Fillable REGISTRY APPLICATION FORM FOR PROVIDERS PASC Homecare Registry (Personal Assistance Services Council)

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REGISTRY APPLICATION FORM FOR PROVIDERS PASC Homecare Registry (Personal Assistance Services Council)

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The REGISTRY APPLICATION FORM FOR PROVIDERS PASC Homecare Registry (Personal Assistance Services Council) form is 6 pages long and contains:

  • 2 signatures
  • 108 check-boxes
  • 87 other fields

Country of origin: US
File type: PDF

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Page 1 of 6
REGISTRY APPLICATION FORM FOR PROVIDERS/ REVISED 07/01/18
Approved:
Yes
No
Approved By: ______________________
Approval Date: _____________________
PASC Homecare Registry
REGISTRY APPLICATION FORM FOR PROVIDERS
First Name:
Last Name:
Middle
Initial:
IHSS Provider Number:
Home Phone: ( ) - Cell Phone: (___ )_____-___________
Message Phone: (____) ____-______Email Address: ___________________
Home address: Apt. #
City: State: Zip: __________________
Gender:
Male
Female
Other_____________
Date of Birth:____________________________
Do you plan on moving to another state or county within the next few
months?
Yes, When?___________
No
List the names and phone numbers of two people we can contact in case
of an emergency relating to your health.
Emergency Contact 1: Phone
Emergency Contact 2: Phone
What language(s) do you speak? 1:________________ 2:________________
3. Sign Language: __________________ Other: __________________
Race/Ethnic Group: (Optional - This information is collected only for
statistical reasons. It is not used for matching or assignments.)
Page 2 of 6
REGISTRY APPLICATION FORM FOR PROVIDERS/ REVISED 07/01/18
Please check the tasks you are capable of and willing to perform for the
consumer.
Domestic
Services
Preparation
of Meals
Meal Clean Up
Routine Laundry
Shopping for
Food
Other Shopping
& Errands
Heavy Cleaning
Accompany to
Dr. App’t
Accompany to
Alternative
Resources
Remove Grass,
Weeds, Rubbish
Remove Ice,
Snow
Shopping for
Foods
Protective
Supervision
Teaching &
Demonstration
Paramedical
Services
Willing to use
your own car
Respiration
Bowel &
Bladder Care
Feeding
Routine Bed
Baths
Dressing
Menstrual
Care
Ambulation
Moving In/Out of
Bed
Bathing, Oral
Hygiene
Grooming
Rubbing Skin,
Repositioning
Care & Assistance With
Prosthesis
Set Up, Remind Meds
Catheter/Colostomy
Bag
Diapers
Exercise
Hoyer Lift
Lifting/Transfer
Memory Problems
Toileting
Vital Signs
Wheelchair Assistance
Prosthetic Assistance
Have you had experience and/or training in any of the following? (Check
all that apply.)
Alzheimer’s
Disease
Heart Condition
Parkinson’s
Disease
Stroke
Arthritis
HIV/AIDS
Range of Motion
Traumatic Brain injury
Asthma
Hypertension
Respiration
Assistance
Visual Impairment
Bowel Program
Insulin Care
Seizures
Feeding Tubes
Cancer
Mental/Emotional
Disability
Special Diet
Wound Care
Dementia
Multiple
Sclerosis
Spina Bifida
Lifting Devices/ Hoyer
Lift
Diabetes
Paralysis
Spinal Cord
Injury
Ventilators
Are you certified in any of the following areas? (Check all that apply)
You will be asked to present certification documents.
First Aid
Certified
Nursing
Assistant (CNA)
Home Care
Worker Training
Vocational Nurse
(LVN)
CPR
Registered Nurse (RN)
Home Health Aide
Page 3 of 6
REGISTRY APPLICATION FORM FOR PROVIDERS/ REVISED 07/01/18
Years of experience in homecare or similar work: ______________________
Are you willing to not use perfume or other scented fragrances on the job?
Yes
No
Are you willing to work for a consumer that has a dog?
Are you willing to work for a consumer that has a cat?
Yes
Yes
No
No
Are you willing to work at a home where smoking is practiced?
Yes
No
Are you willing to comply with a no-smoking rule at your consumer's
home?
Yes
No
Do you have a driver license? Yes No
Do you plan on driving to work?
Yes
No
Are you currently working as an IHSS Provider?
Yes
No
If YES, how many IHSS hours are you currently working per month?______
How many hours can you work per month?____________________________
Times of Availability: Flexibility in times you are willing to work gives you an
advantage in obtaining referrals. Indicate with a check mark ( √ ) the days and
times of day you are willing to work.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Morning
Afternoon
Evening
Overnight
Live-In
Areas of Availability: Please list the cities or geographic areas in which you
would be willing to work.
Page 4 of 6
Educational Background:
Grade School: Middle School:
Years completed________________ Years completed_________________
High School College / University:
Years completed: _______________ Years completed_________________
Did you graduate?
Yes
No Did you graduate?
Yes
No
Degree / Diploma Earned: _________
Vocational / Trade School:
Years/months completed: __________________
Did you graduate?
Yes
No
Degree / Diploma earned:___________________
References: (Do not include relatives.) Upon request, the Registry will give
these references to any of your prospective employers. Please make sure
these numbers are valid and
these references have given their consent to be
contacted in relation to your job search efforts.
Name
Telephone Number
How long have
you known this
person?
I certify under penalty of perjury that the information provided above is
true and complete to the best of my knowledge. I also understand that any
misrepresentation on my part may result in disqualification or removal
from the PASC Homecare Registry at any time. I further authorize the
Registry and/or the consumer to contact the above references concerning
my character and I authorize the Registry to share any such information
with others for Registry purposes. I waive any claim(s) I may have
regarding any such reference information.
X_______________________________________ ___________________
Signature Date
REGISTRY APPLICATION FOR PROVIDERS/REVISED 07/01/2018
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signature
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Revised 07.01.18
Page 5 of 6
PASC HOMECARE REGISTRY -
IHSS PROVIDER’S SERVICES AND RELEASE AGREEMENT
If you need assistance in reading or understanding this document, you should obtain
the help of a trusted family member, friend or representative.
You intend to use the services of the PASC Homecare Registry. The Registry provides
referrals of IHSS homecare Providers to participating Consumers. For certain eligible enrolled
Consumers, the Registry also provides referrals of temporary back-up attendants under the PASC
Back-up Attendant Program. The term “Provider” as used in this Agreement covers both
regular Providers and also Back-up Attendants. As a condition for your use of the services of
the Registry, the following matters are acknowledged and agreed upon:
1.
Registry’s Limited Role: PASC operates the Homecare Registry, free of charge to all
participants, primarily for the purpose of assisting individual Consumers and Providers to
make contact with one another and possibly form an employment relationship. The Registry
does not perform any background checks of the Consumer participants in Registry
programs. Nor does the Registry supervise the Consumer or the employment. You
therefore must use your own judgment and assume all risks of accepting or engaging in
the employment relationship with any Consumer.
2.
Consumer is the Employer: The Consumer has the sole authority to hire, assign duties,
supervise, and terminate you, and you have the right to resign from any Consumer’s
employment. The Registry has no role in such decisions. The provision of paramedical
services such as insulin injections and feeding tube assistance by any Provider (including
back-up attendants) is solely under the authority of the Consumer and the Consumer’s
physician, not the Registry. PASC has no responsibility for employment matters, for any
injuries that may arise out of the referral or the employment, or for investigating or
resolving any disputes, losses or injuries that may arise between a Provider and
Consumer.
3.
Availability of Referrals: The Registry has no control over the nature or volume of
Consumer requests for referrals, nor the number of Providers who may be available at any
given time, and therefore the Registry cannot assure the volume of referrals that may be
available to Providers at any given time.
4.
Criminal Background Checks: The statutory authority for determining the standards
for disqualification of a prospective or existing IHSS provider is Welfare & Institutions
Code (W&IC) Sections 12305.81 and 12305.87. The Registry abides by prevailing state
laws concerning an applicant’s eligibility to work as an IHSS Provider. Also, in the event that
the Registry learns of a later disqualifying conviction or incarceration, it may report that to the
Consumer who is then employing you as a Provider. If any dispute arises concerning the
impact of the criminal background check upon a Provider’s access to the Registry, it shall be
resolved solely under procedures of the Registry Review Committee, and shall not be subject
to any further proceedings or litigation of any nature.
IMPORTANT -- LEGALLY BINDING AGREEMENT -- REVIEW CAREFULLY
Revised 07.01.18
Page 6 of 6
5.
Reference Checks – Consent and Release: You hereby consent to PASC and/or any
Consumer contacting your prior employers and personal references, and you hereby release
any prior employers and any references from any claims or liabilities arising out of any
statements or information they may provide.
6.
Use of Personal Information: As part of its operations the Registry receives personal
information from the Consumer, the County and in some instances third parties about the
Consumer’s or Provider’s participation in the IHSS Program. The Registry will use such
information only as for Registry purposes. The Registry may also use such information to
exclude, suspend, or remove a Registry participant for good cause, through confidential
procedures. Any disputes concerning exclusions, suspensions and/or removals from the
Registry are subject to review and resolution solely by the Registry Review Committee,
whose decisions are final and binding upon all concerned, and are not to be the subject of any
further proceedings or litigation of any nature.
7.
Provider’s Responsibilities to the Registry: As an ongoing condition of Registry
participation, all Registry participants (Providers and Consumers) must: (a) comply with all
Registry policies, procedures and directives, and cooperate fully with Registry personnel; (b)
keep the Registry updated as to all decisions regarding referrals; and (c) treat Registry staff
and all other Registry participants with civility and respect.
8.
Release Agreement: In consideration for the services to be provided to you by the
Registry, you hereby release PASC and Los Angeles County (together with its and their
employees, governing boards, agents, insurers, contractors, volunteers, and others who
have furnished information or services or otherwise cooperated with PASC) from any
claims, damages, injuries, liabilities or remedies of any nature relating in any way to the
Registry, its services or denial of services, or its actions or failures to act. This Release is
also made on behalf of your personal representatives, family, dependents, heirs and assignees.
This Release does not affect any rights or claims you may have either under the PASC-SEIU
Agreement, or against the State of California under Workers Compensation or Unemployment
Insurance laws.
9.
Signature: The undersigned has carefully reviewed and considered each and every one of
the terms and conditions of this entire Agreement, understands them, and voluntarily
decided to agree with them. PASC will rely upon this Agreement when granting Registry
services to you.
Personal Assistance Services Council
Signature of IHSS Provider/Applicant
Print Name of IHSS Provider/ Applicant
Greg Thompson
Date Executive Director
Home Telephone No.
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REGISTRY APPLICATION FORM FOR PROVIDERS PASC Homecare Registry (Personal Assistance Services Council)

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Completed 6 November 2020

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