Please correct the following errors: Apply to Become a Provider General Information First Name: MI: Last Name: Mailing Address: City: State: Zip Code: Residential Address: City: State: Zip Code: Home Phone: Cell Phone: Email: IP Enrollment & Background Check Have you completed the Individual Provider (IP) enrollment process at IPAC (Independent Provider Assistance Center) at 77 Otis Street? Yes No Important: All Providers must be enrolled with the City's Department of Aging and Adult Services (DAAS) before joining the Provider Registry. Please visit San Francisco IHSS Provider Enrollment to enroll. You can call the Public Authority if you have questions about this process at (415) 243-4477. Click to Acknowledge & Continue… Have you cleared the Background Check through the California Department of Justice? Yes No Who referred you to the Public Authority? Choose one please… Arriba Juntos Bernal Heights Comm Ctr CAL Works Case Manager Chinese Newcomers Ctr Employment Fair Employment Office Excelsior Comm Ctr Family Member Flyer Friend Friend / Family Provider Friend / Family Consumer IHSS Client IPAC – 77 Otis IHSS Provider IHSS Social Worker Internet Neighbor Newspaper Public Authority Staff Public Authority Website UDW Walk-In Other Name of IHSS Provider: Phone of IHSS Provider: Languages Spoken Please check all the languages you speak: English Spanish Chinese Tagalog Vietnamese Korean Farsi (Persian) Armenian Russian Arabic Khmer (Cambodian) Hmong Laotian Other Preferred Language: Driving & Access to a Car Do you rely on public transportation to get to jobs? Yes No Are you willing to use your car on the job? Yes* No Are you willing to drive a consumer's car? Yes* No * If yes, you must have a current driver's license and auto insurance. IHSS does not pay for transportation services; gas, mileage, maintenance, etc. Training & Certification Please check if you have recently completed any of these care provider trainings: Homebridge Basic 48 or 72 Hour Training Completion Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 First-Aid / CPR (Cardio-Pulmonary Resuscitation) Completion Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 Expiration Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 Other Name(s) of Certification: Work Preferences Please check boxes indicating all your preferences. We cannot guarantee that consumers service needs will match all your preferences. We encourage you to consider performing all tasks and serving all consumers: Client Type: Willing Experienced Adults Men Women Couples Children Seniors (65 years and older) Physically Disabled Developmentally Disabled Psychologically Disabled Infectious Disease Palliative Care IHSS Consumers Domestic Tasks: Willing Domestic Services Preparation of Meals Meal Clean Up Laundry Shopping for Food Other Shopping and Errands Heavy Cleaning Accompaniment to Medical Appt. Accompaniment to Alternate Resources Yard Hazard Clean-Up Protective Supervision Teaching & Demonstration for Independent Living Personal Tasks: Willing Experienced Respiration Bowel & Bladder Care Toileting (Assist with Toilet) Diaper Changes Feeding Routine Bed Baths Dressing Menstrual Care Ambulation Moving In / Out of Bed Bathing, Oral Hygiene, Grooming Personal Tasks: Willing Experienced Rubbing Skin, Repositioning Care & Assistance with Prosthetics Set Up, Remind Meds Catheter / Colostomy Bag Exercise Hoyer Lift Lifting/Transferring Memory Loss Vital Signs Other Relevant Information Do you smoke? (Must not smoke indoors.) Yes No Will you work for consumers who smoke? Yes No Do you have an allergy that would affect your ability to work in a home with? (Check all that applies.) Cat Dog Other Describe other allergy: Are you willing to provide IP services in the event of a disaster? Yes No Consumer's Home Emergency Shelter Schedule Preferences Most consumers need part-time workers. You can accept more than one part-time job if you prefer a full-time schedule. What are the number of hours per week you would be willing to work? 10 hours per week or less (part-time) 10-25 hours per week (part-time) 25 hours per week or more (full-time) Please check whether you want short-term and/or long-term jobs. (You may answer both options.) Short-Term (Temporary) Long-Term Are you willing to work on: Holidays 2-hour Shifts Interested On-Call Services Check all the days and times you are available to work weekly: Mornings Afternoons Evenings Monday Tuesday Wednesday Thursday Friday Saturday Sunday Geographic Area Please check off all the locations you would be willing to work. If you are willing to travel to many areas, you may be referred to more jobs: Bayview Bernal Heights Castro Chinatown Civic Center Cole Valley Downtown / Financial District Embarcadero Excelsior Fisherman's Wharf Glen Park Haight Ashbury Hayes Valley Ingelside Inner Sunset Japantown Marina Mission Bay Mission District Nob Hill Noe Valley North Beach Outer Sunset Pacific Heights Parkside / Lake Merced Portola Potrero Hill Presidio Richmond Russian Hill SoMa South Beach Tenderloin Treasure Island Twin Peaks Visitacion Valley Western Addition West Portal All Areas District you live in: Work History List three verifiable work references (home care experience preferred) within the past five years for jobs lasting more than 60 days. If three work references are not available, you must submit at least one job reference or volunteer work experience plus two personal references who are not relatives. Employer #1: Phone: Job Title & Responsibilities: Job Supervisor's or Consumer's Name: Permission to Call: Yes No Period of Employment: (Starting date to ending date.) January February March April May June July August September October November December 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 to January February March April May June July August September October November December 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 Reason for Leaving: Employer #2: Phone: Job Title & Responsibilities: Job Supervisor's or Consumer's Name: Permission to Call: Yes No Period of Employment: (Starting date to ending date.) January February March April May June July August September October November December 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 to January February March April May June July August September October November December 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 Reason for Leaving: Employer #3: Phone: Job Title & Responsibilities: Job Supervisor's or Consumer's Name: Permission to Call: Yes No Period of Employment: (Starting date to ending date.) January February March April May June July August September October November December 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 to January February March April May June July August September October November December 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 Reason for Leaving: Personal References Please do not list family members (sisters, nieces, grandparents, etc). Name #1: Phone: Relationship: Name #2: Phone: Relationship: Name #3: Phone: Relationship: Optional Information This section is OPTIONAL but may provide useful information to the Registry. Gender will be used only when a consumer requests a worker of the same gender to provide personal care. Birthdate: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 Gender: Male Female Other Sexual Orientation: Heterosexual LBGTQ Other Decline to Answer Ethnicity: African African-American Asian-Pacific Islander Caucasian Latino Native American Other Acknowledgement & Consent: I consent the IHSS PA to contact me by text message and automated calls for the purpose of receiving program information and reminders. I will ensure that I keep the PA informed of my up-to-date mobile number at all times, or if the number is no longer in my possession. I certify that all information on this form is true to the best of my knowledge and that any omission or misrepresentation of information may disqualify me from being listed in the registry. I also understand that submitting an incomplete application will disqualify me from being considered for the Registry. Submit Your Application