Fillable Provider Registry Application Information (Sacramento County, California)

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Provider Registry Application Information (Sacramento County, California)

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Provider Registry Application Information
The IHSS Caregiver Registry is a database of specially screened caregivers who
are looking to work for IHSS recipients within Sacramento County. By completing
this application, you are interested in being referred to recipients for
employment. Please note that the Registry does not guarantee employment.
** If you already have an IHSS Recipient who would like to hire you as their
provider, you do not need to fill out this application. **
Please complete the Registry Application to be apply for the Caregiver Registry.
You must complete each page of the application. Additionally, two
professional references are required. The professional reference must
complete the Reference Questionnaire included with the application; this
is not to be completed by the applicant.
Applications and Reference Questionnaires can be submitted by in
person or by mail to: 3700 Branch Center Road Suite A Sacramento, CA
95827.
Applications can also be submitted by email to IHSS-PA-Provider-
Registry@SacCounty.net They must have a wet signature. Applications
with typed signatures will not be accepted.
Applicants accepted to the registry will need to pass a background check to
meet program requirements. The cost of the background check is paid for by
the Provider. Applicants accepted to the Registry are also required to attend a
Registry Orientation to become familiar with the Provider Registry. If you are not
an active Provider with In-Home Support Services, you will need to complete
Provider Enrollment.
IHSS Public Authority
3700 Branch Center Road Suite A
Sacramento, CA 95827
Phone: 916-874-2888
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Public Authority
Caregiver Registry Application
First Name
MI Last Name
Physical Address
City
.... State Zip Code
Mailing Address (if different)
City State Zip Code
Home Phone ( ) Cell Phone ( )
Gender: Male Female E-Mail
Date of Birth SSN
ID/Driver’s License # Issuing State Expiration Date
Emergency contact Phone ( )
Areas Willing to Work:
Please refer to the Sacramento area map for more information.
Antelope Folsom North Highlands
Arden/Howe Fruitridge Vista North Sac/Arcade
Broadway/Riverside Galt Northgate
Carmichael Greenhaven Oak Park
Citrus Heights Hood Orangevale
Del Paso Heights Isleton Pocket/Riverside
Downtown Laguna Rancho Cordova
East Florin Road Lemon Hill Rio Linda/Elverta
East Sacramento Meadowview Rosemont
Elk Grove Midtown Walnut Grove
Fair Oaks Natomas West Florin Road
Transportation:
Do you have a current, valid California Driver’s License?
(If no, please skip to the next section) Yes No
Do you have a vehicle you are willing to use for authorized tasks?
Yes No
Are you willing to provide consumers with proof of auto insurance and current
registration? Yes No
Are you willing to transport a consumer? Yes No
Yes
Are you willing to drive a consumer’s vehicle? No
3
Availability and Preferences
Days and Hours Available:
Please list your specific availability. The wider your availability, the more
referrals you are likely to receive.
You CANNOT be listed as available during a time you work another job or
have other regular commitments.
You must indicate the earliest and latest times you are willing to work each
day of the week.
Available Assignments:
Day of the
Week
Latest Stop
Time
Long term (permanent position)
Sunday
Short term (temporary position)
Monday
On-Call (back up/as needed)
Tuesday
Overnights (please indicate)
Wednesday
Short shifts (1-2 hours)
Thursday
Split shifts (mornings/evenings)
Friday
Live in (living with consumer)
Saturday
Characteristics and Consumer Preferences:
Do you smoke? Are you willing to work for a client who smokes
Yes No Yes No Outdoor smokers only
Are you willing to work for a consumer who has pets?
Yes No Cats Large Dogs Small Dogs Other Pets
Willing to Work With:
Children (under 18 years)
Clients with visual impairments
Adults (18-64 years)
Clients with hearing impairments
Elderly Adults (65+ years)
Clients with cognitive impairments (i.e. Alzheimer’s)
Male Clients
Clients with developmental disabilities (i.e. autism)
Female Clients
Clients with terminal illnesses (hospice care)
Couples (spouses, siblings, roommates)
Limited
Languages Spoken:
English (check one): Fluent
Other languages (please list): __________________________________________________
Rapid Response On-Call Network:
This is a service for clients with serious needs who may require a caregiver at the
last minute and/or for a temporary position. Caregivers should be available with
little notice and willing to assist with personal care tasks. Would you
like to be
listed on the Rapid Response On-Call Network? Yes No
4
Services Willing to Perform:
Please list all services you are WILLING to perform.
Accompaniment to Appointments/Alt Resources (assist consumer to and
from appointments via car, bus, etc. - NOT necessarily providing
transportation)
Ambulation (assist with walking/moving about)
Feeding (assist clients with eating meals)
Heavy Cleaning (thorough cleaning of home - one time service)
Laundry (wash, dry, fold, and put away)
Domestic Services (basic house cleaning - sweep, mop, vacuum, dust, etc.)
Meal Preparation and Clean Up (prepare foods, cook, clean up after meals)
Medication Assistance (set up medications, remind consumer to take
medications)
Move in / out Bed (transfer assistance)
Paramedical Services (injections, wound care, etc.)
Prosthesis Care (assist with glasses, hearing aid, prosthetic limb, etc.)
Protective Supervision (observe behavior of consumer with cognitive
impairment)
Respiration (assist with self-administered breathing devices, oxygen, etc.)
Rubbing Skin / Repositioning (give leg/foot massages; assist with range of
motion exercises, etc.)
Shopping and Errands (shop and run errands, with or without consumer)
Personal Care Tasks:
Please indicate if you are willing to assist male and/or female clients.
Bathing (assist with washing, sponge baths)
Male clients Female clients
Bowel and Bladder Care (assist with using restroom, changing diapers)
Male clients Female clients
Dressing (put on/take off clothes/shoes)
Male clients Female clients
