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Page 1 of 6
SDS 0355 (11/10)
Homecare Worker Application
Office Use Only
Provider #:
Seniors and People with Disabilities
Oregon Home Care Commission
Career Restricted
Please print (use blue or black ink), sign and date application.
Personal Information 1
Name: (last/first/middle initial) (as shown on your Social Security card.)
Date of birth:
Other names used, including maiden and nicknames:
E-mail address:
Mailing address: (If different than street address)
Street or PO Box
City, State, Zip
Your phone number(s)
Home:
Cell:
Message:
Specific Client – Employer – New Homecare Workers Only 2
Have you already agreed to work for a particular client-employer?
Yes No
If yes, please include the name of the individual:
Orientation and Certified Training 3
Have you attended a homecare worker orientation? Yes No
If yes, where did you take it?
Date, if known:
Have you attended a live-in orientation?
Yes No
If yes, where did you take it?
Date, if known:
Are you CPR certified?
You must present your
card(s)
Yes No If yes, when does it expire?
Are you first aid certified?
Yes No If yes, when does it expire?
Transportation 4
What kind of transportation do you use to get to work? (Check all that apply)
Motor vehicle Public transportation Bike/walk
Are you willing to: (Check all that apply)
Transport an employer in your car? Yes No
Drive an employer’s car? Yes No
Escort an employer on public transportation? Yes No
Escort an employer in their car? Yes No
Language - In Order of Ability 5
What languages, including Sign Language, do you speak and/or read?
1.
Speak Read
2.
Speak Read
3.
Speak Read
4.
Speak Read
Page 2 of 6
SDS 0355 (11/10)
Availability to Work 6
Are you currently looking for work? Yes No
Check all work types you are willing to consider:
Full-time (over 20 hours per week)
Providing live-in relief
Part-time (20 hours per week or less)
Providing substitute services paid by the hour
Being a 7 day live-in (24 hour service)
Working with short notice
Being a 6 day live-in (24 hour service)
Being a 5 day live-in (24 hour service)
Being a 2 day live-in (24 hour service)
Being a 1 day live-in (24 hour service)
Would you be willing to assist with evacuation and in-home services in the event of a natural disaster? Yes No
Work Schedule 7
Check the days/times you are available for work. If you are available at all times check here
Weekday
Mornings
Afternoons
Evenings
Nights
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays
Services and Work Experience 8
Check all of the services below that you are “willing” to provide. In addition, if you have “experience” in any
of these tasks, please check the “experience” column. You must be physically able to perform all the services
you check in this section. DO NOT check any tasks where you have physical limitations (such as lifting,
bending or stooping) that would prevent you from performing any of these services.
Activities of Daily Living
Willing
Experience
Ambulation
Bathing
Bladder Care
Bowel Care
Cognition
Dressing
Feeding
Grooming
Personal Hygiene
Positioning
Toileting
Transferring
Page 3 of 6
SDS 0355 (11/10)
Services and Work Experience (continued) 8
Check all of the services below that you are “Willing” to provide. In addition, if you have “Experience” in
any of these tasks, please check the “Experience” column. You must be physically able to perform all the
services you check in this section. DO NOT check any tasks where you have physical limitations
(such as lifting, bending or stooping) that would prevent you from performing any of these
services.
Self – Management Tasks
Willing
Experience
Giving or setting up medications
Housekeeping
Laundry
Meal preparation
Shopping
Transportation
Health – Related Procedures
Willing
Experience
Bowel program
Feeding Tube
Home dialysis
Injections
Ostomy care (e.g., colostomy, ileostomy)
Oxygen management
Suctioning
Tracheotomy care
Urinary catheter care
Ventilator care
Wound care
Additional Information 9
Your gender: Female Male
Do you smoke?
Yes No
Do you want to receive quit smoking information and/or materials via E-mail?
Yes No
Are there employers you are NOT willing to work with or services you are NOT willing to provide?
