email address that the provider can be reached at.
• Enter the date the care began or will begin if in the future.
SECTION 7 – APPLICATION AUTHORIZATION
• Parents must read the Application Authorization and sign and date the form.
CATEGORIES OF PRIORITIZED ESSENTIAL WORKERS.
Essential Government Functions:
All services provided by state and local governments needed to ensure the continuing operation of the
government agencies and provide for the health, safety and welfare of the public.
Healthcare and Public Health Operations: Working at hospitals; clinics; dental offices; pharmacies; public
health entities; healthcare manufacturers and suppliers; blood banks; medical cannabis facilities; reproductive
health care providers; eye care centers; home healthcare services providers; mental health and substance use
providers; ancillary healthcare services — including veterinary care and excluding fitness and exercise gyms,
spas, salons, barber shops, tattoo parlors, and similar facilities.
Human Services Operations: any provider funded by DHS, DCFS or Medicaid; long-term care facilities; home-
based and residential settings for adults, seniors, children, and/or people with disabilities or mental illness;
transitional facilities; field offices for food, cash assistance, medical coverage, child care, vocational services or
rehabilitation services; developmental centers; adoption agencies; businesses that provide food, shelter, and
social services and other necessities of life for needy individuals — excluding day care centers, day care
homes, group day care homes and day care centers licensed as specified in Section 12(s) of the order.
Essential Infrastructure: Working in food production, distribution and sale; construction; building
management and maintenance; airport operations; operation and maintenance of utilities, including water,
sewer, and gas; electrical; distribution centers; oil and biofuel refining; roads, highways, railroads, and public
transportation; ports; cybersecurity operations; flood control; solid waste and recycling collection and
removal; and internet, video, and telecommunications systems.
Page 7 of 7
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Completed 14 July 2020

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