Grooming / Hygiene (brush teeth, comb hair, etc.)
Male clients Female clients
Menstrual Care (external application of pads)
Female clients
5
Experience and Training
Do you have any experience (paid or unpaid) providing in home care or any
relevant training? Yes No
Please list any experience and/or training:
Why do you want to be a Caregiver?
Current Certifications and Licenses:
First Aid (Expiration: ) CPR (Expiration: )
CHHA (Expiration: ) CNA (Expiration: )
(Certified Home Health Aide) (Certified Nursing Assistant)
LVN (Expiration: ) RN (Expiration: )
(Licensed Vocational Nurse) (Registered Nurse)
Other: (Expiration: )
Are you willing to have a drug test without prior notice?
Yes No
6
In the last 10 years, have you been convicted of any felony OR misdemeanor
charges, or been on parole or probation? Failure to disclose this information
may automatically disqualify you from the Registry. Yes No
If “yes,” list ALL convictions in the last 10 years . A “yes” answer will not
automatically disqualify you from the Registry. Each case is considered
individually. For each conviction, list the offense, date and place of
conviction, sentence, date of release from custody and/or probation/parole,
and any other facts you would like considered.
How did you hear about the IHSS Caregiver Registry?
7
Background Checks on IHSS Caregiver Registry Applicants
Current law provides that IHSS Public Authorities are to investigate the
qualifications and background of IHSS caregivers. Therefore, the following apply
to caregiver Registry applicants and caregivers listed on the Registry:
I understand that Public Authority staff will conduct a background check on
me using publicly available resources including, but not limited to, Department
of Justice (DOJ) background checks. I understand that prior or future criminal
acts may preclude me from participation on the Registry.
I understand that Public Authority staff will search the California Department of
Justice Sex Offender Database to determine if I am a registered sex offender. I
understand that if I self-disclose that I am a registered sex offender or found to
be a registered sex offender, I will be eliminated from participation on the
Registry.
I understand The Public Authority retains the exclusive right to list, refer,
suspend, or remove an individual caregiver from the Registry.
I understand that my name may be placed on a list to be given to persons
who are seeking assistance in their homes, without further notice.
I understand that the information on this application may also be shared
with prospective employers and their advocates without further notice.
I understand completing this application and being listed on the Registry
does not guarantee me employment.
I understand that my employer is not Sacramento County In-Home Supportive
Services (“IHSS”), the Sacramento County IHSS Public Authority, or the
Caregiver Registry. The IHSS consumer is my employer. I further understand
that an IHSS consumer-employer retains the exclusive right to hire, supervise,
and terminate my employment with or without notice.
I certify under penalty of perjury that all the information provided in this
application and its related process is true. I understand that any false
information may eliminate me from eligibility for participation on the Registry.
Signature: Date:
Print Name:
8
References
The Registry staff must clear your references in order to approve your
application. Your application will be considered incomplete if the
Reference Questionnaires are unfinished or are not submitted with the
application.
Professional references should be work-related people who directly supervised
you. Please DO NOT use coworkers as references. References must be able to
speak freely about you and your job performance. References from
housekeeping, babysitting, and volunteer positions are acceptable.
This application includes two Reference Questionnaires to give to your
references. The professional reference must complete the Reference
Questionnaire. This form is not to be completed by the applicant.
All references must sign the questionnaires and provide a valid telephone
number where they can be reached.
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Professional Reference Questionnaire
Sacramento County IHSS Caregiver Registry Applicant
Applicant Name:
Applicant - DO NOT write anything below this line. This form must be
completed and signed by the reference named below
To Whom It May Concern,
The above named applicant is applying for work as an in-home caregiver and
would like to use you as a reference. Please answer each question to the best
of your ability.
1. What was your professional relationship to the applicant?
2. Applicant’s job title?
3. What were the applicant’s dates of employment?
4. What were the applicant’s job duties?
5. Given the opportunity, would you rehire the applicant? Why or why not?
Your signature below confirms the information you provided is correct to the best
of your knowledge. You also give permission to Sacramento County IHSS
Caregiver Registry staff to contact you regarding this information.
Reference Signature:
Name: Date:
Phone Number
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Professional Reference Questionnaire
Sacramento County IHSS Caregiver Registry Applicant
Applicant Name:
Applicant - DO NOT write anything below this line. This form must be
completed and signed by the reference named below
To Whom It May Concern,
The above named applicant is applying for work as an in-home caregiver and
would like to use you as a reference. Please answer each question to the best
of your ability.
1. What was your professional relationship to the applicant?
2. Applicant’s job title?
3. What were the applicant’s dates of employment?
4. What were the applicant’s job duties?
5. Given the opportunity, would you rehire the applicant? Why or why not?
Your signature below confirms the information you provided is correct to the best
of your knowledge. You also give permission to Sacramento County IHSS
Caregiver Registry staff to contact you regarding this information.
Reference Signature:
Name: Date:
Phone Number
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Provider Registry Application Information (Sacramento County, California)

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Completed 4 June 2021

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