(Check all that
apply)
Activities of daily living (see page 2)
Self-management tasks (see above)
Alzheimer’s or other dementias
65 years of age or older
Behavioral disorders
Smokers
Females
Terminally ill
Males
Under 65 years of age
People with pets
Individuals that use medical marijuana
Page 4 of 6
SDS 0355 (11/10)
Geographical Location 10
Where are you willing to work? (Select a maximum of three counties.)
Counties:
Cities:/areas within the counties:
Abuse Investigation 11
Have you ever been investigated for abuse, neglect or domestic violence? Yes No
If yes, please explain:
Minimum Qualifications for Homecare Workers (HCW’s) 12
An individual who would like to be a HCW must meet the following minimum qualifications:
Submit a completed application packet.
(1) Pass a DHS criminal history clearance and cooperate with a criminal history re-check when
requested.
(2) Complete a HCW orientation within 90 days. Complete a live-in orientation if applicable.
(3) Be capable of providing or learning to provide necessary services.
(4) Be 18 years of age or older (age exceptions may be made on a case-by-case basis for family
members only, but exceptions will not be granted for anyone under the age of 16).
An individual who would like to be a career HCW and be referred to the general public to provide
homecare services through the Registry and Referral System (RRS) must meet the requirements
listed above, plus the following:
(1) Be 18 years of age or older (no exceptions).
(2) Disclose qualifications, skills (including language skills), and experience that can be verified
and evaluated by a potential client-employer, as well as submit references upon request.
(3) Disclose any job related limitations.
(4) Review and update homecare worker information in the RRS at least every 60 days, if looking
for work.
(5) Immediately notify the local SPD/AAA office or the Oregon Home Care Commission of address
and phone number changes.
Applicant Certification 13
I certify that all information I supplied in this application is accurate to the best of my knowledge. I
understand that should I knowingly misrepresent information may result in rejection of my application
and/or denial of placement on the Oregon Home Care Commission (OHCC) Registry and Referral System
(RRS). I understand and agree to the minimum qualifications for homecare workers established by the
OHCC.
The OHCC has an internet-based registry to assist seniors and individuals with disabilities find qualified
in-home providers. I understand that if I agree to be referred to prospective client-employers through the
RRS, my contact information, (name, phone number, provider number and city of residence) will be
released to anyone seeking in-home services.
Page 5 of 6
SDS 0355 (11/10)
Future changes to the following questions must be submitted in writing to the local office.
A. I agree to have my contact information released through the internet. Yes No
I understand that checking “No” will limit the number of referrals I will receive.
B. I agree to have my contact information referred to individuals who pay privately for
in-home services. Yes No
I understand the hours worked for individuals who pay privately for services DO NOT count
towards Service Employees International Union (SEIU) local 503, Oregon Public Employees
Union (OPEU) negotiated benefits and may not have worker’s compensation or
unemployment insurance.
Furthermore, I understand it is my responsibility to keep my availability information updated, and I must
review my information in the RRS at least one time every 60 days to continue to be
referred for new jobs.
Applicant Signature:
Date:
Page 6 of 6
SDS 0355 (11/10)
FOR OFFICE USE ONLY
Branch office where application was submitted:
I-9 form completed?
Yes
Is provider 18 years of age or older?
Yes
W-4 form completed?
Yes
DHS 0301 form completed and submitted to local office?
Yes
Date submitted
/ /
SDS 0356 signed and witnessed?
Yes
If CPR certified, expiration date verified?
Yes
Expiration date
/ /
If first aid certified, expiration date verified?
Yes
Expiration date
/ /
Fingerprints requested from HCW?
Yes
Date requested
/ /
Fingerprints received from HCW?
Yes
Date received
/ /
Fingerprints submitted to Salem?
Yes
Date submitted
/ /
Fingerprints returned from Salem?
Yes
Date returned:
/ /
Initial criminal history fitness determination clearance?
Yes
SDS 0736 form, Enrollment form completed?
Yes
Orientation verified?
Yes
Live in orientation taken?
Yes
Abuse investigation noted on application?
Yes
Application status: Approved Closed Denied Voluntary withdrawal
Provider number:
If denied at initial application, indicate date:
/ /
Reason for denial:
Approved to work in ORACCESS? Yes
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Completed 23 September 2021

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