San Francisco IHSS Public Authority | Back-Up Provider Services Application

General Information

First Name: MI: Last Name:

Mailing Address:

City: State: Zip Code:

Email:

Cell Phone:

Other Phone:

Do we have your premission to send you text messages?

Yes No

Languages

Preferred Spoken Language: (Including English.)

Preferred Written Language: (Including English.)

Other Language:

English Fluency Level:

Fluent Limited No English

Enrollment & Background Check

IHSS Provider #: (Must be enrolled with IHSS.)

Have you completed the Independent Provider (IP) enrollment with the IHSS Program?

Yes No

Have you cleared the background check through the California Department of Justice (DOJ)?

Yes No

Are you currently enrolled with the San Francisco Public Authority's Provider Registry?

Yes No

Who referred you to the Public Authority?

Name of IHSS Provider: Phone of IHSS Provider:

Training & Certification

Please checkmark any of the trainings below if completed within the last 5 years:

Homebridge Basic 48 or 72 Hour Training

Completion Date:

Personal Caregiver Training Online

Completion Date:

First-Aid / CPR (Cardio-Pulmonary Resuscitation)

Completion Date:

Expiration Date:

Other Trainings / Certifications

Name(s) of Trainings / Certification:

Work Preferences

Most consumers need part-time assistance. You can accept emergency assignments that fit your schedule and decline others.

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 select the time ranges you are available to work for each day, with a minimum of 3 hours.

Start Time

End Time

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Are you willing to work for a consumer who smokes?

Yes No

Are you able and willing to work in a home with pets?

Yes No

Are you able and willing to work in a home that uses scents?

Yes No

Work History

Please list names of your current or previous Employer(s) and/or Consumer(s) you have provided personal care for.
(Note: The Public Authority will contact these references.)

Employer / Consumer's Full Name:

Phone:

Period of Employment: (Starting date to ending date.)

From:

To:

Job Responsibilities:

Employer / Consumer's Full Name:

Phone:

Period of Employment: (Starting date to ending date.)

From:

To:

Job Responsibilities:

Back-Up Provider Services Application

General Information

Languages

Enrollment & Background Check

Back-Up Provider Services Provider Eligibility

Training & Certification

Work Preferences

Work History

Optional Information

Back-Up Provider Services Application

General Information

Languages

Enrollment & Background Check

Important:

Back-Up Provider Services Provider Eligibility

Training & Certification

Work Preferences

Work History

Optional Information

Acknowledgement & Consent: